Fostering maturity for senior nursing students:

A pre-graduation clinical placement

Loretta Yuet Foon Chung, Frances Kam Yuet Wong
*
,
Sharon Ching Man Cheung
School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
Accepted 25 July 2007
KEYWORDS
Competence;
Role transition;
Nursing education
Summary
Background: There is considerable literature on graduates role transition to regis-
tered nurse from the employers perspective. Few studies have discussed issues and
strategies related to nursing students preparedness. In response to the Bachelor of
Nursing (Honours) senior nursing students needs in terms of role transition, a pre-
graduation clinical placement (PGCP) was implemented.
Aim: The aim of this paper is to report the learning experiences and outcomes of
the PGCP.
Methods: Both quantitative and qualitative approaches were used. All students
(n = 37) and preceptors (n = 33) involved in the PGCP consented to participate in
summer 2002. The data included: students and preceptors appraisal of pre- and
post-Inventory for Nursing Competencies (INC), students formative and summative
reective journals, and post-PGCP focus group interviews. Paired t-tests were done
to compare students and preceptors pre- and post-INC scores, and thematic anal-
yses were carried out for qualitative data.
Results: There were statistically signicant improvements in students INC. Three
themes learning to work with ward nurses and preceptors, learning total aspects
of care, and acting as RNs were revealed.
Conclusion: The success of the PGCP demonstrates the promising outcome of a long
consolidating clinical block prior to graduation in fostering maturity for role transi-
tion.

c
2007 Elsevier Ltd. All rights reserved.
Introduction
Workplace realities require nurses to be competent
in performing nursing activities. Nursing activities
usually include direct and indirect patient care,
0260-6917/$ - see front matter

c
2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2007.07.003
*
Corresponding author. Tel.: +852 27666419; fax: +852
23649663.
E-mail addresses: hslchung@inet.polyu.edu.hk (L.Y.F.
Chung), hsfwong@inet.polyu.edu.hk (F.K.Y. Wong), hssharon@
inet.polyu.edu.hk (S.C.M. Cheung).
Nurse Education Today (2008) 28, 409418
intl.elsevierhealth.com/journals/nedt
Nurse
Education
Today
shift reports, rounds and case conferences, routine
maintenance of the environment and general man-
agement Lundgren and Segesten (2001). The oper-
ation of these activities is affected by care delivery
models and the clinical environment. These vari-
ables pose challenges to the development of com-
petent graduates.
Background
There is considerable literature discussing issues
related to competency development (Goode and
Williams, 2004). One of the main issues is to pre-
pare the student nurse for a better transition to
being a registered nurse (Bryant and Williams,
2002; Godinez et al., 1999). Issues usually revolve
around the work environment and students pre-
paredness. Various factors such as the nature and
extent of the workload, knowledge of ward rou-
tine, performance expectations, management of
patients with complex health problems, and uncer-
tainty about social integration into nursing have
been commonly cited by students and newly
qualied nurses as areas of incompetence and
requiring support (Evans, 2001; Heslop et al.,
2001). Similarly, Amos (2001) discussed factors
that inuenced role transition, including feelings
of reality shock and unpreparedness, type of pre-
ceptorship practicum (Berry, 2005), the clinical
learning environment (Midgley, 2005), and inter-
personal relationships (Amos, 2001).
New graduate orientation and residency pro-
grammes, externships and internships have been
discussed as possible methods addressing the role
transition issue (Casey et al., 2004; Poster et al.,
2003; Goode and Williams, 2004). Competencies
usually serve as a reference for the development
and evaluation of these programmes. While compe-
tence is essential for nurses, the concept is com-
plex. Its interpretation varies, resulting in the
analysis of many components (Girot, 1993).
Among the existing references, the functional
aspect of the nursing task is heavily emphasized
(Bradshaw, 1998; Zhang et al., 2001). Zhang
et al. (2001) s study identied the personal char-
acteristics contributing to effective nursing perfor-
mance. Nursing competencies can be broadly
categorized into level of knowledge, technical as-
pects of the nursing job, professional aspects of
behaviour, interpersonal skills, personal traits and
motives of the nurse. Among them, personal attri-
butes are identied as the high-order nursing
competence (Zhang et al., 2001). This comment
is supported by Freiburgers (2002) study. The
nurses view of the profession and how one views
oneself will ultimately inuence ones way of
thinking and actions, and consequently the level
of competence.
Competency has been dened in terms of
technical, communicative and administrative skills
(Nelson, 1978) or viewed from the clinical, man-
agement, interpersonal, teaching and administra-
tion perspectives (Buckenham, 1978). In this
study, competency is dened as the demonstra-
tion of behaviour that reects the knowledge,
skills and attributes that staff needs to input into
ones [sic] work for effective performance and
to enhance organizational capabilities for meeting
challenges (Hong Kong Hospital Authority
2001:2). The Bachelor of Nursing (Honours) senior
students verbalized a variety of needs in terms of
role transition in order to tackle variables that
exist and interact in reality. In response, a pre-
graduation clinical placement (PRCP) was estab-
lished with a research component identifying the
outcomes. The following is a brief description of
the PRCP.
The pre-graduation clinical placement
(PRCP)
This batch of students had fullled the required
clinical hours for their registration as registered
nurses (RNs). There was a gap of several months
between their last clinical experience and ex-
pected dates of employment as RNs. Therefore,
a special arrangement known as the pre-gradua-
tion clinical placement was initiated for one
month. The objectives were to consolidate their
clinical skills with the support of a preceptor,
and to familiarize them with their roles as compe-
tent RNs.
The faculty negotiated students choice of ven-
ues, either in the Medical, Surgical, Orthopaedic,
Geriatric or Accident and Emergency Departments
in ve hospitals for one month. The preceptor-
student ratio varied from 1:1 to 1:3, depending
on the numbers of students in the ward and its re-
sources. The adoption of a self-directed learning
approach empowered students to identify and be
accountable for their learning needs. A set of
learning objectives, a check list for consolidation
of psychomotor skills and guidelines for place-
ment were developed in collaboration with stu-
dents and clinical co-ordinators, and were given
to preceptors and nursing managers prior to the
placement.
A monitoring system was put in place, with the
following features:
410 L.Y.F. Chung et al.
Students were required to submit reective
journals and a self-appraisal of the Inventory
for Nursing Competencies before and after the
placement.
Preceptors feedback on students Inventory for
Nursing Competencies was collected before and
after the placement.
Communication channels (e.g. face-to-face,
telephone and web) between clinical co-ordina-
tors, students and preceptors were established
to facilitate dialogues for any issues that arose.
Pre- and post-conferences were carried out for
brieng and de-brieng on the placement.
The PRCP was not only characterized by stu-
dents initiative and self-directed, reective
learning, but also by strong collaboration between
the University and the hospitals. The faculty
liaised with the students, preceptors and nurse
managers of the participating hospitals to ensure
a shared understanding between all parties con-
cerned. Dialogues were established and success-
fully settled issues surrounding the student
preceptor relationship in the early days of the
placement. At the conclusion of the PRCP, a cer-
emony, chaired by the students, was held at the
University to recognize preceptors and ward man-
agers contributions.
The study
Both quantitative and qualitative approaches were
used to understand the learning experiences and
outcomes of the pre-graduation clinical placement
(PRCP).
Objectives
1. To measure students nursing competencies
before and after the PRCP.
2. To measure preceptors appraisal of students
nursing competencies and compare these with
the students scores before and after the PRCP.
3. To understand the learning experiences of stu-
dents participating in the PRCP.
Instruments
The Inventory for Nursing Competencies (INC) with
a Cronbachs alpha of .97 was used to assess stu-
dents learning (Bartlett et al., 1994). This instru-
ment was developed by the author, and has been
used in other studies in Hong Kong. It is a self-com-
pletion instrument consisting of 19 domains of pro-
fessional competence, with a total of 57 items
(Table 1). The subjects were asked to rate how fre-
quently they performed each of the competencies
using a 4-point Likert scale, where 1 = always,
2 = usually, 3 = occasionally, 4 = never. The lower
the score, the more frequent was the listed compe-
tence behaviour.
Data collection
The sample included all students (n = 37) and pre-
ceptors (n = 33) involved in the PRCP who con-
sented to participate. Both quantitative and
qualitative data were collected in summer 2002,
including 37 students appraisals of pre- and post-
INC (pre-data 1 and post-data 2), 33 preceptors
appraisals of students pre- and post-INC (pre-data
3 and post-data 4), 74 students reective journals
submitted in the middle and at the end of the
placement (data 5), and 5 post-PRCP focus group
interviews on PRCP experiences and outcomes
(data 6).
Data analysis
Paired t-tests were done for data 1 and 2, and data
3 and 4, to compare students and preceptors pre-
and post-INC scores, and for data 2 and 4, to com-
pare the score differences between students and
preceptors after the PRCP. Qualitative data was
treated by thematic analysis (Fetterman, 1988;
Leininger, 1985). Transcriptions and reective
journals were read and re-read independently by
three researchers. Labels, codes and themes were
identied and discussed with reference to the
interview data (data 6) and journal entry (data 5)
until a consensus was reached.
Ethical considerations
Ethics approval was obtained from the Ethical
Committee of the University. The potential par-
ticipants were informed of the study aim and
method, and assured that there were no inher-
ent implications of non-participation. Condenti-
ality and anonymity were ensured. The consent
forms were returned by being placed in a desig-
nated box two weeks after completion of the
PRCP.
Fostering maturity for senior nursing students: A pre-graduation clinical placement 411
Results from quantitative data
Thirty-seven students (9 male, 28 female) and 33
preceptors participated; they were practicing in
the AED (5.42%), Geriatric (21.62%), Medical
(43.24%), Orthopaedic (16.21%), and Surgical
(13.51%) departments in ve acute hospitals.
As revealed by the post-INC scores in Table 2, 10
domains of 29 items (50.88%) were rated signi-
cantly higher than the pre-INC scores by students
and preceptors. These were conducting nursing
assessments, evaluating a clients health progress,
formulating care plans, implementing client care,
maintaining verbal and written communication,
fullling legal responsibilities, following ethical
practice, maintaining a quality environment, eval-
uating ones own nursing practice and enhancing
personal skills.
Comparing students and preceptors pre- and
post-INCs, Table 3 shows students mean scores
to be signicantly lower than those of preceptors
in 4 domains of 11 items (19.30%): participating
in multi-disciplinary teams, participating in organi-
zational management, maintaining a quality envi-
ronment and facilitating the development of
nursing knowledge.
Table 4 shows the post-INC that preceptors
rated as signicantly improved. These were 7 do-
mains (24 items, 42.11%): emergency situations,
working within nursing teams, managing subordi-
nates, contributing to the learning of learners and
colleagues, preserving and enhancing the image
of nursing and facilitating the development of nurs-
ing knowledge.
In summary, students competencies were basi-
cally improved during the PRCP, as rated by pre-
ceptors (92.99% signicantly improved and 7.01%
insignicantly improved) and students (50.88% sig-
nicantly improved and 49.12% insignicantly
improved).
Results from qualitative data
Qualitative data enriched the quantitative data.
Three themes were revealed: learning to work with
Table 1 Nursing competencies: constructs and domains used in competence instrument
Constructs Domains Nos. of item
Leadership: the ability to lead
and make decisions
Working within nursing teams 4
Managing subordinates 4
Contributing to the learning of
learners & colleagues
3
Preserving & enhancing the
image of nursing
3
Professional development:
participation in continuing
education and upgrading of
professional standard
Participating in professional
activities
2
Evaluating own nursing practice 2
Enhancing personal skills 2
Assessment: the ability to
observe and diagnose client
needs
Conducting nursing assessment 3
Evaluating clients health
progress
3
Planning: the ability to plan
accurate nursing actions
Formulating care plans 3
Intervention: the ability to
carry out nursing actions
effectively and with
exibility; the ability to
evaluate the nursing actions
accurately and objectively
Implementing client care 4
Maintaining verbal & written
communication
4
Emergency situations 3
Cognitive ability: the ability to
analyze, judge and think
critically
Fullling legal responsibilities 4
Following ethical practice 2
Maintaining a quality
environment
2
Social participation:
participate and show
concern in social affairs
Participating in
multi-disciplinary teams
2
Participating in organizational
management
4
Ego strength: condence and
assertiveness
Facilitating the development of
nursing knowledge
3
412 L.Y.F. Chung et al.
ward nurses and preceptors, learning total aspects
of care, and acting as RNs.
Learning to work with ward nurses
and preceptors
Since no faculty supervision was involved, students
had to be independent in relating to nurses in the
ward. Almost all students appreciated the precep-
tors and ward staffs efforts and willingness in
teaching them. Some of them were particularly
thankful to the ward managers, who planned their
learning schedules with them, and the busy precep-
tors with whom they had discussions. Students re-
ported that they were welcomed and accepted by
the ward staff.
Some students attempted to build relationships
with the nurses by responding promptly to their
needs for assistance, showing initiative and willing-
ness to share their workload, and dining together.
Ward nurses respected us. When we showed initia-
tive, they would assign us tasks, which made it a
lot easier to become part of the staff. At least
Table 2 Improved competencies as perceived by students and preceptors
Constructs: domains Pre-test Post-test t-test
Mean (SD) Mean (SD) t-statistics P value
Assessment: conducting nursing assessments
Students 1.92 (0.40) 1.64 (0.57) 2.69 0.011
*
Preceptors 2.09 (0.50) 1.59 (0.49) 6.24 0.0001
***
Planning: formulating care plans
Students 2.16 (0.51) 1.85 (0.57) 2.86 0.007
*
Preceptors 2.44 (0.81) 1.96 (0.88) 5.72 0.0001
***
Intervention: implementing client care
Students 1.72 (0.39) 1.51 (0.45) 2.17 0.037
*
Preceptors 1.89 (0.40) 1.51 (0.43) 5.88 0.0001
***
Assessment: evaluating clients health progress
Students 1.98 (0.60) 1.65 (0.54) 3.09 0.004
*
Preceptors 2.21 (0.55) 1.60 (0.47) 7.27 0.0001
***
Intervention: maintaining verbal and written communication
Students 1.70 (0.47) 1.48 (0.49) 2.65 0.012
*
Preceptors 2.20 (0.54) 1.54 (0.47) 7.15 0.0001
***
Cognitive ability: fullling legal responsibilities
Students 1.57 (0.54) 1.33 (0.45) 2.24 0.031
*
Preceptors 1.77 (0.39) 1.37 (0.41) 4.98 0.0002
***
Cognitive ability: following ethical practice
Students 1.38 (0.53) 1.19 (0.41) 2.07 0.046
*
Preceptors 1.52 (0.51) 1.29 (0.48) 2.89 0.007
*
Cognitive ability: maintaining a quality environment
Students 1.64 (0.54) 1.36 (0.40) 2.81 0.008
*
Preceptors 2.00 (0.80) 1.64 (0.79) 3.54 0.001
**
Professional development: evaluating own nursing practice
Students 1.84 (0.60) 1.53 (0.50) 2.63 0.013
*
Preceptors 1.97 (0.60) 1.65 (0.55) 3.68 0.001
**
Professional development: enhancing personal skills
Students 1.95 (0.61) 1.55 (0.61) 3.32 0.002
**
Preceptors 2.12 (0.60) 1.73 (0.57) 3.88 0.0002
***
Student, n = 37; preceptor, n = 33; signicance level.
1 = always, 2 = sometimes, 3 = seldom, 4 = never.
*
<.05.
**
<.005.
***
<.001.
Fostering maturity for senior nursing students: A pre-graduation clinical placement 413
Table 3 Comparison of students and preceptors pre-INC and post-INC competencies
Constructs: domains n Pre Post Post vs Pre
Mean (SD) Mean (SD) t-test, P value
Social participation: participating in multi-disciplinary teams
Student 37 2.18 (0.65) 1.93 (0.52) NS
Preceptor 33 2.71 (1.10) 2.42 (0.91) NS
Student vs preceptor t-test, P value 0.015
*
0.006
*
Social participation: participating in organizational management
Student 37 1.95 (0.61) 1.71 (0.52) NS
Preceptor 33 2.42 (1.02) 2.09 (1.06) 0.0002
***
Student vs preceptor t-test, P value 0.024
*
0.024
*
Cognitive ability: maintaining a quality environment
Student 37 1.64 (0.54) 1.36 (0.40) 0.008
*
Preceptor 33 2.00 (0.80) 1.64 (0.79) 0.001
**
Student vs preceptor t-test, P value 0.021
*
0.039
*
Ego strength: facilitating the development of nursing knowledge
Student 37 1.84 (0.63) 1.79 (0.63) NS
Preceptor 33 2.39 (0.64) 2.15 (0.71) 0.022
*
Student vs preceptor t-test, P value 0.001
*
0.006
*
Signicance level: 1 = always, 2 = sometimes, 3 = seldom, 4 = never.
*
<.05.
**
<.005.
***
<.001.
Table 4 Improved competencies rated only by preceptors
Domains Pre Post t-test
Mean (SD) Mean (SD) t-statistics P value
Intervention: emergency situations
3.00 (1.26) 2.28 (1.30) 3.98 0.0002
***
Leadership: working within nursing teams
2.08 (0.54) 1.66 (0.45) 4.49 0.0001
***
Social participation: participating in organizational management
2.42 (1.02) 2.09 (1.06) 3.93 0.0002
***
Leadership: managing subordinates
2.70 (1.08) 2.30 (1.09) 3.09 0.004
**
Ego strength: facilitating the development of nursing knowledge
2.39 (0.64) 2.15 (0.71) 2.41 0.022
*
Leadership: contributing to the learning of learners & colleagues
3.05 (1.13) 2.83 (1.16) 2.57 0.015
*
Leadership: preserving and enhancing the image of nursing
1.90 (0.48) 1.61 (0.47) 3.98 0.0002
***
N = 33; signicance level: 1 = always, 2 = sometimes, 3 = seldom, 4 = never.
*
<.05.
**
<.005.
***
<.001.
414 L.Y.F. Chung et al.
they would call us by our names rather than
merely student or sir.
Two students expressed frustration in their rela-
tionships with their preceptors. However, in one of
these cases, once the student realized that emo-
tions affected her performance and it was impossi-
ble to please everybody, she stayed calm and found
herself able to perform.
Working with ward nurses in patient care not
only required interpersonal skills, but also imagina-
tion and communication skills. One student men-
tioned that through exchanging ideas with some
nurses, I gained a broader understanding of nursing
practice. The majority of the students imagined
they were part of a team to maximize their involve-
ment in patient care. They regarded all care re-
lated to patients as their responsibility. They
reported that they improved in their communica-
tion skills and patient care, and unexpectedly in-
creased their emotional quotient.
Learning total aspects of care
The students were concerned about fullling their
total responsibility of care. This referred to direct
patient care, indirect patient care including admin-
istrative duties, and some ad hoc management for
emergency situations and incidents. While caring
for patients, the students consolidated their estab-
lished skills and acquired new skills in providing
complex care.
Through giving holistic care, I experienced some
managerial work such as discharge and admission,
booking OPD, ward follow-up, chest X-ray, ECG,
etc. These were parts of total patient care.
They expected themselves to be familiarized
with hospital policy, routine ward management,
management of emergencies, the role of in-charge
on the day and night shifts, case management and
team work.
I expected that I would full the objectives in the
placement-specic guidelines. I expected to learn
more about administrative work, e.g. booking
meals, arranging appointments, transportation
and documenting patients records accurately,
clearly and comprehensively. . . so that I could
carry out total patient care.
This placement enabled me to understand the
operation of wards. I was assigned two to three
patients to care for when I joined the team. This
helped me to be more aware of matters that
related to them, e.g. treatment and doctors ward
rounds, blood results, ABG and ECG reports, spec-
imens, etc. Learning how to perform these tasks
was very useful in terms of providing total patient
care, as I had never had the chance to perform
such tasks during previous placements.
Acting as RNs
Students were fully aware that this was their last
placement and took it very seriously by trying to
imitate registered nurses for nursing activities.
They frequently wrote in their journals that they
were gaining a foretaste of being a registered nurse
and were beginning to understand what they should
do. They commented that the placement was a
useful exposure to the RN role.
She taught me every task required of an RN,
including ward rounds, admission, calling doctors,
making appointments, looking after cases, etc.
This time I was able to participate in most activi-
ties. I worked from the start of the shift till the
end, from receiving a report till handing over.
Everything we learnt equipped us better to
become RNs. These tasks enabled me to develop
a deeper understanding of my future role. During
my days on the ward, I realized the importance
of communication between staff members.
Students associated RNs with the sum of nished
tasks, including admission, pre- and post-opera-
tion, education, discharge, and ward routine du-
ties. They felt they were developing the
condence to do these things within a tight sche-
dule. This condence equated to independent
problem-solving ability, courage and discernment
of what was correct to follow. Their concluding re-
marks suggest contentment with this timely fore-
taste and condence in their future role.
I was familiarized with many nursing skills and I
learnt the responsibility of an RN. I think this
timely placement was denitely worthwhile. What
I gained was consolidation of my nursing skills and
a taste of life as an RN. Besides, since there was no
faculty supervision in this placement, there was no
one I could rely on. Thist enabled me to become
independent and adapt to the working environ-
ment by myself. Feeling and acting like an RN
was helpful in this learning process.
Discussion
Both the quantitative and qualitative ndings
showed that students competencies and con-
Fostering maturity for senior nursing students: A pre-graduation clinical placement 415
dence had increased. This result was consistent
with those of other investigations of internships
in increasing new graduate nurses clinical compe-
tence and condence (Blanzola et al., 2004). The
PRCP evidently contributed to the RN role transi-
tion in two aspects: fostering maturity in compe-
tency by timely practice, and providing a forum
for reality-based learning.
Fostering maturity by timely practice
This batch of students were in their graduating
year, and their mean pre-INC scores were more or
less at 2, implying that the graduates had achieved
satisfactory competence levels before joining the
PRCP. These ndings are congruent with studies
of the competence of nal-week graduates (Lof-
mark et al., 2006) and newly-graduated nurses
(Gerrish, 2000). With the PRCP, both the quantita-
tive and qualitative data showed that students
competencies, such as the functional aspects of
nursing tasks that were directly or indirectly per-
formed on patients, and professional aspects of
behaviour and interpersonal skills, had basically
matured. In addition, some students experienced
personal growth while overcoming difculties in
interpersonal relationships.
Despite the students feeling they were mature
enough for a new role, and preceptors favourable
ratings, some signicant differences were found
between students and preceptors pre-INC and
post-INC ratings in 4 domains (21.05%). This is con-
sistent with other ndings that experienced nurses
estimated newly-graduated nurses competence to
be less (Lofmark et al., 2006), and students overes-
timated their competence (Mattheos et al., 2004;
Lee-Hsieh et al., 2003). In this study, the discrep-
ancies between students and preceptors were in
those competencies required for participating in a
multi-disciplinary team, as well as organizational
management, maintenance of a quality environ-
ment and strength of ego. Students rated these
competencies lower than preceptors, showing that
students perceived that they demonstrated these
behaviours more often than the preceptors did.
The possible reasons might be students performed
them in the absence of preceptors, students
over-rating or preceptors under-rating of compe-
tencies as demonstrated in previous studies, stu-
dents and preceptors using different benchmarks,
or different expectations of these competencies.
Students generally appraised the PRCP as timely
in enabling them to consolidate their skills and
familiarize themselves with the work of an RN, as
it occurred just before their expected dates of RN
employment. It was described as timely not
only because it was the right time for practice for
transition, but because the need was recognized
by students rather than imposed by the faculty,
thus increasing the effect of time to maturity. In
addition, it provided a continuous period of attach-
ment facilitating supported participation.
Providing reality-based learning
Providing a forum for reality-based learning, to-
gether with its timely practice, fosters students
maturity to become RNs. It is postulated that the
signicant and insignicant improvements in com-
petencies might be related to either learning dur-
ing or outside practice. For instance, both
students and preceptors scored as insignicantly
improving competencies related to participating
in multi-disciplinary teams and professional activi-
ties. The reasons might be related to the reality
and practice of the venues, which limited students
learning. For example: medical and surgical wards
(56.75%) might not adopt a multidisciplinary ap-
proach to patient care. There were no particular
nursing issues that arose during the PRCP, lessening
students chances to act for the collective interest
of the profession.
In this study, practice led to learning, which was
reality-based. The reality referred to the context
in which the RN practised nursing work. Students
acted on their need to gain more experience and
get a taste of what it was like to be an RN. Their
learning objective was similar to nurse externs
intention to know what it was like to be an RN
(Starr and Conley, 2006). However, the students
in this study took a further step by imagining they
were RNs working in teams and taking total respon-
sibility for patients care. Students deliberately im-
mersed themselves in the role and the working
culture, learning about nursing from the inside
(Rush et al., 2004). This mentality enabled them
to volunteer time and effort to develop relation-
ships with preceptors and ward nurses.
Acting as if they were RNs made the students
feel the patients were really their patients. By
witnessing RNs responsibilities in caring for
patients personal, environmental and service
needs (Lundgren and Segesten, 2001), they read-
ily shouldered total caring responsibility, and at
the same time realized their lack of preparedness.
However, this realization motivated them to prac-
tise more and resulted in increased competence
and condence to care.
416 L.Y.F. Chung et al.
It is argued that the transition to the RN role
started subtly in this way, with students aiming to
taste what it was like to be an RN, and was facili-
tated by their actions stemming from acting as if
I was an RN. Through initiation, reection and
practice in this reality, students competencies
matured.
Study limitation
A small convenience sample was used in the study.
This sample, all students and preceptors involved
in the PRCP, was considered appropriate for the
purpose of gaining insight into students experi-
ence of the PRCP. It is anticipated that more nd-
ings will result from the evaluation of subsequent
PRCPs.
Implications
In this study, students request for assistance with
RN role transition directed their learning and en-
abled them to overcome their limitations and
placement constraints. Clinical learning required
reality-based practice with a reective and insi-
der nature. As university students are usually ex-
posed to frequent readjustment to different
clinical settings, they often report feelings of being
an outsider and role discrepancy (Yung, 1996).
Acting as if one is an RN within a realistic and
participative experience should be promoted
strategically.
The literature reports different methods of
improving participation (Rush et al., 2004; Chap-
man, 2006; Starr and Conley, 2006; Moriarty,
2006; Dornan et al., 2007). For example: Dornan
et al. (2007) recommend a dynamic commodity
that resides within communities of practice for
absorbing into a professional identity to learn.
Likewise, Moriarty (2006) reports using an action
learning approach to develop a practice learning
team to improve the placement experience for
nursing students and practice mentors.
In summary, acting as if one were an RN must
be conducted in a format suitable for participa-
tion by students, preceptors, and faculty. The
PRCP is an example showing how the concerted
efforts of students, preceptors and faculty con-
tributed to reality-based learning in a continuous
period of attachment. After the success of the
PRCP, a long clinical block for consolidation prior
to graduation was developed and implemented in
the University and became a requirement of nurs-
ing registration.
Conclusion
Clinical education is essential in preparing students
for safe and competent nursing practice, requiring
the right conditions for fostering role transition.
This study explored the experience and outcomes
of a pre-graduation clinical placement. In addition
to enhancement of the competences, students
reported that acting as if they were RNs provided
a condition for reality-based learning and insider
practice, thereby increasing their condence.
It is recommended that graduating students be
provided with the opportunity to undertake a con-
tinuous period of attachment for a supportive,
reality-based, insider practice to ease the transi-
tion to the role of RN.
Acknowledgements
The authors wish to acknowledge the School of
Nursing, The Hong Kong Polytechnic University,
for granting a Learning and Teaching Project Fund
(code Z05M) to support this study, as well as the
students and preceptors who volunteered to partic-
ipate in this study.
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