Examining perspectives of instructors and students on the instruction of care plans within the nursing process – a qualitative inquiry

Sub-theme 1.1: challenges experienced in practice

Instructors highlighted challenges associated with clinical practice, emphasizing the significant strain of managing large student groups across diverse clinical settings. The demand becomes particularly pronounced when guiding new mentors, adding an extra workload layer.

We operate within clinical settings with notably large student cohorts across diverse clinics. As instructors, our rotations can entail up to 30 students. Considering the two rotations, we oversee approximately 60 students in a single semester. (9 years of experience-INS)

When orienting new mentors, we face additional responsibilities. To avoid compromising the clinical learning experiences of students, we must also monitor those under the guidance of new mentors. (Eight years of experience-INS)

Students perceived instructors as constrained by the large student-to-instructor ratio during clinical practice. They expressed a need for support from nurses to navigate clinical work and effectively prepare care plans.

Clinic nurses do not consistently offer support, hindering our ability to acclimate to the clinical setting and gather sufficient patient information. Consequently, our ability to prepare care plans is compromised. (Second grade-NS)

Ideally, we would prefer more direct guidance from our instructors, but regrettably, the sheer number of students makes continuous supervision impractical. Following our arrival at the clinic, we are at the discretion of the nurses, absorbing whatever knowledge they impart. (Fourth grade-NS)

Both instructors and students acknowledged that the duration of clinical practice was insufficient to achieve the objectives of clinical teaching.

Our exposure to the clinic spans merely 11 or 12 days in a single semester. Given the rotation structure, the maximum duration of interaction with a student group is limited to 6 days. Six days for acclimating students to the clinical environment is insufficient for imparting the skills required to formulate patient care plans. (Nine years of experience-INS)

With our weekly clinic visits and the constrained time within the hospital, our ability to follow up on the patients for whom we have prepared care plans is compromised. Establishing communication with the patient or ascertaining their needs becomes challenging. (Fourth grade-NS)

Sub-theme 1.2: student-instructor interaction in practice

Instructors asserted their constant accessibility during clinical practice, emphasizing open and facile communication with students.

We are consistently present during practice, actively engaged in data collection, problem identification, and translating care plans into written form. Accessibility is a priority during practice hours, with students accessing my contact details, including phone number and e-mail address. (Ten years of experience-INS)

Students indicated that positive student-instructor communication positively impacted their learning experiences. Contrary to the instructors’ view, students perceived inconsistent accessibility among instructors during clinical practice.

Accessibility varies among teachers and mentors. The reality is this: I can reach some teachers, but the effort is not reciprocated. There are instances where I inquire about a care plan I’ve prepared, and my instructor declines to address the question, citing potential effects on my evaluation. If my teacher doesn’t provide the needed clarification, where do I turn for guidance on a crucial aspect that could influence my evaluation? (Fourth grade-NS)

Sub-theme 2.1: care plan preparation resources

Instructors preferred students to prepare care plans for an average of two patients during clinical practice. Students received multifaceted support from instructors, books, clinic nurses, and their own past care plans and peer interactions, often supplemented by online resources.

Students draw support from diverse outlets during care plan preparation, including peer interactions, our instructional discussions, Internet resources, books, and guidance from clinic nurses. (Twelve years of experience-INS)

Students revealed variations in the number of care plans assigned based on the clinical setting. They emphasized that an excessive number of care plans negatively impacted course success. Students utilized various resources such as books, prior care plans, institution-provided care plans, and online sources, with the Internet being the predominant choice.

The quantity of care plans required varies depending on the clinic. I prepared care plans for five patients in the first rotation this year. Managing weekly submissions proved challenging, leading to incomplete assignments. Some peers opted to prepare only one plan, allocating more time to exam preparation. Unfortunately, I had to divert exam preparation time to care plans, impacting my overall exam readiness. If restricted to one care plan, I could have dedicated more time to exam study. (Second grade-NS)

I observe my patient for two or three weeks when crafting my care plan. I draw insights from the ready-made care plans utilized by hospital nurses, consult the NANDA nursing diagnoses book for precise expression of diagnoses, and reference care plans from previous years. Articles containing patient reviews detail nursing interventions and care plans, providing valuable insights for my assignments. (Fourth grade-NS)

Sub-theme 2.2: difficulties in implementing the nursing process

Instructors identified challenges encountered by students at various stages of the nursing process when formulating patient care plans. Notably, students struggled with posing practical questions during data collection, encountered problem identification difficulties, hesitated in taking the initiative, and faced challenges in making assessments.

They encounter challenges due to a lack of proficiency in formulating questions during data collection. We observe significant difficulties, especially in problem identification. There is also a deficiency in initiative and assessment skills. (Ten years of experience-INS)

Students encounter challenges in completing paper-based data collection forms within the clinical setting, perceiving the preparation of care plans as burdensome. Consequently, care plans are submitted as less meticulous assignments. (Eight years of experience-INS)

Students acknowledged difficulties across all stages of the nursing process, with a particular emphasis on challenges during the planning phase of care plan development.

We encounter challenges in prioritizing care plans, especially when diagnoses closely resemble each other. (Fourth grade NS)

While making a diagnosis isn’t overly challenging for me, I struggle to elaborate on the planning section afterward. I constantly attempt to add content, as I feel something is missing. (Second grade-NS)

Sub-theme 2.3: preferences for delivery of care plans

Instructors exhibited varied preferences regarding the submission of care plans. One instructor emphasized the importance of handwritten submissions for freshman and sophomore students, believing it enhances learning. Another instructor allowed flexibility, permitting both online and in-person submissions, with a preference for computer-prepared sections to improve readability.

I attend the practices of freshman and sophomore students, advising them to handwrite their care plans for better learning. The submissions are received in person on the predetermined date. (Ten years of experience-INS)

Submission methods include both online and in-person options. However, handwritten submissions can pose readability challenges. Hence, I encourage computer preparation before in-person delivery, especially for diagnosis and intervention sections. (Eight years of experience-INS)

Students expressed the flexibility to submit care plans either in person or online. However, most advocated for computer-based preparation due to its ease and reduced stress. They emphasized the convenience of preparing the plan on a computer, printing it, and then delivering it by hand, citing issues with online submission systems and legibility concerns with handwritten submissions.

Having experienced handwritten in-person and online submissions, I find that preparing a care plan on a computer, printing it, and delivering it in person is the easiest and least stressful method. One care plan I submitted online encountered delivery issues due to system problems. Another care plan, submitted in person in handwritten form, couldn’t be graded due to illegibility. Hence, I believe computer preparation followed by in-person delivery is optimal. (Fourth grade-NS)

Sub-theme 2.4.: feedback methods and perceived limitations

Instructors were committed to providing individualized feedback for care plans but acknowledged challenges due to the large student cohorts. Collective feedback, often conveyed through case modeling or addressing common errors, was identified as the prevailing method. Instructors disclosed the utilization of distinct assessment tools for each lesson in clinical practice, emphasizing a fair evaluation system.

As the supervisor for a considerable number of students in clinical practice, the opportunity for individual feedback is limited. Hence, feedback is typically delivered collectively. (Twelve years of experience-INS)

We employ a clinical evaluation guide, allotting 100 points. The initial 50 points stem from our assessment of care plans based on the nursing process approach. The remaining 50 points evaluate the student’s demeanor and conduct within the clinical setting. (Nine years of experience-INS)

Students noted receiving limited verbal or written feedback on their care plan submissions. The perceived inadequacy of feedback was deemed detrimental to their learning process, with concerns about perceived unfair grading practices impacting motivation.

The feedback is restricted, leaving us unaware of our mistakes and points deduction. Knowledge of these aspects would enable improvement efforts, but absent specific feedback leads to repetitive errors. (Fourth grade-NS)

Despite investing significant effort in care plan preparation, instances arise where individuals who exhibit less diligence receive higher grades. This perceived lack of fairness diminishes the value of care plans, leading to a perception that they are merely obligatory tasks for academic success rather than valuable learning experiences. (Fourth grade-NS)

Sub-theme 3.1: increasing clinical readiness

Instructors highlighted the need for an improved student-to-instructor ratio to enhance the effectiveness of clinical theory and practice. They also recommended incorporating more case studies and utilizing concept maps to reinforce the practical application of care plans.

Enhancing students’ readiness for the clinic can be achieved through the implementation of additional case studies. (Twelve years of experience-INS)

The creation of disease-specific concept maps, particularly in surgical, internal medicine, and pediatric areas, could prove beneficial. (Eight years of experience-INS)

Students expressed a desire for more comprehensive information about clinic procedures, patients’ medical diagnoses, and the opportunity to engage in case studies to enhance their preparation for care plan development.

Before commencing practice, obtaining knowledge about the clinic, diseases, treatments, interventions, and diagnoses is crucial. Current practices often delay understanding diagnoses and interventions, hindering our interaction with patients. (Second grade-NS)

Preparing a care plan with sample patient data assisted by our instructor before practical sessions could significantly enhance our ability to create detailed care plans for real patients in the clinic. (Third grade-NS)

Sub-theme 3.2: demand for technology use in teaching

Instructors underscored the potential benefits of leveraging mobile/web-based technologies to enhance the clinical teaching aspect of the nursing process. They proposed developing a comprehensive system resembling the hospital information management system, allowing close interaction between instructors and students. The envisioned system would encompass all stages of the nursing process, facilitating effective monitoring and assessment while contributing to environmental sustainability by reducing paper usage.

I advocate for the electronic preparation of care plans, aligning with hospital practices. The current reliance on paper-based care plans hampers our chronological tracking of students’ experiences. A clinical practice software could enable students to record daily interventions and patient assessments, enhancing our ability to monitor and assess them closely. (Seven years of experience-INS)

A system or software designed to guide student decision-making, prompt critical thinking, and facilitate instructor-student interactions would be beneficial. Such a system would allow me to review the data entered by students, including diagnoses. (Ten years of experience-INS)

Transitioning to electronic media not only addresses paper waste concerns but also enhances the legibility and accessibility of care plans during evaluation. (Eight years of experience-INS)

Students expressed a positive outlook on the potential utilization of mobile/web-based technologies, envisioning enhanced patient data recording and increased interaction with instructors. Embracing digital solutions was seen as a means to streamline care plan preparation, manage time more efficiently, and receive timely feedback for continuous improvement.

I firmly believe that care plans should evolve beyond paper forms. An app could encompass digital versions of all paper forms used for patient data collection, thereby revolutionizing care plan preparation. (Third grade-NS)

A software or system facilitating interaction with instructors and enabling online feedback on care plans would be invaluable. Accessing our instructors’ assessments and feedback online would contribute to more effective preparation of subsequent care plans. (Second grade-NS)

The use of electronic media could expedite care plan creation, allowing us to allocate more time to our academic pursuits. (Third grade-NS)