Crossing Boundaries with Nursing Students: Combining Institutional Ethnography with Educational Theory in Exploring Cross-sectoral Learning in the Everyday Clinical Placement of Nursing Students

BACKGROUND Institutional ethnography (IE) is a method of inquiry as well as a way of thinking and doing analysis in research projects. In this PhD project, I examine the ruling relations in Danish nursing students’ everyday lives as they learn about transitional care during their final clinical placement in their 3½ year nursing education. The education in clinical praxis takes place in hospitals and municipalities. The project questions how nursing students learn how to handle and act in transitions of care – which is when a person transfers to the hospital (and becomes a patient) and is transferred back to the persons own home again. Research within transitional care has already unfolded challenges for health professionals in e.g. communication and cooperation across the sectorial boundaries, leading to a curiosity on how nursing students learn about transitions of care.
RESEARCH QUESTIONS With IE as framework I question: What are the experiences of nursing students with regards to getting to know the work of cross-sectoral activities and how is the clinical praxis as a learning environment helping nursing students to learn about transitional care?
THEORY Exploring this, I aim to combine IE concepts as e.g. ruling relations with theory of learning and education. In taking the students’ standpoint, I explore what ruling relations become visible when the student is part of patient treatment in a transitional care setting and how these ruling relations are connected to education and learning. I draw on educational theory regarding the importance of an attention to the content of learning, the reason for learning, and the fact that the student learns it from someone.
METHODS In taking nursing students’ standpoint, I follow seven nurse students in their everyday practice in clinical placement either in a hospital ward or in elder care in a municipality. The ethnographic fieldwork consisted of 22 days of participant observation inclusive seven individual semi-structured interviews with nursing students. I supported the data material with interviews with the clinical supervisor in each setting, mounting to a total of 13 interviews. I aim to create different kinds of maps showing both the transitional care praxis, the overall learning environment in each context, and the transitional learning environment. To investigate this and make the invisible visible, I use mapping as an analysing tool.
FINDINGS Following nursing students, I experienced how they were on their own most of the day. This included reflecting upon their own practices. Sometimes, the students had an experience of having too little to do, which led to a lot of spare time where they were left by themselves trying to find stuff to do or just pass time. Six out of seven students almost never accompanied their clinical supervisor or had time to reflect with him/her, which was a big wish for them. Also, the supervisors expressed wishes of having more time with each student but are prevented by doing so, partly because they were often not there in the same shifts as the students or simply because supervisor and student were not “put together” when they did have the same dayshift. In this last example from the hospital setting, neither the student asked to switch to follow the supervisor, nor did the supervisor take initiative to switch to be together with the nursing student. This leaves an impression of the attendance sheet as a ruling document in that particular setting. Both student and supervisor expressed time to reflect as key in a good learning environment, but what kept them from changing the plan on the attendance sheet in the morning, when they discovered the issue?
In two out of the three municipality settings, “the driving list” – being the individual day-to-day plan for each nurse and nursing student with citizens names, address, and tasks they must do within the day – ruled the everyday life of the nursing student but also of the clinical supervisor. Being very difficult to change, they can be seen as constituting the learning environment as they were produced without taking student education into consideration.
FUTURE WORK As I explore the fieldwork material, it will be through the lens of both IE and theories within the educational area. When digging deeper into the analysis, the intention is to retrieve an understanding of what is at stake for the nursing students in their clinical praxis in relation to transitional care, but also to try and understand how cross-sectoral learning in many settings is almost invisible in the students’ education.