Nurses in the 21st century need to have the relevant knowledge and skills to be able to safely and competently care for a diverse array of patients (Nielsen et al, 2013). The process of knowledge and skills acquisition begins as a pre-registration student nurse and, as such, the foundations for future practice should be set at this point. Therefore, it is important to understand student nurses' motivations and approaches to learning. The implications of not examining this group could be significant in terms of future nursing practice and the delivery of high-quality patient care.
Background and literature search
It was important to first examine the literature around how students learn within the higher education context, and the approaches to learning that students may take. A ‘surface learning’ (or superficial) approach is said to be common in higher education (Gibbs, 1994). On examining nursing students' approaches to learning, Snelgrove (2004) suggested that student nurses demonstrate a ‘deep approach’ to subjects that have a direct correlation to their academic success. Much of the research around student learning has focused on the different levels at which students engage with formal learning, and ways in which learning can impact on students (Tomlinson, 2014). Entwistle (2007) considered how much of the research into approaches to learning has examined students' perceptions of the teaching they have experienced.
It is recognised that students from all disciplines within higher education share similar approaches to their learning (Entwistle, 1991). Entwistle (1991) discussed what provokes students' approaches to learning; he described approaches as coming from the context and the content. It has been suggested that during a programme of study an individual student's approach to learning will differ according to the topic studied and is often dependent on their interest in the subject (Richardson, 2007). This suggests that students may take a deeper or proactive approach to their studies if the subject matter appeals to them.
When examining how students learn in higher education, it is noted that students use different strategies to tackle individual learning tasks (Entwistle, 1991). The concept of strategy was examined through the present research, in terms of what student nurses perceive to be useful in their education, and why they believe this. Strategic learning has been further expanded upon by Entwistle (1997), when considering three domains of strategic approaches to learning: surface level (to cope), strategic (to achieve) and deep (to understand).
In nursing, the clinical context is recognised as the most significant area for students to learn because they will practise in the real world on placements and after registration (Egan and Jaye, 2009). It can be argued that clinical practice is the most important part of the pre-registration curriculum (Henderson et al, 2011; Clarke et al, 2003; Papp et al, 2003). It may be that student nurses perceive theory and practice as separate entities, and this may be due to the clear 50:50 nature of the undergraduate programme, rather than there being an understanding that they both inherently link to one another.
It has been suggested that, globally, new registrants feel that their pre-registration education has not prepared them adequately for working life, and that this could have been rectified by being supported to develop critical thinking skills and clinical skills (Kelly and Courts, 2007; Pike and O'Donnell, 2010; Pennbrant et al, 2013). The necessity to ‘hit the ground running’ and the associated needed for new registrants to be equipped with the skills and knowledge to practise effectively, has been long discussed within the nursing literature (Greenwood, 2000; McKenna et al, 2006; Wolff et al, 2010).
Methods
The present research investigated the perceptions of student nurses to gain an insight into their motivations and approaches to learning. The research was qualitative in nature and used a phenomenological approach. Phenomenology aims to discover and understand experiences as identified by those living the experience (Polit and Beck, 2010; Rebar et al, 2011). Phenomenology is said to put a value on experience and to consider the whole person. It thus takes a holistic approach to research (Oiler, 1982), mirroring nursing, which examines patients from a holistic point of view. This phenomenological research was conducted from a constructivist position. Constructivism is a process of idea sharing among individuals who learn through appraising and embracing knowledge (Fosnot and Perry, 2005). A key point of constructivism is that, following the research, taking action should be encouraged (Wilson and Clissett, 2011).
Participants
Eighteen students were recruited by purposive sampling from one higher education institution (HEI) in the UK. Students were eligible for inclusion in the study if they were a final-year BSc Nursing student. Purposive sampling is a sampling strategy in which participants are selected as being representative of a larger population (Gray, 2014). Purposive samples have been used in many studies relating to nursing and nurse education from large cohorts (Watts and Davies, 2014; Laurencelle et al, 2016). Similarly, previous studies have found recruiting final-year student nurses useful because of their experience of both the curriculum and clinical practice (Felstead and Springett, 2016). Participants in this study ranged in age from 21 to 45 years, and of the 18, two were male and 16 female.
Ethical considerations
Ethical issues relating to the undertaking of research have been well documented (Gerrish and Lacey, 2006; Parahoo, 2014), and this is an important aspect of any research. Ethical approval was granted through the HEI in which the research took place. Both local ethical policy and Data Protection Act (1998) rules were adhered to.
Data collection
The method of data collection chosen was semi-structured interviews. This linked to the qualitative phenomenological approach, which sought to gain detailed, rich data of the students' lived experiences. Healthcare researchers often use individual in-depth interviews (DiCicco-Bloom and Crabtree, 2006); this allows an exploration of attitudes and experiences that can be expanded upon, allowing for rich insight. The use of interviews correlates with the use of the underpinning constructivist perspective (Mojtahed et al, 2014). In a study that involved final-year student nurses, Clucas and Chapman (2014) noted how the use of interviews allowed for a flexible yet thorough approach to exploring responses.
Data analysis
The method of data analysis applied was interpretative phenomenological analysis (IPA). The aim of IPA is to explore how participants make sense of their personal and social world, including particularly significant experiences or events (Smith and Osborn, 2008). The use of IPA is growing in qualitative research, particularly within social and health sciences, due to its commitment to examining how people make sense of life experiences (Smith et al, 2009).
Small sample sizes suit the use of IPA (Lyons and Coyle, 2007); and the present study involved 18 students. IPA's theoretical underpinnings arise from phenomenology, and this further supported the rationale for why this method of data analysis was pertinent to this study.
According to Graneheim and Lundman (2004), research findings should be trustworthy, in relation to the procedures used to generate the themes. Lauckner et al (2012) noted that a study must be trustworthy to accurately capture the phenomenon of interest. Through the process of analysing the data, the author reviewed each transcript three times to attempt to ensure that the findings were accurate and to assess whether the same themes were emerging. The author also reassessed for any outliers or inconsistencies. This not only ensured trustworthiness, but also added to the rigour of the process that was undertaken.
Results
Clinical skills were perceived to be the most important aspects of the curriculum that participants were motivated to learn. All skills were perceived as important but, overwhelmingly, participants believed that medicines management was the most important skill needed for clinical practice. Participants wanted to gain as much experience with medications management as they could before they graduated and moved on to the professional register.
Participants understood the potential consequences of making a drug error. One participant described the fear of making a mistake through drug administration:
‘I need more help with my medicines management; I just worry about doing medications in case I make a mistake.’
Participant 10
Participants appeared to place value on learning clinical skills and as such took a deeper approach to learning these:
‘Skills sessions really are so important for our survival on the placements.’
Participant 5
The participant discussed this further, and demonstrated anxiety about making a mistake:
‘I do worry you know that I've forgotten so much … what if I do something wrong and harm a patient?’
Participant 5
Participants demonstrated an appreciation of clinical skills because they recognised that they could be used directly in clinical practice. Students reflected on the theoretical subjects they had studied during the programme, such as mental health nursing, health promotion, law, ethics, management, leadership, research, sociology, and psychology, and suggested that they had not learned about these in much detail. When probed as to why this had been the case, the majority of students said that these subjects were not useful in clinical practice. Therefore they approached them as being necessary in order to pass assessments. In this way they approached their learning in a superficial manner.
The following excerpts from three participants demonstrated this significant finding,
‘All that stuff about research and leadership it's of no use to me all I want is to be a nurse. So when assignments came in, I did them, got a pass and concentrated on the important stuff, you know like learning medications.’
Participant 10
‘All these other subjects I just do to pass to get through the course … the stuff like health promotion and sociology, it's a case of passing the assignment and moving on.’
Participant 1
‘Seriously I have too much more relevant stuff to learn about than … public health and health promotion, so I got that done and moved on.’
Participant 18
Participant 2's comment suggested that students differentiate between subjects that have been useful on placements and those that have not:
‘The only real modules that I remember really helping me with my practice were the skills and the anatomy and physiology, the rest of it was all just a bit pointless.’
Participant 2
Participant 7 recognised the use of anatomy and physiology taught in university, and its relevance to clinical practice:
‘Anatomy and physiology in the first year was so hard, but I can see now why it was, as I needed to know this stuff before going onto placement where I had people's lives to deal with. I knew I tried harder to learn these subjects over the other stuff.’
Participant 7
The necessity for a strong emphasis on anatomy and physiology was highlighted by another participant:
‘I just think that I need more physiology and pathophysiology … the role of the nurse is now so medical and we need to know this stuff.’
Participant 6
Participants identified their responsibility for adult learning, and self-directed learning. Participant 18 demonstrated this:
‘I suppose it's … about me going to learn at home.’
Participant 18
Participant 11 further added to this:
‘Let's face it; all we need on a day-to-day basis is to know how to survive each shift and make sure that we don't harm patients … all we need are the anatomy, physiology, and medications management subjects. All the rest are nonsense, you know like management, leadership, research and ethics. All I want to do is to keep my patients safe on a day-to-day basis.’
Participant 11
Participants placed significant value on theoretical subjects that they perceive will directly support their nursing practice and patient care. Therefore, this may be why anatomy, physiology and pathophysiology were frequently mentioned. This was reiterated by participant 15, who rationalised why they believed these subjects would support their learning,
‘The thing is, I'm not saying that the other subjects aren't important because they are, but everything that we do as adult nurses is about patients with illnesses … because we need to keep the patients safe and our registration. In fact, I will have just got it and don't want to lose it.’
Participant 15
Participant 6 added to this:
‘I need the subjects that will help me on the shop floor, the rest of the stuff like, mental health nursing, management, leadership and sociology etc don't help me when I'm trying to save someone's life.’
Participant 6
The majority of participants believed that they simply needed theoretical subjects that they can use in practice immediately. This highlights what the students perceive to be useful, and why, and is a significant insight into their perceptions of useful theoretical subjects. There were no other theoretical subjects that participants felt the curriculum needed in order to support them.
Discussion
Through examination of the findings, it was clear why participants believed that skills such as medications administration and knowledge of science-based subjects were essential to practice. There appeared to be three motivating factors for how this group of participants approached their learning. These were:
- Practice relevance
- Patient safety
- Professional protection.
It was clear that the participants wanted knowledge and skills that they perceived would have practice relevance, to allow them to carry out their role on a daily basis.
Patient safety was an important factor for participants, as they did not want to cause harm to patients.
Professional protection was equally important as a motivation to learn, to ensure participants had a deep level of understanding of the clinical skills and knowledge, that they perceived would not allow them to cause patients harm, and so there would be no ramifications in terms of their professional registration. Paying special attention to these particular skills and knowledge would ensure that patients were unharmed, and so their professional registration would not be threatened.
Nurses are often the last point in the prescription and administration process at which a medication error could be averted (Rainboth and DeMasi, 2006). The participants in this study demonstrated an awareness of the importance of correctly administering medications, and revealed that this can cause anxiety about potentially making an error. This reiterates the importance of ensuring that student nurses are adequately prepared for their future role of registrant, in terms of patient safety, costs, and the legal aspects of medicines administration. It was unclear during the semi-structured interviews whether patient safety, potential harm to registration, or cost to the NHS was the main motivation for participants to ensure that they correctly administer medications, but seemed to be a combination of all three factors. It appears that the motivation for students' learning is not academic success, but practice relevance, patient safety and professional protection.
Whether participants took a deep or surface approach to learning was dependent on how useful the subject was perceived to be in a clinical practice situation. The motivation to learn in this study was to practise safely on a day-to-day basis. Student nurses are motivated by the need to feel safe in their practice, without any repercussions or reprimands that could affect their registration.
It was clear that the motivation to take a surface learning approach appeared to be driven by the need to pass assessments, rather than perceptions of usefulness to practice. This reflects existing literature on deep and surface learning (Entwistle, 1991). The present research highlighted that a surface approach was taken for assessments in subjects deemed non-essential for student nurses practice, and in nursing the implications of this approach could be significant.
Gibbs (1994) discussed how a surface learning approach is common in higher education. It is widely known that students are assessment driven and the demands of a pre-registration nursing degree are high, meaning that surface learning often takes place. There is undoubtedly a lack of appreciation for many theoretical components of the pre-registration curriculum by student nurses, due to the lack of acknowledgement of relevance to clinical practice. It appears that the student nurses in this study did not have the breadth of understanding that all components of the curriculum are equally important, even though they may not understand the relevance of some knowledge components when they practise. The surface approach to learning was attributed to meeting module learning requirements, in order to pass academic work.
Although participants said they had a deep level of understanding of medications, it appears that much of this was in terms of undertaking the task itself safely. An important aspect discussed by Dilles et al (2011), in terms of the administration of medications, is the involvement of nurses in the extra activities involved in medication administration. There were advanced aspects of the medications administration process that were not discussed, such as side effect monitoring, providing patients with information about their medications, the use of health promotion, and therapy adherence, all of which appeared to be insignificant for student nurses. This highlights that although student nurses may believe they undertake this task competently, they are not thorough in their approach. This suggests that they are taking a task-oriented, superficial approach to administering medication.
As there was a clear identification of subjects that were deemed essential to practice, this affected the attitudes, motivations and approach to learning of the student nurses. The findings of this research suggest that student nurses take a deep approach to learning theoretical knowledge that they perceive to be of value to themselves in clinical practice. This meant that students paid more attention to these subjects and endeavoured to have a greater knowledge and understanding of them. Yet, although participants demonstrated that they are taking a deeper approach to these subjects, there are still significant gaps in their knowledge and understanding, and as such, this may have significant implications in terms of the practice that they undertake as registrants.
Cowman (1998) and Snelgrove (2004) argued that the student nurse's approach to learning is generally ‘to just get through’. The present research has found that medications administration and the sciences were approached in a deeper fashion, compared to those subjects that are perceived to be less essential. However, for the less essential subjects students do take the approach described by Cowman (1998) and Snelgrove (2004), and in this respect, the findings concur with this previous literature. Snelgrove's (2004) study, which examined approaches to learning, suggested that student nurses demonstrate a deep approach to learning in subjects that would have a direct correlation to academic success. However, a unique finding of the present study was that the students approach learning in a more positive, deeper fashion in subjects which would aid them in clinical practice. Becoming a safe practitioner seemed to far outweigh their potential degree classification for the students in this study. As such, the findings of this research shed new light on the motivations and approaches to student nurses' learning.
Implications for practice
Students' perceptions that some subjects are important and others are not has implications for participants' practice as registrants and potential implications in terms of the care that patients receive. This aligns to work undertaken exploring issues around newly qualified nurses and the potential implications of insufficient preparation for practice (Mohr and Batalden, 2002; Cipriano, 2010; Johnson et al, 2015). This raises more questions relating to whether, as registrants, the participants would ever build on their knowledge to fill the gaps that they have, or whether they will continue as they are. Potential implications could be that as this process continues with registrants becoming mentors and then teaching new students, nursing knowledge and skills may be depleted. This could have serious effects on patient care and the nursing profession for the future.
Although it is clear why students perceive that some skills and knowledge are more important than others, the implications of this will undoubtedly mean that there is a gap between their perception and the reality of nursing in terms of what is needed to practise and why. Although it is well documented and accepted within the literature that higher education students take both a deep and a surface approach to learning, for nursing this can have significant implications on nursing practice and patient care (Entwistle, 1991).
Recommendations for the future would be to highlight to student nurses how all elements of the curriculum are equally important, to ensure that an appreciation for all theoretical subjects develops. It might be useful to highlight the relevance of studying subjects in tandem, such as medication management and the law, or medication management and health promotion rather than viewing them as separate subjects. It is important that HEI staff reflect on this.
Conclusion
This study explored the approaches and motivations of final-year student nurses through understanding the skills and knowledge they value for their practice. It is clear that, for this group of student nurses, the motivations for learning were to ensure that they were able to practise safely. Owing to this, participants took a superficial approach to learning subjects they believed had less practical importance in clinical practice, while those that they believed were directly linked to clinical practice were given priority and studied at a deeper level. This potentially has significant implications for nursing practice and patient care. It is imperative that student nurses understand that all parts of the pre-registration curriculum are relevant to clinical practice. This is necessary to protect the public and to protect the essence of being a nurse.
KEY POINTS
- Student nurses are strategic learners
- Subjects which are perceived as being of low importance are learned in a superficial way
- Students focus their learning on subjects such as clinical skills that they see as being directly linked to clinical practice
- Nurse educators and practice assessors can plan students' learning journey to incorporate theoretical subjects which will aid holistic care
CPD reflective questions
- After reflecting on the findings of this study, how would you reinforce the importance of all aspects of theoretical learning for a student nurse?
- What approaches would you take to ensure a student learns the so-called non-important subjects in a deeper way?
- How would you plan a student's learning journey as their practice assessor or supervisor?