Self-evaluation

in nursing students in Finland

Helena Leino-Kilpi

The article explores the self-evaluation in nursing students in clinical evaluation: the structure and topics in evaluation sessions and the student-teacher relationships. The data were collected by means of non-participant observation: evaluation sessions of 81 (=n) students were observed in hospitals and health centres. The results indicated the rather passive role of nursing students in self-evaluation; teacher-dominated relationships were the most frequent in sessions. In future there is a need for a deeper analysis of the clinical evaluation.

INTRODUCTION Finnish nursing education started in 1889; national reforms were implemented in 1930s 1970s and at the end of the 1980s. In the last reform the principles of student evaluation were modernized (AKH 1987); the teaching and learning now has a reflective (Carr & Kemmis 1986; Schon 1983; Zeichner 1987) and experiential (Burnard 1985, 1986; Kolb 1984) nature. Central importance is given to continuous professional self-improvement in the nurse’s job and one of the main concerns of nursing education is with critical self-evaluation. There is little reported research in Finland to explain what happens in the student evaluation process during education. In this article the purpose is to describe the process of self-evaluation in nursing students in clinical evaluation. The process is operationalised in two ways. First, there is an analysis of the structure and topics of evaluation sessions. Secondly, there is an analysis

Helena Leino-Kilpi PhD RN, Assistant Professor, University of Turku, Department of Nursing, Uudenmaantie 43, 20720 Turku, Finland (Requests for offprints to HL-K) Manuscript accepted 25 August 1992

424

of the relationships teacher. The research tion here are:

between student and questions under investiga-

1. What is the structure of the evaluation sessions? 2. What are the topics of self-evaluation in sessions? 3. What kind of relationship is there between student and teacher?

CLINICAL TEACHING AND EVALUATION IN FINNISH NURSING EDUCATION In Finnish national nursing curriculum (4.5 years) the theoretical and practical (clinical) knowledge are integrated. The theoretical lectures are mostly implemented in nursing colleges (classroom teaching). Clinical teaching occurs in health care centres and hospitals. Nursing teachers are responsible both for theoretical and clinical teaching; the teachers are special nurses with teacher education at the advanced level of nursing colleges (1.5-2 years) or at the universities (masters degree, 3 years). However, the main part of the clinical teaching is

NURSE EDU(:ATIC)N

done by clinical supervisors. The supervisors are (special) nurses employed by hospitals or health care centres. Their main work is nursing itself. The intensity of the supervision differs: there are units where some/one of the nurses can mostly concentrate on supervision, in most units, however, supervision is the minor part of their work. The teachers usually have students in many different units, which means that they for a short time only visit each unit, arrange clinical lessons and evaluative sessions. In the first clinical courses the teachers are with the students permanently. Clinical evaluation normally takes place continuously (process evaluation) and at the end of each study course (summative). In the evaluation sessions the student, supervisor(s) and the teacher are present. The criteria used are the objectives of the curricula. Grades are no longer (since the reform of 1980s) given in numbers, but the student gets a verbal grade (fair, good, excellent or failed). In this study the last summative clinical evaluation sessions before graduation will be described.

THEORETICAL

BACKGROUND

In this study, self-evaluation is seen as a part of professional growth; it is a skill which has to be practised during education. In clinical evaluation the independence of students often presents the highest desired level of performance (Bondy 1983; Fuhrman & Weissburg 1978; Malek 1988; Pavlish 198’7) and this independence includes self-evaluation skills. Self-evaluation is sometimes seen only as a part of process evaluation (formative evaluation), not intended to be used to make final decisions in the summative evaluation phase. For example, Abbott et al (1988) studied the self-evaluation and its relationship to clinical evaluation. They asked instructors (n = 9) and nursing students (n = 145) about self-evaluation; both groups described self-evaluation as an important source of information in clinical evaluation. They recommended self-evaluation as a part of formaN.E.T.

B

TODAY

425

tive evaluation; the independence in self-evaluation is to be recognised as a long-term goal for students. In Finnish nursing education, the self-evaluation is part of both process and summative evaluation (AKH 1987). The direct association between self-evaluation and professional behaviour has not been validated in nursing literature. There are, however, some relevant studies. For example Fuhrman & Weissburg (1978) suggest that health professionals who engage in self-evaluation are more likely to become self-directed, self-motivated and more analytical than their peers. Self-evaluation has been investigated also in connection with critical thinking. Kintgen Andrews (1991) did a literature review about the impact of nursing education upon critical thinking. She found very mixed results, both positive impact (Pardue 1987) and no impact at all (Sullivan 1987). Her conclusion is that the strong impact of nursing education upon critical thinking is still lacking. Problems have also been identified with already graduated nurses. For example Powell (1989) analysed nurses (n = 8) reflection-in-action in their everyday work and found the higher levels of reflection rare. The human action of nursing students is the topic under clinical evaluation. In this study, the elements of human action are the frame for analysing the topics and structure of evaluation sessions. Theoretically, the elements are illustrated in the Table (Leino-Kilpi 1990a). Table 1 The elements

of human action

Elements 1. The actor herself, her personality: What am I?

Content category

,Characteristics

2. The actors professional goals: What am I aiming at?-Aims 3. The activities taken by the actor to achieve the goals: What am I doing? -Activities 4. The ways in which the actor is pursuing the goals: Howam Iacting?-Ways 5. The prerequisites of action -Prerequisites Reproduced with permission from Leino-Kilpi 1990a Good nursing care.

426

NURSE EDIJCATIOEU’ TODAY

GIVING ADVICE:

CARING:

ADVlCE,INFORMS, TEACHES THE STUDENT; TEACHER‘S PERSPECTIVE OUMINAKT

ENVIROMENTAL FACTORS

ADVOCACY:

COMMON UMERINVOLVEMENT: TEACHER ENCOURAGES STANDING OF TASK: STUVENT TO TAKE PART IN PERFORMING A TASK; THE DECISION

TEACHER‘S ACTION AUTHORIZED BY STUDENT, ACTS AS ADVOCATE

!JN

STUVENT'S INVOLVEMENT TAKEN BY TEACHER

\

STUlJtNTAS INUEPENVENT ACTOR.TEACHER AS RESOURCE: TEACHER‘S PROFESSIONAL KNOWLEDGL AN0 SKILLS AT STUDCNl‘S uISt'oSAL

ACCOMPLISH A

STUDENT IS PASSIVE, NfJTNECESSARltV AWARE THAT SHE T9 RFING PROTECTED

STUDENT IS PASSIVE, SHE IS THE OBJECT OF ACTIVITY BUT VOES kDT TAKE PART IN IT, IS GENERALLY AWARE OF THE SITUATION

T STUOENT MAKES t STUDENT AUTHfJRIZESTEACHER UCCISIUNS AND ACTS INUEPENTO ACT VENTLY,ALSO ASSUMES RESPUNSlBILITV;USES TFACHER‘S EXPERTISE TO ENSURE PI:OTECT !JN AND EDUCATION, SEEKS TO GET

STUIJENTRECEIVES GUIUANCE AM, EDUCATION, IS AN OBJECT

u

STUDENT

Fig 1 Relationships

Acting with

as a nurse

other

analysis

between student and teacher in clinical evaluation

happens

human

of human

during education.

beings.

in collaboration That

relationships

is important

The student-teacher

as teacher-dominated,

student-dominated

collaborative

Leino-Kilpi

(Fig.

collaborative instructor

criteria

used

more

themselves.

(N = 379) were unaware in their

evaluation

student-centred

and

teaching

methods.

1990a). The positive self-evaluation

has benefits from the student-dominated nauskas

of the

to evaluate

the students

required 1,

1991), nursing students tend

to have opportunities However,

relation-

ships are here classified and

survey (Leino-Kilpi

is why the

ones. For example

(1983)

in their

relationships

study

and/or

Griffith

& Baka-

about

student-

see the supportive,

help-

MATERIALS

AND METHODS

The data were collected

in 1989 by observing,

in

ing relationship as ideal; it emphasises students’ personal responsibility in learning and also self-

a non-participant role, the clinical evaluation sessions of 81 graduating nursing students of

evaluation. Also Vaughan study, comparing nursing

one nursing

attitudes students

(1990) found in his students’ (n = 203)

the study

college was given

in Finland.

Permission

by the president

for

of the

towards teaching methodologies, that were more positively predisposed

college and the teachers and supervisors under study. In the beginning of the sessions the

toward student-centred than teacher-centred teaching (Huckabay et al 1977; Linares 1989; Mackie 1973). Based on the literature, self-evaluation is connected with self-reflection and student-centred

purpose of the study was explained to the students and their willingness to take part in it was requested. All students agreed to participate. The evaluation took place in meeting

learning.

In Finland,

according

to the national

rooms of hospitals and health centres. The students’ clinical performance was evaluated by

427

~UKSEEDU(:ATION~‘ODAY her nursing teacher (n = 12) and clinical supervisors (n = 129); no outsiders the researcher. 70 minutes

Sessions

lasted between

per student,

time amounted

were present except 10 and

while total observation

to 39.5 hours. The sessions were

tape recorded and the data were analysed by the method of content analysis. The content

analysis was discursive

in nature

and there were two phases in the analysis. structure no.

and topics were investigated

1 and

occurred frame

2).

Structure

in the

coding

frame

common 1990a).

is illustrated

theoretical

in the Table;

student

and

phase

the

using the classification 1990a).

were

in Figure The

coding

described

numerical codes In the description

(frequencies

and

itself in both

(borrowings

for the content both quantitative

percents)

from the original

and

to

self-evaluations

tended

be brief, plain and retrospective. 11 (14%) of the students referred to no specific area of nursing activity. ‘I’ve really enjoyed myself here.’ ‘I’ve had no difficulties.’ remaining

referred

70 situations,

in their first evaluations

the

students

to what they

‘I think I can plan better care now than before’ ‘Now

I am

more

They also referred

1 as a frame

cases was done in the margin of the written text by using elements.

in

The

skilful

in

the

technical

aspects.’

the relationships

teacher

at least some

had done (n = 62,77%).

of human action (Leino-Kilpi

In the second

(Leino-Kilpi

without

presented

clinical practice.

In the

as it

In analysis of the topics the

elements

between

was described

sessions,

for analysis.

First,

(problems

All of the 8 1 students

verbal account of how they felt they managed

qualitative

data) and expres-

sions are used.

performed

to the way in which they had

their tasks (n = 42, 52%).

‘During

this course

I have gotten

principles,

like individuality, better at’ ‘I think that now the basic care is more safety oriented,

I have a feeling that I do know what I

am doing.’ Finally,

they referred

to their personal

skills

and assets (n = 16,20%) ‘I have been thinking

in a more

professional

way, and have been more professional.’ ‘I think I have been more trustworthy this last course.

RESULTS

during

At least I know where to ask

the questions.’

The structure and topics of evaluation sessions In the structure

of the sessions

three

Experiences practical

eterisation)

different

students

phases could be identified: 1. An evaluative overview in the beginning

of

the session 2. More detailed 3. Feed-back

to the supervisors

at the end of

the session. in all 81 sessions the teachers made a conscious effort from the very outset to encourage self-evaluation by the student. Having first stated the objectives of the study course, the teacher

went straight

evaluate

the situation:

objectives

on to ask the student to what extent

been reached?

to

had those

strongly

of ineptitude

emerged:

(n = 54, 67%)

sufficiently swift or students (n = 16,20%) by reference

discussion

of failure

in various

activities (e.g. giving injections

of the

felt that they were not efficient. Some of the explained these feelings

to their personal

in turn were attributed

or cath-

two-thirds

weaknesses,

which

to their lack of experi-

ence and inadequate practice. In the more detailed discussion

that followed,

spontaneous self-evaluation by the students was very scarce. In the vast majority of the situations (n = 67, 83%) they simply listened to what their evaluators had to say, replied very briefly to any questions they had, and never disagreed on any point. The students’ role in these situations was very much characterised

by subordination.

428

NURSE EDUCATION

In the remaining

TODAY

I4 cases (17%)

where self-

reflection did occur, a distinction between 11 (14%) evaluation-seekers

was made and 3 (4%)

evaluation-escapers. taneous looked

questions at things

The

former

about

their

from

asked own

different

displayed a strong orientation

sponactions,

angles,

and

to the future.

The

protect and promote without

to evade any personal

and to avoid critical self-evaluation the issue in a broader staff situation were

long

whether

admitted

of

to hospital,

patients

the general

was all wrong.

were highly erratic,

at

with the teacher continually

took place at the end

the teacher

asked

the student

the quality of the supervision

received during the clinical practice. the feedback

was positive,

to

she had

In all cases

usually rather

brief

and not very specific.

‘The supervision

teacher-dominated

here.’

(64%)

situations.

A number of different types of student-teacher relationships were identified. These occurred randomly

teachers

often

in the

sense

that

took very different

the

same

attitudes

most common

Advice

occurring

in 52

was given on a wide studies: ‘In future

what you should

is this . . .’ Other

areas

of advice

remember included

the student’s

future

nurse (n = 12, 15%), her

attitude towards nursing studies in general

(n =

8, 10%) and various practical things (n = 4,5%).

identified

the students

received

the advice

without asking any questions.

A common

quite

with work clothes (n = 8,

variety of issues. In 32 (40%) cases it concerned

favourably

Relationships between student and teacher

(n =

the student’s future or further

In all cases

has been fine, no complaints.’

evaluation

about the grades

relationship,

action as a professional

‘All the supervisors have been friendly ‘They have been cheerful and fair.’

diffi-

during the session (n = 4, 5%).

and

of the sessions. In a large number of situations (n = 51, 63%)

the

Giving advice was the second

to supervisors

the

10%) had looked after herself (n = 4, 5%) was comfortable in the place she was sitting

discussions

her evaluation.

evaluate

18,22%) had any problems

to be

trying to shift the focus back to the student Feedback

had been informed

the

atmosphere

These

of

‘excessively’

had had a meal before session (n = 36, 44%)

there

waiting

side

the student

had found any exercises

by empeding

for example

the

cult (n = 39,48%)

criticism

on the ward was appalling,

queues

the hospital

context,

from

student. This manifested itself in a number of different ways; the teachers asked, for instance,

latter also took an active part in the discussion, but attempted

the interests of her student,

any demands

understanding

in 26 (32%)

such an understanding the evaluation

of the task was

situations.

In most cases

developed

in relation

to

situation itself or in relation to the

practical

arrangement

instance,

the students

problem

of scheduling

of

supervision.

were sympathetic supervision:

For to the

‘There

is so

to

much to do here. . .’ or ‘We are always too busy’.

different students. On the whole, however, all student-teacher relationships tended to be quite

The absence of any sharp criticism of supervision was obviously related to this as well; there

positive and constructive: the discussions focused strictly on the objectives of the curricu-

was instead a tendency comings. In a rather

lum, and any critical evaluations were presented with caution and tact. In the evaluation sessions

advocate

the

means

teacher-dominated

relationships

(Fig.

1)

for that

to ‘understand’

loose sense teachers their the

students. student

its short-

also acted as

Advocacy

actively

here

seeks

the

were most frequently seen. Protection and caring on the teachers’ part were observed in all 81 situations. Much in the same way as a mother-child relationship, the

teachers involvement (cf protection and caring, where the opposite can be seen). In 21 (26%) situations the advocacy was on a rather technical

teacher

various

here

has purely

altruistic

motives

to

level: the students had asked the teacher to bring messages

for them

(letters,

results

of

NURSE EDUCATION

exams,

phoneclass),

teachers

in

rearranged

ing to students messages

11

(14%)

lecturing

wishes,

schedules

in 8 (10%)

from their students

The

situations

main

focus

was nursing

accord-

they took

of students’

activities

ways of acting;

(What

429

self-evaluation

am I doing?)

the aims and

action had minor importance.

to other teachers,

TODAY

and

prerequisites

of

The students

felt

and in 8 (10%) situations they arranged for changes in the student’s work schedule. There is no doubt that the students could have - and perhaps should have - taken care of all of these

as though they lacked adroitness or manual dexterity. By contrast, none of the students had

things themselves.

should be noted by people who are responsible for designing nursing curricula.

deeper

Advocacy

also occurred

sense in 6 (7%) situations,

in a

in very per-

any doubts about their goals, their personality, or

about

their

theoretical

knowledge;

sonal problems. There were 5 (6%) cases in which the teachers

very positive and constructive.

were used as a resource

was a clear

to situations

where

in learning.

having

failed

Student-teacher

This refers to resolve

a

complex problem in clinical practice, the student asked the teacher’s and supervisor’s opinion about the alternative strategies she might have used. Basically, what students were asking was, ‘What should the

I have done?’

teacher’s

expert.

role

This

confidential

In these situations

approximated

relationship

that

in

as

students

demands

ation sessions of 81 graduating

student-teacher There teachers

were

students.

two main

of

the

In the

methods

to encourage

ation by the students

the

although

the

made

of data collection

and support

self-evalu-

in the beginning

the determination

(Miles

eight

them

evaluations.

effort on the part of the

of the teachers

to lapse after just a few questions.

learning/

of the tended

The students,

problems

and analysis of validity and

8c Huberman

1984;

did

more

It is, however,

real influence could,

supervisors

somewhat

difficult

of the observer.

for example,

admit

lenient

have rendered

several years of studying, teachers not having adequate

or the result of skills to encourage

serious self-evaluation (cf Flagler et al 1988) - a question that should be given fuller attention in further research. This discovery is a very serious one in light of the emphasis on critical self-evaluation

in Finnish

1980s (AKH

nursing

education

1987; Leino-Kilpi

1991).

since

the

presence

ations more positive as a whole. And in a more general level one might ask whether this kind of evaluation is a convenient way to find the real skills of the students (Hepworth 1991), The

coding

frame

in both themes

The

from

it

the evalu-

form

that comes

that

in their

to know the

Her

broad and needs more exact categories

passiveness’

Weber

it should be

in turn, tended to adopt something as a backstage role. It remains unclear whether this is a of ‘learned

of the

a student-centred

noted that the subjects did not feel the presence of an outside observer affected their behaviour,

and

sessions. This, however, was not a very persistent effort;

were most

Self-evaluation

1990). As far as validity is concerned,

areas:

session

relationship.

was a conscious

on the part

by the finding

teaching attitude (Abbott et al 1988); that is why the research has to be taken further examined.

reliability

topics

on

could

No doubt this

passiveness relationships

involve certain inherent

there

took

students

and is supported

in situations.

there

to be over-

they

adult

themselves.

that teacher-dominated

can be described

that

the

feature serves to increase

common

This study examined self-evaluation by Finnish nursing students by observing the clinical evalu-

and

sense

that

of the student

were generally However,

for teachers

easily have managed

The

stucture

the

responsibilities

an

DISCUSSION

observation

tendency

protective

of

and collegial.

relationships

that

frame,

patterns

however,

was useful

in data. For reasons

was quite in future.

for exposing

of reliability,

pri-

mary data have been used in description. The material consists of students from only one nursing

college:

generalisations

it is obvious

that

no broad

can be made on the basis of the

results. The coding itself is also done only once. The results were offered for inspection and discussion to five randomly selected clinical

430

NURSE EDUCATION

TODAY

supervisors and teachers; based on their opinions no changes were considered necessary. It seems that nursing education, and clinical evaluation in particular, still has certain traditional features in Finland. Nonetheless, behind the rituals of this tradition there is definitely some effort to encourage critical self-evaluation in nursing students. That effort should be given every support in the future. The results also have much relevance to teacher education with regard to the evaluative activities of teachers (Leino-Kilpi 1990b; Zeichner 1987).

References Abbott S, Carswell R, MC&tire M, Best M 1988 Selfevaluation and its relationship to clinical evaluation. Journal of Nursing Education 27: 2 19-224 AKH 1987 Opiskelija-arvioinnin ohjeet ammatillisia opptlattoksia varten. Helsinki Bondy K 1983 Criterion-referenced definitions for rating scales in clinical evaluation. Journal of Nursing Education 22: 376-382. Burnard P 1985 Learning human skills. A guide for nurses. Heineman. London Burnard P 1987 Towards an epistemiological basis for experiential learning in nurse education. Journal ofAdvanced Nursing 12: 189-193 Carr W, Kemmis S 1986 Becoming critical: education, knowledge and action research. Falmer Press, London Flagler S, Loper-Powers S. Spitzer A 1988 Clinical teaching is more than evaluation alone! Journal of Nursing Education 27: 342-348. Fuhrmann B, Weissburg M 1978 Self-assessments. In: Morgan M, lrby D, eds. Evaluating clinical competence in the health professionals. CV Mosby, St Louis: 139-152 Griffith J, Bakanauskas A 1983 Student-instructor relattonships in nursing education. Journal of Nursing Education 22: I04- 107

Hepworth S 199 1 The assessment of student nurses. Nurse Education Today 11: 46-52 Huckabay K, Cooper P, Neal M 1977 Effect of specific teaching techniaues. Nursing I>Research 28: 3 16-37. 380-3G n Kintgen-Andrews J 1991 Critical thinking and nursing education: Perplexities and insights. Journal of Nursing Education 30: 152-157 Kolb D I!%4 Experiential learning. Prentice-Hall, New Jersey Leino-Kilpi H l99Oa Good nursing care. On what basis? Annales Universitatis Turkuensis D49. University of Turku, Turku, Finland Leino-Kilpi H 199Ob Self-reflection in nursing teacher education. Journal of Advanced Nursing 15: I92- 195 Leino-Kilpi H 1991 Kehittavan opiskelija-arvioinnin kokeilu terveydenhuoltoalalla. Opetushallituksen .julkaisuja l/l99 I. Helsinki Linares A 1989 A comparative study of learning characteristics of RN and generic students. Journal of Nursing Education 28: 354366 Mackie J 1973 Comparison of student satisfaction with educational experiences in two teaching process models. Nursing Research 22: 262-266 Miles M, Huberman A 1984 Qualitative data analysis. Sage, Beverly Hills, CA Pardue F 1987 Decision-making skills and critical thinking ability among associate degree, diploma, baccalaureate and masters prepared nurses. Journal of Nursing Education 26: 354-361 Pavlish C 1987 A model for clinical performance evaluation. Journal of Nursing Education 26: 33% 339 Powell J lYg9 The reflective practitioner in nursing. Journal of Advanced Nursing 14: X24-832 Schon D l9H3 The reHective practitioner. How professionals think in action. Temple Smith, London Sullivan E 1987 Critical thinking, creativity, clinical performance and achievement in RN students. Nurse Educator 12: 12-16 Vaughan .J 1990 Student nurse attitudes to teaching/ learning methods. Journal of Advanced Nursing 15: 925-933 Weber R 1990 Basic content analysis. Series: quantitative applications in the social sciences. Sage, Newbury Park, CA Zeichner K 1937 Preparing reHective teachers. Journal of Education Research 1 I : 565-575