Participatory Action Research and Photovoice: Applicability, Relevance, and Process in Nursing Education Research.

ABSTRACT: Participatory action research (PAR) is a philosophy and approach to qualitative research. The purpose of this article is to generate a clearer understanding of PAR and its relevance to the discipline and profession of nursing. The authors provide a description of the principles and process of implementing PAR methodology, using photovoice as an innovative, participant-directed data collection method in rural nursing preceptorship. Participants were undergraduate nursing students and faculty advisors assigned to rural communities during the final clinical preceptorship. Participants described opportunities and challenges experienced during the preceptorship and how these experiences influenced their learning and overall preceptorship experience.

Crisis and continuity: Rural health care students respond to the COVID-19 outbreak.

The COVID-19 outbreak in Winter (2020) has caused widespread disruption for health sciences students undergoing clinical placements-vital periods of experiential learning that cannot be substituted with distance alternatives. For students placed in rural areas, already coping with isolation, precarious supply chains and shortages of essential personnel, the effects of the COVID-19 outbreak may have far-reaching implications for psychosocial wellness, self-efficacy and clinical judgment. Four nursing and eight medical students (n = 12) supplied photographs and commentary documenting the experience of withdrawing suddenly from clinical sites in rural Alberta. Collaborative, thematic analysis revealed continuities between pre- and post-outbreak life, both for the students and their rural hosts. Social determinants of health such as seclusion, environmental hazards, and health-seeking behaviors carried over and compounded the effects of the outbreak on the placement communities and clinical sites. Other continuities included the reliance on technology for clinical and social connectivity, and capitalizing on natural settings to cope with isolation and confinement. Prolonged liminality, lack of closure, and the loss of team identity were the greatest stressors brought on by the suspension of clinical activities. However, the participants felt well equipped to deal with these circumstances through the resilience, adaptability, and community ethos acquired during their placements.

'We have to drive everywhere': rural nurses and their precepted students.

INTRODUCTION: Travel safety culture is a vital aspect of nursing in rural western Canada, where long distances and severe weather are commonplace. However, this culture is poorly understood owing to the absence of official policy, and the tendency of rural nurses to take travel risks and burdens in stride, rather than advocating for change. Travel risks and burdens include extreme weather events such as tornadoes and blizzards; unmarked routes and hazards; distance, time and expense; and driver fatigue. In such rural settings, the safety and health of visitors, novices and students are of particular concern. The researchers sought to elicit the tacit knowledge of rural registered nurses, and their students undertaking rural nursing preceptorships, pertaining to rural travel issues and best practices for safety and wellbeing. METHODS: Through purposive and snowball sampling, the researchers recruited seven senior nursing students and five nurse preceptors. Seven rural acute and community care sites, between 42 km and 416 km distant from the students' primary place of study, were covered by the study. Photovoice, a participant action modality, was employed to collect photographic and qualitative interview data from participants over 10 weeks, between February and April 2016. The data were analyzed thematically, in collaboration with participants, who in turn validated the results. A digital storytelling initiative was attempted, to further involve participants in dissemination of findings, but only one participant took part in this phase of the project. RESULTS: The central finding of the study was that nursing students learn to accept and manage limitations - and to recognize and capitalize on opportunities - when undertaking rural preceptorships. With regard to road safety, the students were found to be particularly vulnerable to long distances, hazardous conditions, fuel and cellular data expenses, and fatigue. These issues were compounded by the students' reluctance to speak up, or to miss shifts, when they felt unsafe or unwell. Their preceptors role modeled autonomy and community ethos as the foundations of a frontline, extemporaneous road safety culture. This entailed personal safety measures borne from rural experience and background, familiarity with the countryside, and community connectedness with other healthcare sites in place of any official public alert system. The preceptors furthermore benefited from strong union protection for occupational health and safety concerns, but students being taught in rural settings had no such advantage. CONCLUSIONS: Nursing students should have the same occupational health and safety protections as their rural preceptors, especially the right to refuse travel, without penalty, in unsafe circumstances. Better travel subsidies and road safety measures during rural preceptorship may help increase the likelihood of students considering a rural career path. Furthermore, the frontline, community-based road safety experience of rural nurses is an untapped source of information for educators and policymakers. Such information will become more and more vital as a diminishing number of rural nurses are called upon to care for an aging client base.

Community Spirit, Cultural Connections, and Authentic Learning in Rural Preceptorship.

BACKGROUND: An authentic learning environment fosters socialization of nursing students to a particular community context and unique culture of the individuals who reside in that culture. The final preceptorship provides an extended clinical practice experience allowing for this immersion, while providing consolidation of learning as preparation to enter practice. METHOD: PhotoVoice was used as an innovative data collection method to engage participants throughout the research process. Participants self-selected photographic images that represented the unique rural preceptorship experience through their eyes. RESULTS: Rurality was described by participants as more than a geographic location, but as a sense of place, or a way of being and doing, that represented rural life. Rurality was depicted more specifically by participants in terms of community spirit and cultural contexts. CONCLUSION: Rural practice placements have the potential to enrich undergraduate nursing education and to expose undergraduate nursing students to the role of the rural nurse. More research is needed about rural health to understand the cultural and contextual factors that uniquely affect the health status of rural Canadians. [J Nurs Educ. 2019;58(3):144-151.].

Socializing for Authentic Caring Engagement in Nursing Practice: Nursing Student Moral Development in Preceptorship.

BACKGROUND: The purpose of this study was to explore the basic psychosocial process of undergraduate nursing student moral development in clinical preceptorship. METHOD: A grounded theory approach was used to explore the process within the context of clinical practice and the student-preceptor-faculty member relationship. RESULTS: Socializing for authentic caring engagement in nursing practice emerged from the data as the basic psychosocial process of nursing student moral development in preceptorship. This process included four key categories: (a) distinguishing nursing and moral identity in practice, (b) learning to recognize the patient's experience, (c) identifying moral issues in practice and creating meaning of practice encounters, and (d) becoming an advocate and reconciling moral issues in practice. CONCLUSION: Findings emerging from this study illustrate the processes of how nursing students work through moral issues and the role of faculty and preceptors in engaging students with moral encounters in the context of preceptorship.

Balancing the seen and unseen: Nurse educator as role model for critical thinking.

Critical thinking is an important indicator of student learning and is an essential outcome of baccalaureate nursing education. The role of nurse educators in the development of students' critical thinking has been overlooked despite the importance of their actions to facilitate critical thinking in nursing education. We used a constructivist grounded theory approach within a larger mixed methods triangulation study to explore how nurse educators revealed their critical thinking in practice. From the grounded theory approach, a model emerged from our research, outlining the important aspects of nurse educators' critical thinking and how it is revealed in the clinical setting. The important categories of this model include: a) fostering the student-educator relationship; b) role modeling critical thinking; c) mobilizing and operationalizing resources; as well as d) balancing factors that impact nurse educators' critical thinking. Our findings inform what is known about nurse educators' critical thinking and how it can be implemented in nurse educators' teaching practice. Given our findings, we offer recommendations for future nursing education practice and research, including the need to apply our findings in additional settings and further develop nurse educators' awareness of their own critical thinking.

Nurse educators' critical thinking: A mixed methods exploration.

Nurse educator's critical thinking remains unexamined as a key factor in the development of students' critical thinking. OBJECTIVES: The objective of this study is to understand how nurse educators reveal their critical thinking in the clinical setting while supervising students. DESIGN: This study uses a single-phase triangulation mixed methods design with multiple data gathering techniques. PARTICIPANTS/SETTINGS: Participants for this study are clinical nurse educators from a large Western Canadian baccalaureate nursing program who teach 2nd or 3rd year students in medical-surgical settings. METHODS: Participants for this study completed a demographic survey, the California Critical Thinking Skills Test (CCTST), the California Critical Thinking Disposition Inventory (CCTDI), participant observation in a clinical practice setting, and semi-structured interviews. RESULTS: The results from the California Critical Thinking assessments (CCTST and CCTDI) show that participants are positively inclined and have a moderate to strong ability to think critically, similar to other studies. Participants find it difficult to describe how they reveal their critical thinking in the clinical setting, yet all participants use role modeling and questioning to share their critical thinking with students. When the quantitative and qualitative results are compared, it is apparent that the confidence in reasoning subscale of the California Critical Thinking Skills Test is higher in those educators who more frequently demonstrate and voice engagement in reflective activities. Dispositions associated with critical thinking, as measured by the California Critical Thinking Disposition Inventory, are more easily observed compared to critical thinking skills. CONCLUSIONS: This study is a beginning exploration of nurse educators' critical thinking-in-action. Our mixed methods approach uncovers a valuable approach to understanding the complexity of nurse educators' critical thinking. Further study is needed to uncover how nurse educators' can specifically enact their thinking abilities to support student learning in the clinical setting.

Process Matters: Successes and Challenges of Recruiting and Retaining Participants for Nursing Education Research.

Researchers who study nursing education encounter difficulty when trying to recruit and retain nurse educator participants. Researchers would benefit from knowing more about effective and ineffective sampling strategies and methods to increase the efficiency of the research process. This article outlines the struggles and successes encountered with a mixed methods study that examined nurse educators' critical thinking. Specific examples are interwoven with current literature to uncover some important insights and future recommendations for researchers in nursing education.

An Integrative Review of the Concealed Connection: Nurse Educators' Critical Thinking.

BACKGROUND: The role of nurse educators in the development of students' critical thinking has been overlooked despite the emphasized need for effective teaching methods. METHOD: An integrative review was performed to examine both quantitative and qualitative research published from 2000 to 2015 related to nurse educators' critical thinking. RESULTS: Many barriers and facilitators existing on individual, interpersonal, and contextual levels affected nurse educators' critical thinking. Various tools have been used to measure nurse educators' critical thinking. This review also highlighted the continued lack of a consensus definition of critical thinking and the limited presence of conceptual models to guide the use of critical thinking in nursing education. CONCLUSION: Continued examination of nurse educators' critical thinking is needed, given the limited number of studies that have been completed. Much needs to be explored further, including conceptualizations of critical thinking and confirmation of emerging themes identified in this review. [J Nurs Educ. 2017;56(11):648-654.].

Preceptorship and the Nurse Practitioner Student: Navigating the Liminal Space.

BACKGROUND: The purpose of this study was to explore the process occurring in preceptorship to prepare nurse practitioner students for their future role in professional practice. The researchers examined this process through the eyes of the preceptors, nurse practitioner students, and faculty. METHOD: A grounded theory method was used to explore the process involved in preceptorship to prepare nurse practitioner students in the clinical setting. RESULTS: The process of navigating the liminal space emerged from the data to explain what actually was occurring throughout the nurse practitioner student preceptorship. This process was reflected on three levels: (a) positioning in preceptorship, (b) repositioning on the threshold of nurse practitioner, and (c) embracing the new nurse practitioner role. CONCLUSION: As the data emerged, the researchers uncovered a multidimensional process that was occurring in preceptorship. This process was identified as navigating the liminal space.

Letting go: How newly graduated registered nurses in Western Canada decide to exit the nursing profession.

BACKGROUND: The Canadian Nurses Association (CNA) estimates a nursing shortage in Canada will rise to 60,000 registered nurses by 2022. Further compounding this crisis is the approximate 14-61% of new nursing graduates who will change nursing roles or exit the profession. AIM: To explore the factors and basic psychosocial process involved in the decisions of newly graduated registered nurses in Western Canada who permanently exit the nursing profession within five years. DESIGN: Data was collected through unstructured and semi-structured interviews using the Glaserian grounded theory method. FINDINGS: Participants were found to be in a process of letting go of nursing that commenced as students and continued as they entered practice as registered nurses. Four major themes were identified. 1) Navigating constraints of the healthcare system and workplace: participants encountered difficulties adjusting to shiftwork and workload. 2) Negotiating social relationships, hierarchies, and troublesome behaviors; specifically hierarchal and horizontal violence. 3) Facing fears, traumas and challenges. 4) Weighing competing rewards and tensions which resulted in leaving the nursing profession. CONCLUSION: Students and subsequently new nursing graduates require a variety of supports to establish a nursing identity and remain in the profession. These supports include a manageable workload; meaningful orientation; interprofessional teamwork; and engagement within transformational and authentic leadership constructs. New nurses require a sense of being welcomed, valued, respected and accepted into the workplace environment, as well as constructive feedback, emotional support and debriefing to face workplace challenges.

Nursing preceptorship experiences in rural settings: "I would work here for free".

AIMS: The primary aim was to capture the experience of preceptorship in a rural setting, via photographic narrative. It is hoped that this narrative will highlight areas that require greater support; communicate the experience of rural preceptorship for students, educators and policymakers; and emphasize the benefits of this experience for these current and future stakeholders. METHODS: In a photovoice study, preceptors (n = 4) and students (n = 4) in rural, Western Canadian health care settings were given digital cameras and asked to provide images and commentary about the experience of preceptorship. Participants selected the photographs to be included as data, and participated in thematic data analysis, through facilitated group discussions during and following the preceptorships. FINDINGS: This article explores the category of teaching and learning, encompassing three themes: confidence, conscientiousness, and mutual growth. Preceptors emphasized the importance of students bringing sufficient knowledge to the rural preceptorship, pertaining not only to the nature of care but also to the predominant health care issues in the community. IMPLICATIONS: The implications were generated in part by the participants, who indicated a need for more student practica in rural settings; curricular changes to incorporate knowledge about rural health care and communities; post-graduation rural mentorship programs; and site/community-specific preparation.

Intergenerational conflict in nursing preceptorship.

BACKGROUND: Within the preceptorship model of clinical teaching/learning, the creation of a cohesive relationship between a preceptor and a nursing student highly influences the overall success of the experience. Invariably, preceptors and students tend to be of different generations and as such, there exists within this context the potential for generational misunderstandings and conflict. DESIGN: A phenomenological study guided by van Manen's approach to human science research was conducted. OBJECTIVE: The aim of this study is to explore the phenomenon of preceptorship in the intergenerational context. PARTICIPANTS: A purposive sample of seven preceptors and seven nursing students was recruited from an undergraduate nursing program. FINDINGS: The collective experience of all participants was illuminated through three key themes: being affirmed, being challenged, and being on a pedagogical journey. In this article we focus on encountering conflict, a key subtheme of being challenged, and one that emerged from the participants' narratives. CONCLUSIONS: The study findings suggest that interpersonal conflict continues to be a reality in our profession, owing to which a collective effort must be made by nurse educators, practicing nurses, and nursing students to effect change and create a more cohesive culture. The findings have the potential to enhance generational understanding and foster a more cohesive culture in clinical practice settings.

Generational clashpoints in nursing preceptorship.

The success of the preceptorship approach to teaching-learning depends on the formation of positive working relationships. Preceptors and nursing students are frequently of different generations and often have differing world-views. A phenomenological study, guided by van Manen's approach, was conducted to develop an understanding of how generational differences influence the formation of the preceptor-student relationship and the overall success of the experience. Three main themes were revealed: being affirmed, being challenged, and being on a pedagogical journey. A key subtheme of being challenged was colliding generational worldviews; in this article, our purpose is to explore this particular subtheme. The data suggest that generational clashpoints are occurring during preceptorship experiences, and the implications of these are serious, particularly from a nursing recruitment and retention perspective. It is vital that proactive measures be taken to inspire the future generation of nurses, rather than stifling their spirit and assertiveness.

Preceptorship and affirmation in the intergenerational world of nursing practice.

Research has shown that while preceptorship offers a reality-oriented learning environment and facilitates competence of students, there are inherent rewards and stressors associated with the experience. Students and preceptors can be from different generations, and as such, they may often come to the learning space with differing values and expectations. The nature of the preceptorship experience in this intergenerational context was explored in a recent phenomenological study with seven preceptors and seven nursing students in an undergraduate nursing program in Eastern Canada. Overall the experience was found to be inclusive of three main themes: being affirmed, being challenged, and being on a pedagogical journey. In this paper we explore the first of these themes, being affirmed. Highlighting the positive aspects of the preceptorship experience in the intergenerational context is necessary to promote a culture of openness and respect for generational differences within clinical nursing practice settings and to improving the overall quality of the educational experience.

Putting the evidence into preceptor preparation.

The term evidence-based practice refers to the utilization of knowledge derived from research. Nursing practice, however, is not limited to clinical practice but also encompasses nursing education. It is, therefore, equally important that teaching preparation is derived from evidence also. The purpose of this study was to examine whether an evidence-based approach to preceptor preparation influenced preceptors in a assuming that role. A qualitative method using semistructured interviews was used to collect data. A total of 29 preceptors were interviewed. Constant comparative analysis facilitated examination of the data. Findings indicate that preceptors were afforded an opportunity to participate in a preparatory process that was engaging, enriching, and critically reflective/reflexive. This study has generated empirical evidence that can (a) contribute substantively to effective preceptor preparation, (b) promote best teaching practices in the clinical setting, and (c) enhance the preceptorship experience for nursing students.

A phenomenological perspective on preceptorship in the intergenerational context.

Pairing a student with an experienced nurse through preceptorship is an approach to teaching/learning that promotes critical thinking, cultivates practical wisdom, and facilitates competence. Frequently, nursing students are of a different generation than their assigned preceptors and differences in worldviews and expectations can impact upon the success of preceptorship. A phenomenological study, guided by van Manen's approach to human science research, was conducted to explore preceptorship within this intergenerational context. Data were generated using unstructured interviews with a purposive sample of seven preceptors and seven students recruited from an undergraduate nursing program. The findings reveal three main themes: being affirmed, being challenged, and being on a pedagogical journey. The findings of this study have the potential to enhance generational understanding in the pedagogical context and foster a teaching/learning culture in the clinical practice setting inclusive of divergent generational expectations.

Putting the (R) ural in preceptorship.

Rural nursing is recognized as a unique health care domain. Within that context, the preceptorship experience is purported to be an important approach to preparing safe and competent rural practitioners. Preceptorship is the one-to-one pairing of a nursing student with a professional nurse who assumes the mandate of teacher and role model in a designated clinical/contextual setting, in this case the rural setting. A research gap exists in the literature in which rural preceptorship is specifically explored. The purpose of this paper is to review preceptorship in relation to preparing nursing students specifically for the rural setting. Understanding how preceptorship as an educational model can prepare nursing students to transition to rural practice is an important endeavor. An authentic rural preceptorship may serve to influence the recruitment and retention needs for registered nurses in rural areas. A greater understanding of rural preceptorship serves to illustrate the appropriate support, socialization and contextual competence required to prepare nursing students for rural nursing practice. This paper's review may serve to highlight the research that currently exists related to rural preceptorship and where additional research can contribute to further understanding and development for authentic rural nursing preparation.