Determination of Student Centered Effective Learning Strategies in Clinical Practices in Nursing Education

Clinical experience process that follows clinical practices in nursing education gives students the chance of a transition fromtheory to practice as well as from being student to being a professional. Educators in particular, nurses and other health careworkers, universities and students bear important responsibilities in clinical education affected by physical setting andschool-hospital collaboration so that the nursing students can be educated in the best way. To this end; e and f articles of 9 thclause and an article of 5 th clause were enacted under Nursing Code dated 03.2010 and numbered 27515. However; thesearticles do not include an explicit and sufficient explanation about how clinical nurse, student nurse and hospitalmanagement should approach these responsibilities. The aim of the researchers is to point out that problems can be noticedmore easily and analyzed more appropriately by the experts in each law and code to be enacted by governments and thusmore systematic and effective results can be achieved.


Introduction
Clinical practice makes up an important part of education process in nursing education.Clinical experience is an educational process that gives students the chance of transition from theory to practice.An effective clinical education environment is affected by many factors such as physical setting, instructors, clinical nurses and members of health care team.In order to create a suitable learning setting; educators in particular, nurses and other health care workers, universities and students bear important responsibilities (Akgun& Aras,2012).
Studies in our country indicate that the student nurses cannot get the help they expect about nursing care from clinical nurses though it is legally an obligation to assist student-nurses.Also, it was also determined that the nurses didn't take responsibility, failed to be good role models for the students and seemed to contribute to students' clinical education less (Akgun& Aras,2012;Konak et al., 2008).This shows that there is problem in implementation of the law.Based upon this deficiency, a new policy was tried to be developed by the authors of this study.

Determination of Problems and Putting Them in Agenda
Clinical teaching occupies an important place in nursing education programs.Clinical teaching is defined as a process that provides students with an opportunity to put theoretical knowledge in practice, to gain a professional identity and to experience learning by doing (Cavusoglu, 1991;Tiwari et al., 2005).The most important objectives of clinical teaching are to enable students to integrate previously acquired basic scientific knowledge with practice-skills, to master in diagnosis, treatment and patient care and to gain basic professional and personal abilities and behaviors.In clinical settings; nursing educators should focus on motor and intellectual learning, problem-solving, effective time management, opportunities for professional decision-makings, encouraging creative skills and providing sufficient guidance for students (Cavusoglu, 1991;Mannix J et al., 2006).
Areas the strategy will change: It is undeniable that in clinical practice settings, clinical nurse plays an effective role in the development of students.Therefore, in 2010 Nursing Regulations, nurses' duties and powers are defined with the article that "Nurses participate in scientific events about their profession, support and contribute to the education of society, student-nurses, health care workers and candidates."Therefore, nurses are primarily responsible for executing the article that "Nurses effectively serve in all areas in which health care services are provided and participate in decisionmaking mechanisms according to regulations in order to execute health care policies enacted."Nurses, who are expected to execute these duties and powers in professional terms, should suitably back students in clinical practice so that they can gain professional skills in clinical practice.Because students are not trained with effective clinical strategies in clinical practices; they experience problems in hospital setting and thus, this process is not useful enough for students.
Enabling students to gain effective skills through clinical training in clinical practice allows them to meet both individual and social needs in a productive and sustainable way with minimum errors as much as possible.In order to achieve this; not only academicians but also clinically responsible nurses, clinical nurses, expert nurses should take responsibilities and be a good role model in clinical teaching.
A well educated role model should guide the students: They should have sufficient knowledge and skills, demonstrate well-standardized behaviors, see students as adult individuals, work in an atmosphere that facilitates learning, provide information to students during practices, allow them to ask questions, make presentations if necessary, provide students with opportunities to independently practice so that the students can gain the ability, give timely and constructive feedbacks, create a positive atmosphere in which students can feel free when they need the role model's help, know educational objectives, collaborate with members of the team in order to meet students' educational needs, have communicational and leadership skills and guide the students in terms of critical thinking and implementing care in different situations.
Determination of Title: Determination of student-based effective educational strategies in nursing practices in nursing education.

Inspection of Problem
Educators are irreplaceable part of clinical education, which is the basic element of nursing education (Karaoz, 2003).In clinical settings, studies on regulations that will facilitate student learning have been focused on and mainly supervisor relations have been emphasized (Tiwari, 2005).According to the results of the studies conducted, some nurses who work in clinical environments do not consider student-education in clinical practice as a professional responsibility although they are in a critical position in student-learning and think that students' presence hinder their work (Akyuz et al., 2007;Erenel et al., 2008).Nurses who do not take this responsibility may become inadequate in being a role model for students and creating a positive communication with students and educators (Karaoz, 2003).
In the study done by Akyuz et al. on clinical nurses, nurses stated that they are of the opinion that students cannot learn anything only by observing and therefore they should guide the students by agreeing that first, instructor and second, clinical nurse are responsible for clinical teaching (Akyuz et al., 2007).
However, as the number of the patients they care is high, the rate of those supporting the above mentioned opinions decreases.Besides, when the number of the students for whom the instructor nurse is responsible is small, clinical teaching becomes more effective.Nurses think that the number of the students whom they teach in clinical practices should averagely be 4 so that students can completely learn.Additionally; nurses who work in clinics selected as applied-teaching places should help the responsible academic instructor in the education and inspection of nursing students.Thus, behavioral characteristics of nurses whom student-nurses can see as role model are emphasized (Eskimez et al., 2005;Tascı, 2006).Today, nurses have legal responsibility that they must create a setting appropriate for student-learning.In the 6/g article of 6th clause of Nursing Code issued on the 8th March 2010 in official gazette with number 27515; it reads that "Nurses execute training, counseling, research activities about nursing and contribute to the education of society, studentnurses, health care workers and candidates."In the 9/e article; of the responsibilities of head nurse, it reads that "Head nurse creates a suitable work-environment for the education of student-nurses and builds a school-hospital cooperation by collaborating with academic instructors."In the 10/i article; of the tasks and duties of the responsible instructor nurses; it reads that "They provide a proper learning environment for the student-nurses."The studies done report that the expected collaboration and harmony between students and nurses is sometimes hindered in clinical teaching (Aytekin et al., 2009;Celikkalp et al., 2010;Erenel et al., 2008;Eskimez et al., 2005;Gozum et al., 2000).Other factors that affect clinical education are nurses' ages, work-duration and educational levels.As age and workduration rise, nurses believe that presence of students increases their work-burden in the clinic (Akyuz, 2007).The study of Sibson and Machen indicates that young nurses are positively affected by the interactions made with students and thus their job satisfaction increases (Sibson& Machen, 2003).It is identified that working with students in clinics increases their job satisfaction as nurses' educational level increases and newly graduated nurses with bachelor's degree consider clinical teaching in a positive way (Akyuz et al., 2007).

Covering of Interest Groups and Stakeholders
1.In collaboration with academic instructors, administrative nurses, clinical nurses and studentnurses; a workshop on "Determination of Education Strategies for Students in Clinics" will be held, failing issues will be explored and correct solutions will be planned.
2. There will be a competition titled as "You are the Nurse" among the student-nurses in order to uncover educational strategies.The competition will be organized with national television channels.
3. As a pilot program, an educational program titled as "Student-Based Effective Education Strategies in Clinical Practice in Nursing Education" will be initiated at one of the most advanced health centers in Turkey.Later the program will be implemented in other provinces.Besides, each year a workshop will be held and the results and outcomes of the workshop will be sent to Turkish Parliament. 4. A report titled "Empowering Clinical Education of Student-Nurses" will be presented by Nurse Sevim Savaser -one of the parliament members of Turkish Parliament-during a formal session of the parliament when the President, Prime Minister and Minister of Health are present.5.During these events, clinic and university collaboration will be prioritized and a protocol will be signed.
6. Supports from governmental organizations and non-governmental organizations will be achieved for these strategies to be executed effectively; public service ads and posters will be designed and shared in social networking sites, websites of hospitals and faculties and notice boards.Thus; awareness will be created about the events and the topic.

Student Centered Effective Learning Strategies in Clinical Practices in Nursing Education Regulation Draft
Section One: Objective, Scope, Basis and Definitions Objective  ARTICLE-1 -The objective of this regulation is to educate leader nurses who meet international standards and that the country needs and who are educated with modern approaches and methods, professionally competent, respectful of universal and cultural values, in compliance with quality in teaching, training and practice and leader nurses that present the produced services and technologies for society's benefit.

Scope
 ARTICLE 2 -This regulation involves all nurses working in both public and private health organizations and institutions and all other fields where nursing service is provided.

Student nurses coordinator:
Nurse that has at least a postgraduate degree (preferably in nursing education or education field), completed formation education or with a teacher formation certificate, who ensures coordination among students, clinical nurses, education personnel and the coordination unit the hospital is associated with to increase quality of nursing education.

Clinical education nurse:
Nurse that has at least 5 years of experience, holding a graduate degree, with a completed formation education or with a teacher formation certificate, who builds an effective communication between the student and the clinic so as to operate as a foundational element in educating professionally competent nurses, cooperates with student nurses and nurses coordinator on educational objectives and has knowledge and authorization on this cooperation and is a role model in clinical education.

f)
Observes native and foreign broadcasts and activities, inspects educational methods, types, techniques and makes researches about general and private qualifications, activities of local and foreign publications, educational needs and fields.g) Obtains the tools for educational needs.h) Ensures the distribution of students among clinics accurately and inspection of the clinical nurses on this topic by providing cooperation with students and clinical education nurses.i) Cooperates and consults with experts that contribute to researches and project planning and carrying out.

j)
Ensures the reflection of research and project results onto practices.
k) Participates in and carries out the studies in quality assurance and setting standards for providing of nursing services.

f)
Ensures the practices to be taught in compliance with students' psychomotor, cognitive and affective processes.g) Repeats the practice where the student stays behind or fails in self-development until students feel themselves competent to make application again.h) Evaluates students with practice-checklists. i) Controls and records the practices in clinical education process repeatedly and ensures that they're carried out correctly and safely.

j)
Determines the required resources and materials for the education-environment where the training programs are to be carried out.p) Follows native and foreign periodicals and books about medicine and nursing.q) Provides personally counseling and guidance for the nursing students' educational needs and self-development.r) Makes studies about quality assurance and sets standards for providing nursing services.


Contact-meeting will be held at Ministry of Health for all healthcare service managers in all ministerial hospitals. Announcements will be made to all ministerial hospitals about regulatory changes.


As a pilot program, an educational program titled as "Student-Based Effective Education Strategies in Clinical Practice in Nursing Education" will be initiated at one of the most advanced health centers in Turkey and later, the initiation will be extended to other provinces.


Clinical education program and educational objectives will continually be updated, shared with clinical nurses and thus strategies for learning by doing and learning by living will be designed in order to reinforce school-clinic cooperation.


In case of clinical instructor nurses who do not meet the criteria or in case of insufficient number of clinical instructor nurses; volunteers that meet the criteria will be recruited and they will be certified by the Ministry.
 Each clinic's educational nurse will be determined based on educational status and information on clinical education will be kept up-to-date via in-service trainings.


Educational nurses' (student nurses coordinator and clinical education nurses) in-clinic duties will be regulated in order to avail them to help clinical education as required.
 Instructor nurses will be financially sponsored for the internship they will have under the budget used for health transformation program.


Besides, certificates of appreciation and specially designed crests will be given in order to motivate instructor nurses who actively join education of the students.


Meetings will be held in each city with student nurses coordinator, clinical education nurses and academics, subject related to evidence-based research will be encouraged nurses.


Results of the study will be announced and shared all over the country and in international platforms.

Conclusion
Consequently, this developed policy will help raise professionally competent, will contribute to the training of professional autonomy gained professional nurses and will avail patient and familyoriented nursing which includes quality care and self-sufficient services as the society needs.

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STUDENT CENTERED EFFECTİVE LEARNING STRATEGIES IN CLINICAL PRACTICES IN NURSING EDUCATION" ENTITLED NURSING REGULATION ON THE AMENDMENTS TO THE REGULATION STEPS The regulation is composed of five steps.The first step is Determination of Problems and Putting Them in Agenda, second step Determination of Title (Determination of Student Centered Effective Learning Strategies in Clinical Practice in Nursing Education), third step Inspection of Problem, fourth step Covering of Interest Groups and Stakeholders, fifth step Formulization of the Policy.


ARTICLE 3 -This regulation is prepared based on e and f subparagraphs of 9th Article and a paragraph of 5th article of Nursing Regulation, dated 08.03.2010 and numbered 27515 (Nursing Cod, access date: 12/01/2016).Definitions  ARTICLE 4 -In this regulation; Ministry: Ministry of Health; 08.03.2010 dated and 27515 numbered Nursing Regulation, Section Two: Objectives, Authorizations and Responsibilities of Student Nurses Coordinator and Clinical Education Nurse  ARTICLE 5 -(1) Student nurses coordinator; a) Acts towards planning, practice and evaluation of training programs, institutional policies towards Head Nurse/ Nursing Services Directorate vision and mission.b) Evaluates the educational needs coming from students, clinical nurses and academics in order to determine the educations to be given.c) Organizes in-service education to all students by cooperating with instructors.d) Designates the program manager to be charged in every training program.e) Cooperates with the related people and institutions to create, to maintain and to evaluate results training programs.


ARTICLE 6 -(1) Clinical Education Nurse; a) Ensures the orientation of student nurses arriving at clinic.b) Prepares working plans for student nurses in clinic.c) Ensures the prioritized education of nursing interventions to determine and to provide patients' care needs based on nursing process.d) Supports the learning process by learning-by-doing and learning-by-experiencing as a role model in skill-demanding practices.e) Corrects the wrong practices in nursing interventions and consolidates the right ones by providing one-on-one feedback to students.
k) Presents the reports about activities and training programs verbally and written to student nurses coordinator.l) Provides cooperation between nurse clinically in charge, clinical nurse and student nurses.m) Guides nurse clinically in charge and clinical nurses towards student development.n) Keeps up to date with current professional publications.o) Participates in activities such as professional seminars, conferences and working groups.