The survey was completed by 134 of 990 nursing students placed in the health service during the study period (response rate 13.5%): 85 were in the second year and 49 in the third year of their three-year Bachelor of Nursing program. The majority were aged 18-25 (56.7%). One hundred and thirteen Bachelor of Nursing students provided responses to open ended questions on placement facilitation. Five new graduates, seven E2P facilitators, four ward-based RNs, and three nurse academics participated in interviews.
Student and new graduate responses
Scale reliability ranged from 0.77 – 0.90. Students rated the effectiveness of their E2P facilitators highly (4.43/5±0.75) and were highly satisfied with the behaviour and qualities of the ward-based RNs (Table 1) and E2P facilitators (Tables 1 and 2).
Students’ open-ended survey comments and new graduate interview findings resonated with each other, with both data sets grouped into three areas: ‘access to learning’; ‘source of support’, and ‘lack of clarity about facilitation.’
Access to learning
Both students (SN) and new graduates (NG) indicated that the model provided good learning opportunities, with access to authentic experiences. For example:
‘I had a great experience with all staff and facilitators and…have learned a lot while on placement’ (SN86)
‘[it provided a] chance to work with a number of different nurses…that was very good because you got to see different styles of nursing’ (NG7)
Source of support
Views on the level of learning support differed across the two groups. For example, students were more likely to report the absence of E2P facilitators in comments such as:
‘more support from the [E2P] facilitators would be good. I think they are too busy with too many students and some more practical hands on with a facilitator would be better’ (SN 86).
New graduates largely felt well supported by the E2P facilitators, and emphasised the support from ward nurses:
‘The [E2P] facilitators…give you your own chance to learn and then there’s support if you need it, and if they think that you’re obviously not doing as well as what you could be, they’re there to tell you that and talk you through things and give you feedback and advice to fix anything so I think there would just be a perfect amount of support’ (NG4)
Lack of clarity about facilitation
Students appeared to be confounded by the E2P teams and to seek one person to be ‘their facilitator’ as per previous models. This was manifest in comments such as:
‘it was a draining experience not knowing who was the actual [E2P] facilitator’ (SN34).
In summary, the learning was positive for both students and new graduates, but students appeared to be more focused on support from E2P facilitators and new graduates more focused on support from the ward-based RNs. The transition to multiple E2P facilitators was confusing for students.
Academics, RNs and E2P facilitators
Thematic analysis of the interviews with ward-based RNs, E2P facilitators, and academics revealed three main themes: 1) students’ and new graduates’ integration into the workplace can promote learning; 2) tensions arise in new ways to approach performance assessment; and 3) aligning expectations requires high levels of communication.
Students’ and new graduates’ integration into the workplace can promote learning
Ward-based RNs valued the multiple perspectives that students would learn by working with different staff and indicated that the CCEM potentially reduced the impacts of personality clashes that arose in traditional supervisory relationships. Although some expressed concern about the impacts of a lack of continuous facilitator supervision:
‘they get a variety [of E2Ps]…so if there's a personality clash with a facilitator and a student there isn't that issue because you've got quite a few that cover the wards’ (RN1)
‘With the old model…if things were quite busy on the ward the facilitator would come up and spend a bit more time with the students to work on any needs…I worry that the students aren't getting the support in that sense because the facilitator does have so many students to cover…[some may] ‘slip through the cracks’ (RN1)
E2P facilitators and academic nurses agreed that the model encouraged greater integration of learners into the ward culture, developing the student-RN relationship and students’ problem-solving and independence:
‘With the new model [learners] integrate into the ward much, much better. They become part of the team because you’re not on the floor all the time with nurses [saying] ‘your facilitator can do that with you’…now the unit staff are taking ownership…I think it’s a better experience for [learners] in that they…actually become part of that unit…they have to develop their problem-solving skills in that situation a lot better than the old model where you are problem-solving for them a lot’ (E2P7)
‘it definitely fosters the students to be independent, and to seek their own learning opportunities’ (E2P5)
[Third years] ‘felt that they were becoming part of the team and that they could troubleshoot and communicate with other staff and felt comfortable about that … (Academic Nurse (AN) 1)
However, this was also identified as an area of concern for those students who may not be strong communicators or who are earlier in their career trajectory, such as second year students:
‘… felt that those who weren't as confident … would have difficulty in asking for help from anyone else but their facilitator, so they were thinking it would be more difficult for the second years’ (AN1).
Tensions arise in new ways to approach assessment of performance
E2P facilitators identified other benefits with the CCEM, including better cover for sick leave, a better relationship with ward-based RNs, and broadening their perspectives of student performance through sharing feedback during handover:
‘you’ve got a lot of people working with the same students, so you’ve got different perspectives of how that…group of students are performing’ (E2P2)
There were continuities in how student learning was facilitated such as ‘giving feedback…[investigating] before you give that feedback [to moderate it]…timekeeper for sick leave…written assessments…troubleshooting issues…role model and mentor’, and encouraging student reflection (E2P5); ‘helping the buddies [RNs], being able to educate and giving them support’ (E2P2), ‘ building those relationships with…all the staff’, ‘identifying issues quickly (E2P6); and ‘[supporting] the students when they need it clinically and emotionally’(E2P3).
However, there were also tensions, particularly in relation to the assessment of student performance such as: trying to find students and the RNs supporting them (E2P1, E2P6), feeling rushed (E2P1, E2P4), and insufficient time to gather enough information to inform assessment (E2P1, E2P5, E2P 6, E2P7). Academics were also concerned about assessment:
‘the [Clinical Assessment Tools] that came back…[had] generic comments…I really want to make sure that [students are] clinically sound and I can’t do that when the comments are just not there’ (AN3).
In summary, while learning appeared to be enhanced by the CCEM, the tensions associated with multiple staff and perspectives, particularly around processes for providing feedback on performance (assessment), required further development.
Aligning expectations requires high levels of communication
Good communication and role delineation were considered integral to the success of the model, for example:
‘constantly keeping that communication line open with those key people in that area, [which is] pivotal...in making that student’s clinical placement a positive experience just by negotiating and ensuring that they’re learning what they need to learn’ (E2P7)
‘It’s important that the [ward-based RNs] understand their education role more effectively…[they think] if the students [or new grads] are getting on with it and look like they are doing it, they must be great. But there’s not that in depth asking of questions or delving a little bit more to see whether or not that is the case’ (E2P1)
‘Maybe we need to have a bit more discussion on what is expected [regarding] whether you see every student every shift’ (E2P1)
Processes for communication across the stakeholder groups were negotiated through the reference group activities and discussions. However, further communication appeared to be required. For example, academic nurses noted that third year students were expecting the supervisory model they had previously experienced, and this was potentially related to insufficient communication about the changes:
‘I [had] complaints from students because they didn't understand why they couldn't actually get their [E2P] facilitators as often and now I understand that they should not be looking to their facilitators as much for the education as their [ward-based RN], but that wasn't the understanding then when that class was on [placement]’ (AN3)
Academics continued to monitor students on placement. The academics reported feeling frustration as they adjusted to the model. For example, having more than one E2P facilitator confounded communication:
‘it’s very frustrating from my end trying to contact the people who are looking after my students’(AN3)
As the model was transitioning, E2P facilitators adjusted as well, stressing their perception that their role is now educational support and liaison rather than clinical expert:
‘I think someone from general could go to mental health and step into the role if they had to in this model. It’s the nurses who are the specialists in that area…so they do the teaching, whereas this role now is more liaising and anyone can do that if they’ve got the skills that they need for that, so I think the role is better’ (E2P3)
In summary, the transition to the CCEM required alignment of stakeholder expectations and the communication strategies to achieve alignment were inadequate to support the transition.
The students who responded to the survey strongly agreed that the E2P facilitators supported their learning and scored E2Ps and ward-based RNs highly on professionalism, currency of knowledge, flexibility, and willingness to provide feedback. For new graduates, the opportunity to work with multiple nurses with intermittent E2P facilitator support provided structured support and an opportunity to learn about different styles of nursing. However, students appeared to prefer, and expected, supervision from one E2P facilitator whereas new graduates preferred learning from the staff. The acceptability of the CCEM for nursing students appeared limited by their preference for a closer relationship with a single E2P facilitator.
Academics, E2P facilitators and RNs appeared to find the model acceptable, noting that improved communication of expectations is required. They valued the increased independence of more senior students and new graduates in their learning, noting that more junior students may require additional support. Although there was general agreement that learner exposure to multiple perspectives is a strength of the model, processes to communicate about individual learner performance were confounded by multiple stakeholders and required the establishment of clear lines of communication in order to sustain the model.