student nurse management essay

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• v.32(2); 2020 Jun

Strategies for sustaining and enhancing nursing students’ engagement in academic and clinical settings: a narrative review

Mohammad reza ghasemi.

1 Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Iran

Hossein Karimi Moonaghi

2 Department of Medical Education, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Abbas Heydari

Students’ engagement in academic-related learning activities is one of the important determinants of students’ success. Identifying the best teaching strategies to sustain and promote nursing students’ engagement in academic and clinical settings has always been a challenge for nurse educators. Hence, it is essential to provide a set of strategies for maintaining and enhancing the academic engagement of nursing students. The purpose of this review was to explore and summarize the strategies that nurse educators use to sustain and promote nursing students’ engagement in academic and clinical settings. A narrative literature review was conducted. CINAHL (nursing content), ProQuest, Medline, the Cochrane, Google Scholar, and Scopus were searched. Of 1,185 retrieved articles, 32 teaching strategies were identified and extracted from the nursing literature. We used thematic analysis approach to organize these strategies into five main categories as follows: technology-based strategies (15 articles), collaborative strategies (10 articles), simulation-based strategies (two articles), research-based strategies (two articles), and miscellanea learning strategies (three articles). As a general comment, these strategies have the potential to promote nursing students’ engagement. Among the strategies discussed in this review, the use of technology, particularly the response system and online learning, was more common among nursing educators, which is in line with today’s advances in smart technologies. The collection presented in this review can be used as a starting point for future research to evaluate the effectiveness of an educational intervention on the academic engagement of nursing students. Nevertheless, due to the lack of experimental studies, the optimal strategies remain to be elucidated through future high-quality experimental study.

Introduction

One of the essential requirements of healthcare systems to meet the broad needs of patients is the employment of well-qualified nurses [ 1 ]. In this respect, one of the important responsibilities of nursing education systems is providing high-quality education to nursing students and preparing competent nurses so that they can provide patients with safe and high-quality care in the future [ 2 - 4 ]. As a step toward that end, nursing educators need to use new educational strategies to actively engage nursing students in learning activities in academic and clinical settings [ 5 , 6 ]. Previous studies have shown that increasing academic engagement of students could increase their desirable academic performance and success [ 7 ]. Recent evidence indicates that engagement in academic-related learning activities is one of the important determinants of students’ success in university [ 8 - 10 ]. As a result, identifying the best teaching strategies to sustain and promote nursing students’ engagement in academic and clinical settings has always been a challenge for nursing educators. Hence, it is essential to provide a set of strategies for maintaining and enhancing the academic engagement of nursing students.

In educational literature, the concepts of academic engagement, student engagement (SE), educational engagement, student involvement, and school engagement have often been used interchangeably [ 11 ]. In this study, the term ‘SE’ was used. The concept of SE has been extensively studied in educational literature as an important determinant of quality in academic education. Several definitions of this concept have been proposed; however, one of the most widespread definitions of SE is provided by the prolific author, Kuh [ 12 ]. Kuh [ 12 ] defined SE as “the time and effort students devote to activities that are empirically linked to desired outcomes of college and what institutions do to induce students to participate in these activities.” However, several authors argue that this concept is more than student involvement in school-related activities. It is rather a multidimensional concept, whose dimensions include behavioral, emotional, cognitive, and motivational [ 11 , 13 , 14 ]. SE, also, refers to the quality of the effort that learners spend on the targeted educational activities such as attending classrooms, studying, doing practical work, and engaging with professors or other students to reach the desired outcomes [ 15 ]. In the most recent definition of SE proposed by Kahu [ 13 ], the amount of time students spend on learning-related activities is considered as one of the main components of SE. In clinical disciplines such as nursing, many educational activities are accomplished in clinical settings. Hence, it is expected that the concept of SE in nursing education includes at least two concepts of “academic engagement” and “clinical engagement [ 16 ].” However, a search of the literature revealed small number of studies regarding clinical engagement, and this concept has recently become an important issue in nursing students’ education. In addition, most nursing researchers have not provided a unique definition for the concept of SE [ 11 , 16 ]. Recently, Bernard [ 14 ] using concept analysis, theoretically defined SE as “a dynamic process marked by a positive behavioral, cognitive, and affective state exhibited in the pursuit of deep learning.” This definition included the previously discussed dimensions and focused on deep learning; however, this definition lacks practical and measurable characteristics of SE, particularly time spent to engage with educational activities. Given the lack of an operational definition of SE in nursing education, based on the literature, we used the following working definition for conducting the current review. SE is “the investment of time, effort, and other relevant resources by both students and their institutions intended to optimize the student experience and enhance the learning outcomes and development of students, and the performance and reputation of the institution [ 11 ].”

In the last decade, many nurse researchers have investigated various educational strategies to explore and develop the best ways to increase nursing students’ academic engagement. The result of these efforts has led to the creation of new teaching strategies or modification of the techniques used by other disciplines. However, the lack of a study that reviews these strategies and techniques as a collection is felt. Previously, Crookes et al. [ 17 ] explored the strategies and techniques that nurse educators have employed to help nursing students to contextualize theory learned in the classroom to their practice. However, most of those techniques borrowed from other disciplines. Therefore, the ultimate purpose of this review was to explore and summarize the strategies that nursing educators use to sustain and promote nursing students’ engagement so that we can provide a set of these educational strategies to nursing educators and researchers. This review has been carried out as part of a nursing doctorate dissertation attempting to assess the lived experiences of nursing students on academic engagement activities.

The following question was used to guide this non-systematic narrative literature review: What strategies or techniques have nursing educators used to sustain and promote nursing students’ academic or clinical engagement? To answer this question, we reviewed the literature to identify the most significant studies and theoretical foundations regarding the academic and clinical engagement strategies used by nursing educators.

1. Sources of information and search strategy

The following databases were searched for peer-reviewed scholarly articles: CINAHL (nursing content), ProQuest, Medline, the Cochrane, Google Scholar, and Scopus. Two authors (G.M.R. and K.M.H.) with the assistance of one librarian searched the databases using predefined search strategies. They individually screened the titles and abstracts of retrieved studies against the inclusion criteria for choosing relevant articles. We used several combinations of the following search terms ‘engagement, nurse, student’ and their related concepts by using the Boolean operator, “AND”, to obtain any link between them. The scope of the search was limited to English-language written international articles and publication dates were limited from January 2000 to June 2019. To find additional articles, we manually examined the reference sections of the retrieved studies and relevant review.

2. Selection criteria

To keep the focus directly on nursing students, the inclusion criteria for selecting articles were as follows: The sample should be nursing students and the used strategies must be done by nursing educators. As well, we included original articles, reviews, innovative papers, discussion papers, learning projects, and theoretical frameworks. We excluded the dissertations and articles related to the other professions. Duplicate articles were also excluded. Given that we intended to provide a comprehensive set of educational strategies for sustaining and promoting nursing students’ engagement, we did not appraise the quality of included studies and did not remove any studies due to the low quality.

Of 1,185 retrieved articles, 32 articles have met the selection criteria. Fig. 1 shows the process of study selection for inclusion in review.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Nursing researchers have explored and applied several strategies/techniques for sustaining and promoting nursing students’ engagement. Given the heterogeneity of the educational methods, we used a thematic analysis approach to collate, summarize, and map the literature to identify themes across the retrieved studies based on the similarities of concepts and teaching techniques that educators had used. The second author reviewed each paper and data was coded to describe the main teaching methods. Similar codes were grouped together into categories to organize the main teaching strategies/techniques. New categories were developed or modified as analysis continued. At the end of analysis, we organized these strategies into five main categories as follows: technology-based strategies (15 articles), collaborative strategies (10 articles), active learning strategies (three articles), simulation-based strategies (two articles), and research-based strategies (two articles). It should be noted that there are some similarities between and within categories. Table 1 summarizes the students’ engagement strategies. Regarding the methodology of retrieved studies, five were innovative, 10 were discussion paper, six were quasi- experimental, five were descriptive, and six were qualitative studies.

Summary of Students’ Engagement Strategies

1. Technology-based strategies

There is growing evidence that shows the value of technology for engaging students in academic learning activities [ 18 ]. We found 15 articles discussing the importance of using online and offline technologies in promoting nursing students’ engagement.

1) Online technologies

a. Kahoot in the classroom: Kahoot is a free web-based technology that incorporates a quizzing program to increase the participation of learners during the lecture. As well, it can be used as a mean for formative assessment of students. It is believed that the learners’ attention is reduced in the first minutes after the beginning of the lecture and educators need to alter the situation and engage the learners to regain their attention [ 19 ]. The underlying assumption of Kahoot method is that an interesting program could increase students’ participation during the lecture. Barnes [ 20 ] introduced this technique as an innovative tool for nurse educators for engaging students during the lecture. However, the effectiveness of Kahoot to increase the engagement of nurse students is under research and currently, there is no experimental research that examined the effectiveness of this method.

b. Online teaching techniques: Along with advances in technology and the Internet, many traditional teaching methods have been transformed into interactive web-based educational methods [ 21 ]. In recent years, web-based courses provide many opportunities for actively engaging nursing students in learning activities [ 22 - 24 ]. Nursing education experts believe that online forum courses can bridge the gap between theory and practice in nursing discipline as well as it can facilitate the process of nursing students’ engagement [ 17 ].

c. Asynchronous discussion boards: These boards enable multiple learners to engage in discussion with each other. All discussions of the learners are collected on a board and the members contribute their comments by responding to the initial discussion question or by responding to each other. It is believed that asynchronous discussion boards, by use of the Web and other Internet technologies, encourage deeper learning and help students to be more engaged in learning activities related to analysis, synthesis, decision-making, and the use of knowledge [ 25 ]. In nursing education, Dickson [ 26 ], proposed the basic structure of asynchronous discussion boards for enhancing the engagement of nurse students. The foundation of the technology is that educators can enhance students’ engagement by posting a series of questions on the discussion board and then encourage those students to reflect and respond actively to those questions. At present, no experimental research has evaluated the effectiveness of this technology in terms of SE.

d. Posting videos on YouTube: Johnston et al. [ 27 ] incorporated a collection of YouTube videos into the bioscience course to support nursing students’ engagement. The total number of views, comments, and subscriptions from students were collected directly from the Biological Sciences YouTube channel over four semesters. The videos are highly successful; with more than 300,000 views, 1.5 million minutes of viewing and more than 5,000 international subscribers during the study. More than 90% agreed that watching videos increased their engagement time in learning. Authors concluded that posting educational videos on YouTube can significantly engage students in learning activities and enrich the student experience and performance [ 27 ].

e. Virtual Community: Giddens et al. [ 28 ] designed and implemented an intervention called “the neighborhood virtual community (VC)” to assist first-semester baccalaureate nursing students (n=350 participants) in learning complex, health-related content. They described VC as an online teaching application presenting an imaginary community with multiple interconnecting character stories. VC included households’ and health care nurses’ characters. Students should follow the character stories each week during the semester by logging on to the Website. Using a two-group quasi-experimental study, they found that engagement in learning activities were significantly higher in the experimental group than those of the control group (analysis of variance, F=2.40, p<0.05). In addition, a significantly positive relationship (r=0.416, p<0.001) between the frequency of VC use and perceived benefits among students was found [ 29 ]. In another study, using VC in nursing education leading to the improvement of students learning through emotional connectedness to families and engagement of characters into learning activities [ 30 ].

2) Offline technologies

a. Response systems (clickers): Response systems are a set of software and hardware that educators have used to attract learners’ attention and increase their engagement during the class lecture. By asking questions in the classroom, the educator encourages the students to respond to these questions through a technology-based response pad called “clickers”. Using this system, students can get instant feedback from the educator regarding the asked questions. In this way, clickers actively engage students during the lecture. Recently, several nursing schools across the world used this technology [ 31 - 34 ]. Filer [ 35 ] in a pilot quasi-experimental study with 90 nursing students assessed the impact of an audience response system (clickers) on students’ engagement and participation in the classroom. The control group responded verbally, while the intervention group responded anonymously using the clickers to questions posed during the lecture. The author found that students in the intervention group reported a greater level of motivation (p<0.001); were more comfortable in the classroom (p=0.00); and expressed a higher level of participation (p<0.001) than students in the control group. In addition, almost all students indicated the clickers were easy to use and they would like to use it in future classes [ 35 ]. In another quasi-experimental study, Revell and McCurry [ 36 ] compared the effectiveness of a personal response system with didactic presentations. These interventions were incorporated within two undergraduate courses, nursing research (n=33) and junior medical-surgical nursing (n=116). The efficacy of each intervention was evaluated by multiple-choice, true-false, and quiz questions. Authors found that using a personal response system could significantly increase faculty-student participation and enhance active learning (p<0.001) compared with the lecture [ 36 ]. In a study with 47 first-year nursing students, Fifer [ 33 ] evaluated the perceptions of first-year nursing students regarding the use of student response system technology. A 14-item Likert scale survey was used to collect students’ perceptions. More than 80% of the student had a positive perception regarding the strengths of this technology for increasing SE. Many students expressed that this method maintained their focus during the lecture [ 33 ]. Berry [ 32 ] incorporated clickers to enhance student interaction and learning in a didactic pediatric nursing course. Exam grades and level of participation were monitored and exam scores and final scores were compared between two groups of ‘with clickers’ (n=65) and ‘without clickers’ (n=61). Student t-tests demonstrated that one of the three-course exams and final course grades were significantly higher for the students who used clickers (mean±standard deviation, 93.33±1.99 versus 95.03±1.64; p<0.001). Satisfaction feedback also supported the use of clickers as a tool to engage students and enhance learning outcomes [ 32 ].

b. Barcode scanning: Quick response (QR) code is a specific two-dimensional code that are used to encode and decode information such as text, Uniform Resource Locator links, Short Message Service messages with a mobile device that is equipped with a camera and QR reader software. QR codes can be integrated with learning activities such as linking a specific topic to information on the Internet, reviewing information, or evaluating classroom assignments. As an interactive technology-based approach, many health care systems incorporate barcode scanning or QR codes into nursing students’ clinical rotations to ensure patient safety. In addition, many educators incorporate this approach into the classroom activities to enhance students’ engagement. In this regard, Aul and Johnston [ 37 ] explored the experiences of undergraduate nursing students during the oncology course. The authors created barcodes consisted of one review question using a web-based, QR code generator tool. The authors printed the barcodes on an index card and then the cards were strategically taped throughout the classroom and the hallways outside of the classroom. Sixty-seven students were instructed to circulate around the room to scan the codes with their smartphones to find a range of oncology review questions. Afterward, the students should present and discuss the answer to the scanned questions. The authors found that barcode scanning is an attractive method for increasing SE and performance of nursing students. At present, the efficacy of barcode scanning to increase the engagement of nurse students is under research and currently, there is no experimental research that examined the effectiveness of this method.

2. Collaborative strategies

Collaborative learning is defined as a set of instructional methods to encourage students to work together to achieve a common learning goal. It involves mutual intellectual works by students themselves or students and educators. In this approach, students themselves are responsible for group governance and education output [ 38 ]. We found 10 articles discussing the importance of using collaborative strategies in promoting nursing students’ engagement.

1) Team-based strategies

a. Team-based learning: Team-based learning (TBL) is a shared learning and teaching approach, which is frequently used by health sciences educators in their preclinical and clinical programs to foster self-directed learning [ 39 ]. In nursing education, Dearnley et al. [ 40 ] reviewed the outcomes of TBL in nursing education programs to explore the experiences of nursing students regarding the TBL. They discussed that there is a great body of evidence, which supports TBL, as collaborative teaching and learning strategy, for sustaining and enhancing students’ engagement [ 40 ]. In an exploratory, descriptive study, Oldland et al. [ 41 ] explored the perceptions of nursing students regarding the role of TBL in shaping their professional clinical behaviors. Authors found that TBL can maximize students’ participation in the learning activities, develop active and deep learning, and raise teamwork performance, which in turn can enhance the students’ engagement in both academic and clinical settings [ 41 ].

b. Interdisciplinary partnership: Many schools across the world have been implementing partnership projects between students and the school’s staff in order to increase students’ engagement in academic learning activities. Bramble et al. [ 42 ] implemented a participatory action research to develop a “3-month mentorship partnership intervention” between nursing students and a group of academics as a mentor. They found that interdisciplinary partnership could increase students’ academic engagement and success; however, the acquisition of mutual trust and security were the main issues for developing mentorship capacity [ 42 ].

c. Collaborative testing: Quizzing has become a popular method of assessing learning and retention of knowledge as well as a mean of engaging students. In collaborative testing, students work together in small groups to complete quizzes before they select their final answer. Therefore, an important aspect of collaborative testing is the peer interaction, education, and collaboration during discussing each question. In nursing, Burgess and Medina-Smuck [ 43 ] used a collaborative testing approach using quizzes during maternal-infant course in the undergraduate nursing program. During this course, four multiple-choice quizzes were electronically administered. The outcomes were perception and attitude of students regarding collaborative testing strategy. Seventy-eight percent of students described this method as helpful and enjoyable in supporting their learning of the course material. Authors concluded that this strategy provided a structured method to enhance students learning and retention of course contents [ 43 ]. At present, no experimental research has evaluated the effectiveness of this technology in terms of SE.

d. Faculty-student interaction: D’Souza et al. [ 44 ] highlighted and summarized the important roles of nursing educators to promote nursing students’ engagement in the clinical environment. The suggested that to increase students’ academic engagement, nursing educators should: (1) involve students in teaching strategies, (2) balance student’s clinical activities with clinical assignments, (3) provide wide range of clinical activities, (4) appreciate the individual difference, (5) provide them with multidimensional resources, (6) group students for reflective activities, (7) create an atmosphere to enable students to learn, and (8) continuously supervise their activities. Authors found that when students and faculty actively share learning opportunities with each other, students are motivated to be more engaged in the new clinical learning environment.

e. Crossword puzzles solving: Raines [ 45 ] incorporated two models of crossword puzzles, as a cooperative learning activity, into nursing courses to promote students’ engagement and their critical thinking. Students worked in two phases of individually and in a small group. In the first model, which was designed for simple courses, students should solve the clues and in the second one, they should construct the content for the crossword puzzle (advanced courses). This process forces the students to actively engage and share their thinking and reasoning process with each other. The author found that these methods can actively engage students, promote their decision-making process, and help them to solve the problems [ 45 ].

2) Service-based strategies

Service-based learning involves learning that takes place outside the classroom in a structured way between the learner and a service, and seeks to achieve common goals. It is a kind of partnership that bridges academic and community needs. This type of learning is mostly done in the community, but it can also be used in clinical settings [ 46 ]. It is believed that service-based learning is one of the most effective strategies for students’ engagement because it has the potential to positively engage learners into the real-life situations and encourage the learner to be an active learner [ 46 , 47 ]. In this regard, Hart [ 46 ] provided a three-step framework, called “ABCs of service-learning,” that indicated the process of establishing and evaluating a service–learning project. The main components of this project are taken from the nursing process. In this project, A stands for “assessment and evaluation of community and educational needs,” B stands for “be flexible and engaging,” and C stands for “collaboration and celebration.” The authors claimed that service-learning project has the distinctive potential for engaging students because it can capture the learners’ attention, develop their partnerships and collaboration [ 46 ].

3) Peer-based strategies

Peer assessment (PA) refers to a process whereby students evaluate the learning or task performance of their peers and conversely, their learning are evaluated by their peers [ 48 ]. Although a few studies have focused on PA as a strategy for enhancing students’ engagement in academic learning, some nursing authors agree that PA can actively engage nursing students in their learning activities by enhancing the confidence of students in judging about their own work/performance. In addition, PA can encourage them to reread their own assignment in light of their peers’ feedback [ 49 , 50 ].

3. Simulation-based techniques

This category includes two strategies of “Simulation with Manikins and Tag” team simulation.

1) Simulation with manikins

Manikins have been long used in nursing education since they can provide safe and repeatable conditions for practicing. In this regard, Power et al. [ 51 ] simulated five separate case studies during ten teaching weeks. They aimed to explore student perspectives (n=9) of the use of vignettes to increase engagement with manikins. Authors through thematic analysis and group discussion found that manikins are an effective procedure for increasing SE. Authors believed that if the appropriate educational scenario is selected in this learning method, the instructors will be able to actively engage nursing students in the learning process and to promote their decision-making skills [ 51 ].

2) Tag team simulation

The word “tag team” refers to a combination of two or more people who have formed a team to meet similar goals. The tag team is a small group, so the participation of the members in that team is maximal and active. In nursing programs, simulations are regularly led in large groups, with few students playing an active role and most observing. In contrast, tag team simulation (TTS) as an innovative educational strategy emphasizes the active engagement of both participants and observers in the simulation scenario. This method is inspired by the principles of theater and allows learners, as actors, to take responsibility for the actions and outcomes in a real context. Levett-Jones et al. [ 52 ] provided a TTS with pain scenario for 444 second-year nursing students. Satisfaction with Simulation Experience Scale was used to evaluate the active engagement and satisfaction of observers and participants. The mean satisfaction score was not different between participants and observers (4.63 versus 4.56, p=0.16). This indicated that TTS is an effective approach for ensuring observers’ and participants’ active involvement during group-based simulations. Authors showed that TTS could promote the active engagement of learners and enhance their satisfaction with the simulation experience [ 52 ].

4. Research-based strategies: Q methodology

Q methodology is a mixed-method approach for conducting research that focuses on individuals’ preferences and subjective attitudes. Participants can express and share their viewpoints within the group [ 53 ]. In nursing, Judge et al. [ 54 ] incorporated Q methodology into a nursing education course about “substance abuse in school.” The basis for using this method was that if students’ attitudes and preferences are recognized and fulfilled, their participation and engagement in educational activities will be enhanced. The authors aimed to promote students’ engagement and enhance their learning of evidence-based practice. Nursing students (n=35) participated in a 2.5-hour session to create a mock Q study on their opinions about substance abuse education. The outcome was the overall opinions of students regarding the characteristic of Q methodology and the class format. At the end of the study, most students expressed favorable opinions. Authors found that Q methodology can provide a means to extract the participants’ opinion around a given topic and thus provide a way to keep students as active and engaged learners [ 54 ].

5. Miscellanea learning strategies

We found three articles discussing uncategorized learning strategies in promoting nursing students’ engagement.

1) Active learning

Undoubtedly, active learning is one of the key strategies for enhancing students’ engagement within the nursing educational programs. Active learning is a student-centered approach in which requires students to participate and cooperate in the teaching and learning process [ 55 ]. Many of the discussed educational strategies in the current review can be classified as an active learning strategy. In general, the available evidence about the effectiveness of active learning in nursing education shows that this cooperative educational strategy has a potential to promote nursing students’ engagement in the academic and clinical learning activities [ 9 , 55 ]. In contrast, some studies have shown that in the absence of active learning, academic engagement is not created. Popkess and McDaniel [ 9 ] examined the relationship between pre-college students’ inputs and academic engagement levels among baccalaureate students in nursing (n=1,000) and non-nursing professions (n=2,000). The National Survey of Student Engagement instrument was used to measure engagement on five subscales with a total of 41 items. Their findings showed that nursing students scored significantly higher (mean=58.71) on some aspects of academic engagement than other professions (mean=55.22 or 56.14). However, they were less engaged in active and collaborative learning than other majors [ 9 ].

2) Homework completion

Although many studies have shown that homework, as an active learning approach, can increase the academic performance of students, this learning activities has received little attention in nursing education [ 56 ]. Salamonson et al. [ 56 ] described the relationship between academic engagement (homework completion, lecture attendance) and academic performance in nursing students (n=126) who were enrolled in a pathophysiology subject. Students spent about 6 hours per week studying. The mean percentages of lecture attendance and homework completion were 67.5% and 48.9%, respectively. Authors found that active learning activities such as homework completion are one of the best way to engage students. As well, it is a strong positive predictor of academic performance and success for nursing students [ 56 ].

Engaging nursing students in academic environments and clinical settings is a challenging issue for nursing educators, worldwide. In recent years, many nurse researchers have investigated various educational strategies to explore and develop the best ways to increase nursing students’ academic engagement. Results of these efforts are the creation of new teaching strategies or modification of the techniques used by other disciplines. Accordingly, our main goal of this review study was to provide a set of useful tools for promoting nursing students’ academic engagement. In this review, we summarized the teaching strategies that nursing educators used to sustain or enhance the academic and clinical engagement of nursing students and eventually, we highlighted the gap for further research. We organized the teaching strategies into five categories based on the similarities of concepts and teaching techniques that educators had used: the main categories were technology-based strategies, collaborative strategies, simulation based strategies, research based strategies, and miscellanea learning strategies. Many of the training strategies had been created innovatively or derived from other disciplines such as management, technology, art, and theater. But the role of today technologies such as Internet in creating educational strategies was more prominent than the other [ 57 ]. Generally, in many of the strategies used, students’ academic engagement increased, but the main problem was that the tools used to measure the degree of engagement were mostly self-reported or subjective. In other words, due to the lack of experimental educational studies in nursing regarding the SE (only 6 quasi-experimental studies), we could not judge the strengths and weaknesses of the extracted strategies. Therefore, regarding the optimal strategy to sustain and promote nursing SE, further experimental study is needed. Moreover, given that the effectiveness of these techniques has been evaluated in the small number of studies, more experimental research is recommended.

Another important point is that educational strategies were mostly used in the classroom, and few were able to be transferred to clinical settings. Therefore, because more than half of nursing education takes place in clinical settings, the findings of these studies do not support the role of these strategies in increasing the academic engagement of nursing students in clinical education. In contrast, previous studies have shown that nursing students have greater motivation, both internally and externally, to learn clinical activities; therefore, they are more engaged in these activities [ 44 , 58 ]. However, there are limited studies on the clinical engagement of nursing students and there is a need for further research in this area. It is necessary that nursing instructors sustain and enhance the academic and clinical engagement of nursing students using innovative educational strategies in order to increase the level of students’ knowledge and abilities and improve the quality of clinical services provided.

Based on the results of this review, among the strategies discussed in this review, the use of technology, particularly the response system and online learning, was more common among nursing educators, which is in line with today advances in smart technologies. Students of new technologies’ era (‘digital native’ learners) are constantly engaged with the updated smart technologies [ 57 ]. In addition, online learning has witnessed a noticeable growth within healthcare education, nowadays [ 18 , 25 , 36 , 57 ]. Accordingly, if nursing educators want to maintain and enhance the students’ academic and clinical engagement, they should equip themselves more with innovative technologically-driven learning techniques.

Active learning was the foundation of most educational strategies used to enhance students’ academic engagement. In this regard, several studies in different fields of study have shown that any teaching method that can actively engage the student in learning process, can promote academic engagement and ultimately academic achievement of students [ 55 , 59 ]. Among the educational strategies reviewed in this study, strategies based on online technologies and simulation were more attractive to students and made their participation more active in the learning process. Accordingly, as a practical point of this study, if nursing teachers want to improve students’ academic engagement, they need to use attractive teaching methods that are based on the latest technologies of today world, such as smartphones and online discussion systems; however, at present little is known about the methods of promoting academic engagement in clinical activities.

1. Limitations and strengths

Our main limitation was that the number of experimental studies that accurately assessed the effectiveness of a particular teaching strategy on students’ engagement was limited. Some educators evaluated an innovative method in a limited group of nursing students without using a particular research plan and some others discussed the advantages and disadvantages of particular teaching strategies. These factors limited our conclusion about the effectiveness of a particular technique. Notwithstanding, the collection presented in this review can be used as a starting point for future research that to evaluate the effectiveness of an educational intervention on the academic engagement of nursing students. One of the strengths of our study is that we only considered the studies that were conducted in the field of nursing.

2. Conclusion and directions for future research

The main goal of this review study was to provide a set of useful tools for promoting nursing students’ academic engagement. In this review, we organized the teaching strategies into five categories based on the similarities of concepts and teaching techniques that educators had used. The main categories were technology-based strategies, collaborative strategies, simulation-based strategies, research-based strategies, and miscellanea learning strategies. Among these educational strategies, technologies- and simulation-based strategies were more attractive to students and made their participation more active in the learning process. At present, little is known about the methods of promoting academic engagement in clinical activities. Further experimental research is needed to confirm or disprove the effectiveness of the methods discussed in this paper. We did not find a unique strategy to enhance academic engagement in clinical education activities. One of the possible reasons for this is that learning in clinical settings particularly requires maximum engagement in clinical learning activities. It is recommended that future researchers design and test unique strategies for improving academic engagement in clinical settings.

Acknowledgments

This review was not funded by any companies, research grants, or funds.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Author contributions

Study conception and design: MGH, HKM; data analysis and interpretation: MGH, HKM, AH; drafting the article or revising it critically for important intellectual content revisions for important intellectual content: MGH, HKM, AH; and final approval of the version to be published: MGH, HKM, AH.

Keeping a Positive Outlook: My Clinical Experience as a Student Nurse 

Submitted by Ashley P. Cohen, Student Nurse, Massachusetts College of Pharmacy & Health Sciences School of Nursing, Class of 2011, Boston, MA.

Tags: clinical clinical experience health care nursing students preceptorship student nurse

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An attitude is an important thing. It can shape the way the individual sees an experience and how observers see the individual. An attitude can entirely make or break an experience. This is as true in clinical experiences as it is in life. My experience in my senior year clinical preceptorship was without a doubt unique but I feel its uniqueness was in what I made of it, something every nursing student can do for themselves. If there is one lesson to gain from reading about my experiences it should be that the success of a clinical, whether a preceptorship or group experience, is entirely what the student makes of it.

My first day I walked into the ICU and almost ran right back out, thinking “Get me out of here!” It was a 10 bed unit, the traditional glass ICU room doors, two crash carts at either end of the unit, patient charts seemingly everywhere, precaution carts, glucometers, IV poles and pumps, doctors running into the room at the end of the hall, telemetry monitors beeping and spitting out rhythm strips. Little did I know these sounds and sights would eventually become more calming than frightening. I kept thinking to myself how was I, a student, going to handle a clinical placement on this floor? My last medical surgical clinical had been the previous summer, it was now March, how could I possibly remember the necessary skills to be ok here? What if I forgot the important skills? I had been in the same group of large Boston teaching hospitals for every other clinical experience, now I found myself in a small 95 bed suburban hospital. “A Paper chart… this hospital uses paper charts?” was another of my first impressions. I met with my preceptor, a nurse with 30 years experience. I was intimidated. She let me know that I would work towards covering her patient load, with her supervision of course. I would also be expected to know my dosage calculations and all of my medication facts; she let me know that “robot nursing” was not how we would handle things. Nurses around the floor began to tell me that she had taught many of them and that she was tough but I would learn a lot. To a new student this was reassuring but hearing that she was nicknamed “sarg” only added to my mounting fears of this experience.

On my first day we met at the patient assignment board to receive report from the night shift charge nurse. She methodically went through each of the patients on the board, “Patient presents to emergency department unresponsive…” “Patient intubated and heavily sedated…” “Patient on Cardiezem drip” “Patient in septic shock, treating with Xigris drip.” Hearing this certainly didn’t help my nerves. My first patient was on a ventilator, in congestive heart failure and acute respiratory distress syndrome (ARDS). We went into the room and my preceptor told me to “get started.” I froze. Then, suddenly it came to me, “we always assess first,” and I did my head to toe assessment.  I remembered this from one of my first nursing classes, Health Assessment. “Ok” I thought, “I remember how to do this.” My preceptor let me know I forgot the check pedal pulses. “Darn” I thought, how could I forget something like that? My preceptor reassured me, it was my first time doing a full assessment in a while, and forgetting one thing was “not a big deal.” As the day went on she allowed me to complete more and more tasks. We went to get 8 am medications; she quizzed me on each of them. By 11 am I was deep suctioning my patient on the ventilator. I was learning ventilator settings, what was PEEP, PIP, Ftot, Fi02, VT, VE, and what the numbers that went along with each meant physiologically. I also began to learn what each of these numbers meant for my patient’s health. Little did I know that five days later I would be extubating this patient as his family moved him to comfort care only. Little did I know that later that same day I would be performing the post mortem care on this patient. I learned quickly that I would need to adjust to the pace of the ICU, as I had to adjust to every other floor I was on for clinical. Each floor has its own pace, its own rhythm, and as a student we must become a part of the flow, not obstruct it or try to work against it.

Another patient I had during my experience was a woman with COPD who was in end stage heart failure. She was another ventilated patient, slowly I was becoming really good with these ventilators. I wasn’t messing up on my head to toe assessments. I could fill out those seemingly silly paper charts. I was figuring out where to find things in the supply room. After a another few days my patient was able to be extubated. As she began to gain consciousness a lively 70 year old woman came from someone who had been a living version of my anatomy book on the bed. She would eventually tell the nurse and me that she wanted to be moved to comfort measures only and hospice home care. She let the nurse and I know that she wanted to go home to smoke and drink her vodka until she passed away in peace. I learned that we don’t always like our patient’s decisions, but we must respect them.

One of my last patients was a man in severe septic shock; a complication of a prostate biopsy. He had what seemed like ten medications going in IV lines at any given time, not including all of the fluids they were piggybacked off of. He had two peripheral IV sites as well as a right internal jugular central line for his infusions. A problem came up however; he wasn’t putting out any urine. At one point his input was somewhere around 1600ml to a 15ml output, his output became a huge cause for concern, someone being fluid resuscitated and not putting out urine, I began to wonder about his kidney function. Another part of my education I began to appreciate, all of my classes were coming together, I was thinking systematically. I watched as a team of nurses and doctors tried to save this man’s life. We ran blood cultures times what seemed like a million, a urinalysis, ultrasounds of the heart and kidneys, EKGs, CPK/Troponin levels, serum blood levels, and electrolyte levels among other things. Then I began to hear my preceptor say “start the bicarb in the distal port” “what is his output?” “let’s get him on the cooling blanket” “get a set of vitals,” I was being actively involved in this critical patient’s care. Although I was petrified I kept a positive and open attitude. I thought, “I can do this, I have been here for four weeks, I know how to do this.” I was practicing skills I had learned back in my old, at the time outdated, basement nursing lab. These skills I thought were long lost somewhere in my memory were coming back to me, just as the cliché says, like riding a bike.  As unprepared as I had felt going into this clinical experience I slowly began to realize that I was prepared and I did know what I was doing.

Knowing what I was doing surprised me. How could a few labs and clinical placements on an orthopedic floor, a labor and delivery floor, a detox unit, and a general psych floor help me be prepared for the acuity of patients on an ICU? I couldn’t believe it. Every single clinical experience, every single lab, and every single clinical simulation helped. The smallest skills I learned in clinical and lab, those skills that seemed so easy that I wondered if the professors were questioning my mental capacity, became the skills I used on a regular basis, the ones that made the biggest difference in my practice. You think making a bed is so easy? Try doing it with a six foot, five inch man who weighs 250lbs and getting the sheets straight because he’s sedated and you don’t want to risk skin breakdown. You think oral care is a joke to be learning about in lab? Tell that to the patient with oral candidiasis who wants nothing more than a swab to keep his mouth comfortable. These little things make an enormous difference to even the most complex patients. Again, the attitude in learning these skills should be a positive one. You want to provide your patients with the best care possible, in order to this you must start by practicing the best possible skills in clinical, lab, and preceptorships. Every day in clinical presents a new challenge, you will come upon things you didn’t even know you were afraid to do, but with the help and guidance of a preceptor or clinical instructor, you will get through the experience and be better for it. You should seek out these challenges, and do what scares you. If it scares you now imagine what the feeling would be when you have that “RN” or “LPN” at the end of your name, those little letters making you responsible for your patient’s care. As students we need to advocate for ourselves, gaining as many experiences as possible before we graduate and are on our own. Expose yourself to as much as possible. If a nurse down the hall has a patient getting a procedure done, ask to watch. If another nurse’s patient needs a dressing change, ask to do it! Be determined, remember to wake up thinking “I get to practice for my career today,” don’t go in with the “ugh, I’m tired, why do I have to be here” attitude. Remember that your education is your choice. Nobody will force you to attend clinical, sure there are consequences for not going, but ultimately the decision to be in school and to attend clinical is the student’s.

We all get tired, we all have challenges outside of school, but with a positive attitude about learning and a little determination to succeed we can all get through any clinical experience, learn a great deal from it, and enjoy the learning. I can’t say it enough; any clinical experience will be what you make of it. Two students in the same clinical group can have incredibly different experiences if one goes in positively and the other negatively. Nurses will notice who the students are that want to learn, they will seek you out to teach you if they think you want to be taught. There will always be the one intimidating, scary, or “grumpy” nurse on the floor. From my experiences I have learned that they usually can be won over if you show them that you are a serious student, there to learn from them, not to judge the way they practice. If nurses notice that you are just stuck on autopilot, doing only what is absolutely required of you in clinical, they won’t have an interest in teaching you, and why should they?

They say life is what you make of it, well, it is my opinion that the same is true for clinical and preceptorship experiences.  The more you as a student advocate for yourself, the more experiences you gain exposure to, the better nurse you will be. You will be more prepared for your eventual practice and feel more comfortable joining the professional world. Remember that you are more prepared for clinical than you think. You will make mistakes, we all do, nurses with years of experience still make mistakes. The important thing to do is look at your mistakes, learn from them, and move forward. Keep a positive attitude and realize that you are learning. Never be afraid to try a skill again just because you made a mistake, you should in fact force yourself into this experience again, so that you know you can do it. It would be hard to find a nurse who didn’t miss trying to insert a catheter, but with practice we all become comfortable with it. You didn’t stop trying to walk after your first fall, did you? Skills will come with time and practice. You will be scared; there will be days you want to quit. There will be days you will question if nursing is for you. Over time these days will become few and far between, and you will feel the rewards of nursing. A patient’s thanks and appreciation will make all the hard work worth it. In regards to mistakes, my preceptor had this to say for all students, “It’s the learning curve, none of us (nurses) are expecting you to be perfect, we’re just expecting that you try your hardest and show us you want this.” So remember, we’re students, not super heroes, we won’t be perfect, but with a positive attitude, we can make any experience a great and rewarding one.

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‘Student nurses should be encouraged to pursue management and leadership’

01 August, 2022 By Mutsa Chitate

When most nurses qualify, they want to go on the ward as early as possible. Some nurses want to devote more time to their education to expand their work prospects in the future. Other nurses work for a specific goal, such as nursing leadership and management positions.

"Nurse leadership is required at all levels and in all contexts"

If the aim of a changed healthcare system is to be achieved, strong leadership is required. Research shows that not all nurses begin their careers with the intention of being involved in leadership. The nursing profession must a set a benchmark for future student nurses who can deliver as full partners with other medical practitioners and be responsible for their own efforts to delivering high-quality care while working collaboratively with leaders from other health professions throughout the healthcare system, from the bedside to the boardroom.

Nurse leadership is required at all levels and in all contexts. Despite teamwork being typically a noble objective, there are instances when nurses must act as advocates with a single voice to provide great patient and family care and this is a great example of nurses becoming leaders. I have seen this constantly in multidisciplinary team meetings.

Simultaneously, successful leadership necessitates the awareness of instances in which it is more vital to mediate, cooperate, or follow those in leadership roles. Nurses must recognise that their leadership skills are just as vital as their practical competence to provide safe and effective care.

Depending on expertise and credentials, nurse leaders and managers take on a variety of tasks during their careers. Nurse leaders manage department and facility improvements, discover creative approaches and develop innovative techniques to provide better patient care, and reinvent how the organisation achieves goals and connects with core values.

Nurse managers may be given leadership roles as they advance in their careers, but their primary responsibility within a medical facility is to direct patient care, treatment plans, and clinical knowledge. The nurse manager job is largely responsible for managing nursing teams as well as critical nursing procedures such as reporting and documentation.

Hospitals and health systems that respect nurse leadership in change implementation will be in a better position to influence patient safety and quality initiatives. In the ever-changing health sector, nurses are constantly challenged with new concerns, practices and possibilities. Having a skilled nurse as a leader in place to help navigate these changes, may make the difference between a nurse remaining in an organisation or leaving.

While nurses both newly qualified and experienced understand the nuances of change in the healthcare industry, they will be better prepared for success in their roles if leadership can implement change in a way that allows the team to see the overall benefit of the change. Leadership for students is critical because it teaches us how to examine situations and distinguish our strengths and weaknesses.

If all nurses are leaders and newly qualified nurses are to effectively lead teams from the start, they must have a firm grasp of leadership and management as well as the essential skills and talents.

Management and leadership positions are critical duties that I believe student nurses should be encouraged to pursue. These responsibilities will include knowing and understanding what leadership is, the distinction between leadership and management, successful collaboration, effective leadership styles, recognising everyone as a leader, and the importance of excellent leadership in the future of the NHS.

Mutsa Chitate is a second-year adult nursing student at University of Bedfordshire and 2021-2022 Nursing Times student editor

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More student blogs ‘A nurse’s journey in research should start as a student’ ‘The mentally unwell Muslims who suffer in silence’ ‘Patient education can challenge health inequalities’ ‘Student nurses champion improving the healthcare experiences of vulnerable groups’ ‘Mentorship training should be mandatory for registered nurses’ ‘Learning disability nurses should build on their presence in primary care’ ‘How caring during lockdown inspired me to lockdown on career goals’ ‘It is everyone's responsibility to broaden their knowledge of communication’ ‘Peer support should be seen as a vital part of team work’ ‘Virtual placement or virtually no placement’ ‘Hang in there all students, nurses and other allied health professionals’ 'How nurses are perceived versus reality'

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Anna’s Student Nursing Experience

On Wednesday 2nd September (8pm-9pm UK time) @EBNursingBMJ is co-hosting a twitter chat on student nursing and midwifery with @RCNStudents 

To celebrate the contributions our student nurses/midwives make – we are sharing blogs of their experiences in practice.  Today’s blog is from Anna Jones , a second year student nurse on the children’s branch, from the University of Leeds 

My name is Anna Jones and I am a second year student nurse. I am studying at the University of Leeds and my branch is children’s nursing. I am currently on my summer annual leave and I have to say, I’m enjoying every minute! As much as I enjoy my course, it’s a relief to have a break! To say that second year has been difficult would be an understatement. Continual deadlines whilst working on placement all year has been exhausting, but a challenge I am proud to say that I have overcome. Being a student nurse brings many challenges every day. Whether it’s completing an assignment, frantically trying to get a certain skill signed off or ironing your uniform after a twelve and a half hour shift ready for another the next day. What I would give for my own fairy god mother!

However, these challenges do not compare to the ones many patients encounter daily and I am forever putting my own life into perspective to realise how truly lucky myself and many others are to have good health. Working within the field of paediatrics is incredibly rewarding and a joy to meet and care for so many courageous children and families. The strength and resilience they have to face each day is remarkable and gives me the motivation to deliver the best care I can, because my patient’s deserve nothing less.

Like I mentioned, this year has been a tough one – I thought first year was difficult but nothing can prepare you for the jump to second year. I first worked on a day case surgical ward which I loved. Whilst the no nights and weekends were a bonus, meeting so many children and families every shift was a delight. I was able to accompany patients throughout their short stay in hospital, from their admission and the journey to the anaesthetic room to bringing them back to the ward and saying goodbye as they were discharged. Although this was a short experience for patients and their families, do not underestimate the fear and anxieties that are experienced and how valuable the role of nurses are to lend a comforting smile and words of encouragement as children prepare for their surgery.

Being a children’s nurse means delivering the upmost care to that patient, but also ensuring family centred care is encapsulated within practice because they are also on this journey, experiencing a vast range of emotions. Comforting a parent who was crying as their child had been anaesthetised and taken to surgery, having only known them for a few hours seems a bit of an awkward situation. But when you are in that role, that caring role of a nurse, you pat them on the back, lend them a shoulder to cry on or even give them a hug, all with no hesitation. Because if you cannot show that level of compassion and empathy, how can you truly fulfil your role as a nurse?

The rest of my placements this year have been based in the community, one of which was health visiting. Students often have mixed reactions about health visiting but for me it was very different to life on the ward! 9am starts was one of the best perks, an extra two hours in bed was bliss! Working 9-5 Monday to Friday was also a very different routine, and one which I actually found more tiring than 3 long days on a ward. Community placements were slightly more relaxed compared to the busy pace of a ward, but do not doubt the workload. One baby is born every forty seconds in the UK, and each one needs a health visitor. But I enjoyed the placement and an area of health care I would certainly consider further along in my career. Another placement within the community was based at a SILC school. These are Specialist Inclusive Learning Centres for children with special needs. This was a special placement for several reasons; meeting children with specialist and complex needs was so valuable as a student nurse. To see the small yet significant impact you were making on these children was endearing and a valuable learning experience for future practice. The school was also where my grandma had nursed for 20 years; I had quite literally stepped into her shoes! As you can see, nursing runs in the family…

I found that working in the community was a valuable experience to ascertain the care that is delivered outside of the hospital setting. It was also important to become aware of all the services available for children and families to ensure that you are working as part of a wider team to ensure that the care you deliver is holistic within the context of that patient. I realise I sound like I’m writing an essay but it is so important to deliver effective, person centred care. To put my job into perspective, I always try to imagine if it was my younger sister or brother being cared for which gives me the drive to deliver the care that my patients deserve. If my parents or grandparents had to go into hospital, I would want the best level of care delivered to them, as would everyone. This is why the notion of ‘person centred care’ should resonate throughout the nursing workforce and an aspect I will channel within my career. At the beginning of my nursing programme I discovered a quote by Maya Angelou that encapsulates this well within the context of nursing:

‘People will forget what you said, people will forget what you did, but people will never forget how you made them feel.’

I have one more placement of my second year, 4 weeks on a respiratory ward which I begin in a few weeks time. It’s been nice to relax and have some time off but I am looking forward to being thrown back into the whirlwind that is nursing. I will then continue straight into third year. My final year. With so many assignments and placements, qualifying has always seemed like a lifetime away, but now it’s only 60 weeks away (to be precise!) Am I apprehensive? Yes. I can already feel the huge weight that is third year beginning to rest on my shoulders with the prospect of dissertation and applying for jobs. Am I ready? Sometimes I’m not so sure, but I’ve got this far so there is definitely no turning back now! Am I excited with what the next few years will bring? Absolutely.

Anna Jones @AnnaJones6

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