Guadalupe Mata-Valderrama,1 Guillermina Romero-Quechol,2 Marilin Victoria Martínez-Olivares,3 Estela Galarza-Palacios,4 María Guadalupe Rosales-Torres5
1,4,5Instituto Mexicano del Seguro Social, Hospital de Especialidades del Centro Médico Nacional La Raza; 2,3 Instituto Mexicano del Seguro Social, Coordinación de Investigación en Salud. Ciudad de México, México
1Unidad de Cuidados Intensivos, 2Unidad de Investigación Edipemiológica y en Servicios de Salud, 3Programa para la Formación de Investigadores, 4Subjefatura de Educación e Investigación en Salud de Enfermería y Cursos Técnicos, 5Dirección de Enfermería
Correspondence: Guadalupe Mata-Valderrama
Introduction: Nurse tutors’ socio-affective skills refer to the teaching professional nursing practice with students, on the basis of the dimensions of organization, communication, integration and control while tutors are accompanying nursing students during practice.
Objective: To describe the level of socio-affective skills of nurse tutors with nursing students, as well as with postechnical courses of intensive care and administration.
Methods: Cross-sectional descriptive study. It was administered a questionnaire to a sample of 63 students. This questionnaire was validated by a round of 5/5 experts (0.952), structured in three sections: socio-demographic data, employment-related data, and socio-affective skills, which were divided into four dimensions: organization, communication, integration and control, with their respective sub-dimensions. The analysis was performed using descriptive statistics and chi-square.
Results: The general opinion of the students about the socio-affective skills of nursing tutors was excellent in 45%, good, 27%, and normal, 25%. Students felt that clinical tutoring was excellent in the subdomains of orientation (38%), planning (41.8%) and ranking (40.7%). 58.7% rated as excellent the subdomains of nonverbal communication, confidence (58%) and respect (63.4%).
Conclusions: Having expert nursing tutors and the training for such teaching practice in health care institutions certainly could potentiate the skills of students.
Keywords: Nursing education; Teaching; Nursing students; Professional competence; México
Clinical tutoring refers to the teaching function in the accompanying process that the nursing professional carries out with the student during his/her practice, at which point he/she provides orientation, support and stimulation of reflection to promote learning,1 as well as the adoption of new behaviors and skills. Therefore, mentoring is considered a key strategy in the education of health professionals.2
This has led to significant changes in the way nursing instructors should guide the student in clinical practice. In this formative process, the use of effective methods and the way to lead the student are fundamental elements, because, however it is, the personality is taught, as well as the behavior patterns that the student must follow.3
In this context, the World Health Organization (WHO) indicates that a comprehensive approach, supported by strong national leadership, good governance and adequate information systems, is necessary to ensure the existence of trained, motivated and supported health personnel. This approach should also focus on theoretical and practical training programs, as well as on performance-enhancing measures and actions to correct imbalances in the distribution of skills in the context of health care.4 For its part, Consejo Internacional de Enfermería (CIE),5 based on analysis and solution strategies to reduce the gap and improve the relationship between training and service, states that the lack of defined objectives for clinical training, the use of inappropriate methods, lack of good clinical references, and the advancement of scientific knowledge have an impact on the development of more complex capacities of nursing students worldwide. This involves training students with axiological principles for life and for the profession who are able to solve problems and unprecedented situations with creativity.
In this respect, the European Parliament's Directive (2005)6 facilitates the comparison between different national qualifications by linking examinations and educational levels to a common frame of reference. This is designed to help Europeans study and work abroad and focuses on the recognition of professional qualifications and the importance of clinical training in the learning process. In addition, it provides orientation about practical competences and establishes as essential the objectives that students and clinical tutors have to pursue throughout the different rotations, making it possible to introduce transversal competences related to ethical behavior, or essential values, ability to work in a team or therapeutic communication skills. Thus, clinical practices are no longer subject to a hidden curriculum, with the inconsistencies and variability involved, to turn them into visible, tangible and evaluable learning objectives.6 Reyes et al.7 studied the different negative learning experiences experienced by 71 nursing students in their first clinical practice rotation. These experiences are directly related to the behaviors and attitudes of nursing staff professionals with whom the students are assigned. The five dimensions of the questionnaire are: support, membership, treatment, participation in interesting learning experiences ,and transmission of values. The dimensions in which the students scored higher were: transmission of values (mean 1.59 [SD=0.69]) and participation in interesting learning experiences (mean: 1.06 [SD=0.73]). In this regard, they propose the design, implementation, and evaluation of a training intervention program with a focus on nursing professionals and the use of strategies or skills to identify and correct negative learning situations during practice, in order to establish a healthy and cordial relationship with the students.
Canaza-Alta et al.8 identified expectations about the ideal instructor profile in practice in 110 internal nursing students. According to the students, the teacher should be receptive (94%), respectful (94%) and relate cordially (91%). In this regard, the authors comment that clinical tutoring should be based on a teacher-student interaction that is affective and equitable to reinforce the desired behaviors in the student.
In this sense, approaching the formation and practice of human values involves maintaining a balance between the rational and the affective, and recognizing that emotions and feelings energize the moral, individual, and collective behavior of learners; therefore, it is important to promote development of emotional, social, and intellectual abilities in the student and strengthen the process of meaningful life learning.9 This is taking into consideration that traditional educational models in which knowledge prevail above emotions, lack the socio-affective component, and do not take into account that both aspects can not be unlinked.
Development of socio-affective ability allows students to conduct themselves in the intrapersonal, interpersonal, and axiological dimension;1 it is then that they are able to control their own emotions and be empathic, since they assume responsibility in making decisions and solve problems with an ethical sense and values, which allows them to control and direct actions, expanding the capacity to develop in their environment and to make it change.10-12 On the other hand, the clinical tutor with an emotionally stable personality must know what they do or explain in an atmosphere of trust and respect impacts the meaningful learning of the person whom they are in charge. This is why the formative work of the clinical tutor contemplates four dimensions and a different number of socio-affective subdimensions, all of them according to the development of teaching practice (Table I).13-15 Another relevant aspect of the teacher's task is moral judgment. Morality is not simply the result of unconscious processes or early learning, but is the product of mature rational judgment, which means that it can be modified or perfected.16
|Table I. Dimensions and subdimensions of socio-affective skills|
Its purpose is to reinforce the logical meaning of the practice and, consequently, make learning more meaningful
|Orientation||- Facilitate understanding of the environment
- Establish and clarify goals and values that guide behavior in practice
|Planning||- Analyze past experiences (prior knowledge)
- Outline needs and ways of working
|Hierarchization||- Order teaching actions to achieve the goal
- Take into account the needs of the learner and be flexible to their demands
Transmit information from one person to another
|Verbal communication||Transmit clear and direct messages that allow the exchange of ideas
- Answer questions
|Non-verbal communication||- Ability to listen to the student
- Be assertive with body expressions that support the student
Interpersonal influence of the tutor in common coordination with the student to achieve the objectives of the practice through the accompaniment
|Motivation||- Awaken students' curiosity and need to learn|
|Empathy||- Put themselves in the students' shoes
- Understand what the learners live or feel
- Facilitate individualized learning experiences
|Trust||- Generate a favorable environment
- Provide credibility to the student about his/her ability to achieve learning
|Respect||- Recognize the student as a person with learning needs|
Regulation of own attitudes, in accordance with the tutoring plan to achieve the student's learning objectives
|Criticism||- Deliberate and informed thinking, reasoning to judge and demonstrate ways of constructing knowledge, in order to solve problems, make decisions, or propose alternatives|
|Self-criticism||- Ability to openly recognize scope and limitations in mentoring, discover its causes, analyze the situation that generates it, and study the means to correct it|
|Availability||- Cooperative behavior, tendency of the tutor to participate in the learning activities of the student|
|Collaboration||- Interpersonal ability to support the student in the pursuit of the objectives of practice, in an environment of cordiality and teamwork|
Based on these concepts, it is essential to contextualize health service institutions and the scenarios where the clinical practices of the students are carried out. At the present time, the Instituto Mexicano del Seguro Social (IMSS) is one of the main organizations that form human capital in the field of health, due to its infrastructure and the coverage it has at the national level.17 In particular, mainly due to its presence in the various hospital services and for being the first contact with the students, the Hospital de Especialidades del Centro Médico Nacional La Raza of the IMSS, a teaching hospital, has 703 nursing professionals who may serve as clinical tutors. However, there is no explicit method of selection, either by experience or qualities to facilitate the learning process in students.18 Moreover, in the student's curriculum map, clinical tutoring is not considered to integrate theory with practice. Therefore, there is no fixed mentor plan for the student, nor performance guidelines for conducting clinical tutoring.
Considering the situation in which the clinical practice of the students is realized, it is necessary to identify and describe the socio-affective skills of the nursing professionals who work as clinical tutors. This knowledge will establish the strategic bases for training competent professionals with problem solving and human qualities based on values, which will give prestige to nursing, the institution, and the country.
A descriptive cross-sectional study was carried out with a non-probabilistic convenience sample of 63 students, in which each student evaluated the clinical tutor who accompanied them during the practice. The sample consisted of 25 eighth-semester undergraduate nurses who evaluated the general nurses. 30 students of the post-technical nursing course in intensive care evaluated the intensive care nurses and eight students of the post-technical course of administration evaluated the were floor manager nurses. All three groups were approached on their last day of clinical practice rotation and only those students who agreed to participate in the study were included.
For this purpose, a self-administered questionnaire was designed with 40 items with answers according to the Likert scale (1=never, 2=almost never, 3=sometimes, 4=almost always and 5=always). This questionnaire was validated in content and construction by a round of 5-on-5 experts and obtained an internal consistency of Cronbach's alpha 0.952.
The first section of the questionnaire included socio-demographic data such as age, sex, service practiced, shift, and course taken by the student. The second considered work experience and how many years of work experience the student had. Finally, the third looked at the socio-affective skills of nursing clinical tutors: based on this section, information was obtained on the four dimensions and subdimensions of each in relation to the student's experience. The organization included the criteria for orientation, planning, and hierarchization (items 1-9). Communication was valued through verbal communication and non-verbal communication (items 10-16), integration was assessed based on motivation, empathy, respect, trust (items 17-28), and control was estimated with the capacity for criticism, self-criticism, willingness, and collaboration (items 29-40).
The level of socio-affective skills of the clinical tutor was weighted as excellent from 151 to 200 points; good from 101 to 150 points; regular from 51 to 100 points; and deficient if the score was less than 50 points.
To verify the clarity and precision of the items, a pilot test was done on a sample of 10 students with practical rotation in a third level hospital whose study population was of similar characteristics, which determined the reliability, variability, and estimated time for its application (20 minutes).
The information was collected on the last day of the student's practice rotation in the administrative area of nursing, kidney transplantation, neurosurgery, neurology, coronary care, intensive care, and hemodynamics units. Participation was requested verbally and in written form, with letter of informed consent attached to the ethical principles and the rights of participants in research provided in the Ley General de Salud on the development of actions that contribute to psychological knowledge in human beings, and in which the criteria of respect for their dignity and protection of their rights and well-being must prevail.19 Based on article 17, an investigation is considered risk-free when there is no intervention or intentional changes to the psychological and social well-being variables.20 In accordance with the Declaration of Helsinki, the participants were treated with respect; their physical and mental integrity and their personality were cared for.21
For the analysis, we used descriptive statistics with frequencies and percentages for qualitative variables and for quantitative variables, dispersion measures, mean, median, standard deviation, and Chi-squared test.
Of the total number of students surveyed, 42.9% were under 24 years of age and 25.4% were between 30 and 34 years of age. The female sex predominated with 74.6%. More than half of the students (55.6%) were attending their eighth semester of the nursing degree program; 31.7% the post-technical course in intensive care; and 12.7%, the post-technical course in administration. 60.3% of the total number of students reported that they did have work experience. Of these, 39.5% had five to nine years of experience and 20.8% had less than five years.
Regarding the clinical tutor, 47.6% of the tutors worked as intensive nurses, 39.7% as general nurses and 12.7% as senior nurses. 59.7% of the clinical tutors worked ithe morning shift and 41.3% the afternoon shift. The service units where the students received clinical tutoring were: kidney transplantation (8%); coronary care (23.8%); hemodynamics (19%); intensive care (15.9%); administration (12.7%); neurology (11.1%); and neurosurgery (9.5%).
Socio-affective skills of clinical tutors
With respect to the general opinion of the students about the socio-affective abilities of the clinical tutors, the highest frequency was at the excellent (45%) level and, to a lesser extent, at good (27%) or regular (25%).
For the organizational dimension, more than one-third of the students thought that clinical tutoring was excellent in the subdimensions of orientation (38%); planning (41.8%); and the hierarchization category(40.7%); and it was considered good by 33.9% of students in the subdimension of orientation. More than half of the students (58.7%) rated the subdimension of non-verbal communication as excellent. At the same level of excellence were the subdimensions of integration, referring to trust (58%) and respect (63.4%). The score was similar for the control dimension in its subdimensions of availability (55%) and collaboration (42.9%).
It is important to note the four dimensions and subdimensions that were evaluated in a smaller (but no less important) proportion: verbal communication skills (29.2%); motivation (33.9%); criticism (31.7%); and self-criticism (21.2%) (Table II).
|Table II. Opinion of students on socio-affective skills of clinical tutors by dimension and sub-dimension
|Dimension and subdimensions||Level of socio-affective ability|
Source: Cédula de Evaluación de Habilidades Socioafectivas del Tutor Clínico
According to the students' opinion, the clinical tutors are excellent in the afternoon shift (47.6%) and morning shift (44.3%). When associating the level of socio-affective ability of the clinical tutor with the practice service, 51.3% of students considered that the tutoring received in the hemodynamic service was excellent, but the administrative area received only 37.1% and 36.2% in the excellent and regular levels, respectively. With regard to the level of socio-affective ability of the clinical tutor in the hierarchization category, 49.1% of students rated the general nurse tutoring as excellent; with 44.5% for intensive care nursing; and 38% for nurse floor manager tutoring. This latter is in the regular level with 35.2% (p=0.002) (Table III).
|Table III. Opinion socio-affective students on clinical skills tutors per shift, practice and service category hierarchy
|Variables||n||Level of socio-affective ability||p*|
|Kidney transplant unit||5||2||42.0||1||27.0||2||31.0||–||–|
|Intensive care unit||10||4||40.0||3||31.8||2||22.0||6.2|
|Coronary care unit||15||7||46.1||4||30.0||3||17.1||1||6.8|
|Floor manager nurse||8||3||38.0||1||19.1||3||35.2||1||7.7|
|F = frequency; N/s = no meaning [statistic]
*For statistical significance Chi-squared was used
Source: Cédula de Evaluación, Habilidad Socioafectiva del Tutor Clínico
It is relevant to comment that the socio-affective ability of nursing clinical tutors has been little studied. Recapitulating the results of the present study reflects a proportional distribution of students in terms of their opinion about the socio-affective skills of clinical tutors at excellent, good, and regular levels.
This contrasts with what Galicia et al.22 have mentioned in that planning is a process that is not explicitly performed by clinical tutors, which affects the practice environment and specifically the organization of work. In the present study we found that two-thirds of all students think that the planning of clinical tutoring is excellent and good in the criteria of analysis of past experiences (previous knowledge) and the outline of needs and ways of working.
Empathy as part of social competence and other values of clinical tutoring are tools that generate environments that facilitate student development, promote bonds that promote teaching and meaningful learning and, therefore, achievement of objectives. However, in the present study, a quarter of the students placed the clinical tutors at a regular or deficient level in the subdimension of empathy. In this regard, Reyes et al.7 report that the dimension with the highest negative score in the experience of students in practice was transmission of values. Prado et al.9, for their part, describe tutors who only sometimes take into account the needs of the other.
The fact that one third of students expressed that motivation to integrate the practice was excellent or good differs from the results of Reyes et al.,in which the students express that they were only allowed to learn by means of observation or carrying out routine activities, without participatiing in interesting learning experiences. Prado et al.9 state that for the majority of the study population, motivation was never present as a socio-affective process of learning. Likewise, Galicia et al.22 mentioned that the environment was determinant for the student's integration process not to be set in practice, since it set instead when performing routine activities in daily practice.
The above is relevant from the socio-affective perspective of motivation or the stimulus for the clinical tutors to maintain the students' interest through learning. At the same time, it enhances the integral development of the students.
The subdimensions of nonverbal communication and respect (which were rated by the majority of the students as excellent) were found to coincide with that reported by Hidalgo et al.,23 in reference to the fact that academic tutors always communicate with respect towards students. Additionally, those who perform clinical tutoring are nursing professionals of the health institution. Without a doubt, the fact that the clinical tutors are from the same health institution where the students perform the practice means a mastery of knowledge and experience in the area, teaching skills or professional awareness, so the impact on integration of the educational process in the students will be transformive for their professional attitudes and behaviors.
In the subdimensions of criticism and self-criticism, a similar proportion in excellent, good, and regular levels were found, a situation confirmed by Hidalgo et al.,23 for whom almost half of the population sporadically demonstrates knowledge and experience in the subjects. On the other hand, it is similar to the results in the subdimension of arrangement and collaboration, in which the tutor always shows interest in the tutoring process.
The results of the present study may be a good starting point not only for research studies at another level of approach, but also they can also be a point of support for generating training proposals on clinical tutoring for nursing professionals who work in the health services and in the institution.
From the perspective of the theory-practice integration, having expert clinical tutors, training for such a teaching exercise, and also working in the same health service institutions where the students perform the practices could certainly potentialize the skills and competencies of the latter.