The Effect of Internships on Clinical Decision Making and Professional Values of Nursing Students

Abstract

This study was conducted to determine the effect of internships on nursing students clinical decision-making skills and professional values. This descriptive study used a pre/post-test design with a single group. The study sample consisted of 100 nursing students. A significant difference was found between the interns Nurses Professional Values Scale total (pre-test=113.55±22.39; post-test=125.56±20.47). No significant difference was determined between the Clinical Decision Making in Nursing Scale total (pre-test=138.98±16.13; post-test=137.97±16.24) pre-test and post-test mean scores (p>0.05). It was concluded that nursing internships positively affected nursing students professional values, but did not affect their clinical decision-making skills.

Headnote

Abstract This study was conducted to determine the effect of internships on nursing students clinical decision-making skills and professional values. This descriptive study used a pre/post-test design with a single group. The study sample consisted of 100 nursing students. A significant difference was found between the interns Nurses Professional Values Scale total (pre-test=113.55±22.39; post-test=125.56±20.47). No significant difference was determined between the Clinical Decision Making in Nursing Scale total (pre-test=138.98±16.13; post-test=137.97±16.24) pre-test and post-test mean scores (p>0.05). It was concluded that nursing internships positively affected nursing students professional values, but did not affect their clinical decision-making skills.

Keywords: nursing student, internship application, decision making, professional values

Introduction

Many countries pursue educational policies and make efforts to transfer nursing training programs from hospitals to university settings, to raise the quality of nursing education and to develop nursing as a discipline with both academic and practical aspects. Nursing, a discipline based on practice, aims to enable students to be academically prepared for acquiring and developing specific knowledge and skills to manage their healthcare practices and applications, and to gain sufficient practical experience to use them in real life Therefore, professional nurses design and use various clinical training models to help nursing students improve their practical knowledge, and thus optimize their overall learning process (Edmond, 2001). Simulation and laboratory experiences provide important contributions to the development of nursing students knowledge and skills. However, the clinical experience developed by providing patient care in a practical setting is an indispensable component of the nursing profession and is regarded as a sign of quality in nursing education (Tanner, 2006a).

Clinical nursing education has two legs academia and health institutions which affect each other. One of the most important components for successful clinical learning is a supportive clinical environment. The clinical experience provides students with the ability to use their knowledge in a real environment, and to develop psychomotor skills and professional socialization. Many universities experiment with new methods to make clinical practice more efficient and instructive. The most common method used in recent years is the internship (Budgen & Gamroth 2008).

The most important aim of the internship is to provide students with professionalism in all of the cognitive, emotional and behavioral skills expected to be gained in graduation, together with the experiences they gained during their three years of study. Other aims of the internship include ensuring students adapt to the field of practice and occupation, providing them with experience to build their technical skills in different application environments, strengthening their clinical decision-making skills in real life environments and making them aware of professional values (Hatipoglu et al. 2012). Clinical decision-making in nursing involves giving patient care by understanding the effect of illness on individuals, families and society. The internship also aims to offer individualized care to patients by identifying the emotional, sociocultural and economic inadequacies of them, their families and the society in which they live (Tanner, 2006b). The World Health Organization considers the development of clinical decision-making, problem-solving and critical thinking skills as gold standards for the training of professional nurses in nursing schools (WHO, 2009).

Intern nursing students are expected to acquire knowledge, skills and attitudes appropriate to the nursing profession so that nursing care can be carried out most efficiently. Nurses need to act in accordance with professional values beyond their personal values when giving healthcare to patients, advocating professional behavior and attitudes, explaining their justifications, and making decisions in ethically challenging situations (Babadag, 2010; Atabek Asti & Karadag 2015). In addition to being valued by an occupational group, professional values are key to the professional identity of the nursing practice and constitute a basis for the professionalization of the nursing profession (Sabanciogullari & Dogan 2012). In light of this information; evaluating the effects of internships offered for the first time such as students' decision-making skills, and perceptions of professional values, is considered important for creating more efficient and productive internship programs in the nursing education.

Materials And Methods

Type of Study:This study was conducted to determine the effect of internships on the nursing students' clinical decision-making skills and professional values. This descriptive study was performed using the pre/post-test design with a single group.

Study Population and Sampling:The study participants were fourth-year nursing students (N: 145) from the Nursing School of the Faculty of Health Sciences who completed internship. The study sample was composed of 100 nursing students who met the research criteria and were selected using a simple random sampling method from probabilistic sampling methods. 18 students were reluctant to participate in the survey, 8 students were not in class at the time when the research data were collected, 9 students asked to withdraw from the survey without conducting the post-test, and 10 students did not complete the questionnaire.

Data Collection Instruments: The research data were collected using face-to-face interviews in the form of a pre-test post-test before and after the internship. The data collection tools used in the research was the Sociodemographic Characteristics Form, the Nurses' Professional Values Scale (NPVS), the Clinical Decision Making in Nursing Scale (CDMNS).

The Sociodemographic Characteristics Form contains questions about the nursing students' age, gender and clinical practice.

The Nurses' Professional Values Scale (NPVS): The Nurses' Professional Values Scale was developed by Darlene Weis and Mary Jane Schank in 2000 to evaluate the development of nursing values that reflect the ethical codes of the American Nurses Association (ANA) (Weis & Schank 2000) and was adapted to Turkish by Şahin and Ecevit in 2005 (Sahin Orak & Ecevit 2012). The NPVS, with 44 items (score: min 44, max 220) developed by Weis and Schank in 2009 was used in this present study. The high scores indicate that nurses attach great importance to professional values and, therefore, their professional value perceptions are high. The Turkish version of NPVS reflects five factors: human dignity, responsibility, taking action, security and autonomy. The Cronbach's alpha value of the scale was found as 0.94 by Weis and Schank (Weis & Schank 2000) and 0.95 by Sahin Orak and Ecevit (Sahin Orak & Ecevit 2012).

The Clinical Decision Making in Nursing Scale (CDMNS): The Clinical Decision Making in Nursing Scale (CDMNS) was developed by Jenkins in 1983 (Jenkins, 1983) and the reliability and validity study of the scale was conducted by Dicle and Durmaz (Dicle & Durmaz 2012). The scale describes clinical decision-making perceptions of nursing students. The total score ranges from 40 to 200 points, and each subscale scores ranges from 10 to 50 points. The score evaluation can be done on the basis of total mean score and mean score on the subscales. The high score from the scale indicates a high and positive perception in decision-making. The Cronbach's alpha value was found to be 0.83 in the original study of the scale (Jenkins, 1983). The Cronbach's alpha value of the total scale was found to be 0.78 in the reliability and validity study (Dicle & Durmaz 2012).

Evaluation of the Data: The research data were analyzed using the Statistical Package for Social Sciences for Windows 22.0 program (Tanner 2006b). Arithmetic mean, standard deviation, minimum-maximum values, frequency and percentage values were used as descriptive statistics in the evaluation of the research data. The Wilcoxon sign test and t-test were used to compare the pre-test and post-test mean scores of the scales. The Cronbach's alpha coefficient was used to test the reliability of the scales.

Ethical Aspect of the Study: Before conducting the study, ethical consent was received from the Ethics Committee of the Faculty of Health Sciences, and verbal permission was obtained from the Dean of the Faculty to collect the research data. The principles of "Informed Consent," "Privacy and Privacy Protection" and "Respect for Autonomy" were fulfilled by explaining the purpose of the research to the participating students, stating that the information obtained from them would be kept confidential, and ensuring participation of all volunteer students in the research, respectively. This study can be generalized to the intern students who studied at the Faculty of Health Sciences.

Results

The mean age of the interns was 22.12 ± 0.9 years old and 76% of them of were female. 51% of the intern students stated before taking part in the internship that they liked the nursing profession; this ratio increased to 58% after the internship, and the difference between them was found to be statistically significant. In addition, 10% of the interns reported before the internship that they felt self-confident in healthcare; this ratio increased to 35% after the internship. The difference between them was found to be statistically significant. Moreover, 24% of the nurses explained before the internship that they felt self-confident in clinical practice; this ratio increased to 56% after the internship. The difference between them was also found to be statistically significant.

The intern students' mean NPVS score was determined as 113.55 ± 22.39 before the internship and 125.56 ± 20.47 after the internship, and the difference between them was found to be statistically significant (p<0.05). After the internship, the mean scores of the subscales of "human dignity," "responsibility," "taking action," "security" and "autonomy" were found to increase from 40.58 ± 8.86 to 45.98 ± 7.29, from 25.30 ± 5.30 to 27.36 ± 5.61, from 18.05 ± 4.00 to 20.06 ± 3.86, from 14.83 ± 3.42 to 15.88 ± 3.43, and from 14.79 ± 3.90 to 16.28 ± 3.04, respectively (p<0.05). A statistically significant difference was found between the intern students' pre-test and post-test mean scores of the subscales of NPVS (p<0.05).

The intern students' pre-test and post-test mean total scores on the CDMNS were determined as 138.98 ± 16.13 and 137.97 ± 16.24, respectively, and no statistically significant difference was found between these scores (p>0.05). Also, no statistically significant difference was found between the interns' pre-test and post-test mean scores on all of the CDMNS subscales (p>0.05).

The interns' pre-test and post-test mean total scores on the ICS-A were determined as 4.19 ± 0.52 and 4.35 ± 0.41, respectively, and a statistically significant difference was found between these scores (p>0.05). After the internship, the mean scores of the subscales of "clinical status," "personal life status," and "decision control" were found to increase from 4.79 ± 0.63 to 4.99 ± 0.48, from 3.51 ± 0.36 to 3.61 ± 0.33, and from 4.27 ± 0.58 to 4.56 ± 0.42, respectively, and a statistically significant difference was found between the pre-test and post-test mean scores of all of these subscales (p<0.05). The interns' pre-test and post-test mean total scores on the ICS-B were determined as 4.29 ± 0.47and 4.33 ± 0.42, respectively, and a statistically significant difference was found between these scores (p>0.05). After the internship, the mean scores of the subscales of "clinical status," "personal life status," and "decision control" were found to increase from 4.82 ± 0.57 to 4.97 ± 0.51, from 3.50 ± 0.32 to 3.63 ± 0.28, and from 4.29 ± 0.54 to 4.39 ± 0.49, respectively, and a statistically significant difference was found between the pre-test and post-test mean scores on all of these subscales (p<0.05).

Discussion

Measuring the professional values of nursing students is important as professional values in nursing are accepted as the basis of nursing practices (Weis & Schank 2000). The interns' mean NPVS score was found as 174.81 ± 23.63 by Kaya et al., (2012), 100 ± 15.61 by Lin and Wang (2010), 106.45 ± 13.61 by Geckil et al. (2012), 101.43 ± 12.78 by Iacobucci et al. (2013), 132.3 ± 15.8 by Karadagli (2016) and 121.06±11.27 by Dikmen (2016). It was also found as 140.27 ± 16.81 for Taiwanese students and 106.16 ± 12.93 for American students in the study conducted by Alfred et al., (2013). This present study reports that the mean pre-test NPVS score (113.55 ± 22.39) is at moderate level and the mean post-test NPVS score (125.56 ± 20.47) is higher than the mean pre-test NPVS score, which indicates that participating in an internship increases nursing students' level of professionalism. This result also suggests that the values of professionalism are essential for nursing students. Students with high professional value perceptions will provide better quality and qualified care in their professional life, help increase patient satisfaction levels, and increase professional identity. This present study suggests that the increase in interns' mean NPVS score after the internship may be due to their ability to care for and treat patients on their own without the need of a faculty member to assist with decision-making, and also because of the fact that they can easily use the knowledge they have gained over the past four years during their nursing undergraduate education.

The present study determined that after the internship, the mean score of the NPVS subscale of "human dignity" increased from 40.58 ± 8.86 to 45.98 ± 7.29. The interns may have given more importance to human dignity because they cared patients for four days every week during the internship, spent time with patients, and thus had a better understanding of patients and their needs. In addition, the significant increase in the interns' human dignity scores suggest that they performed occupational practices respecting the individuality of patients. The present study determined that after the internship, the mean score of the NPVS subscale of "responsibility" increased from 25.30 ± 5.30 to 27.36 ± 5.61. The increase in the level of responsibility of the interns suggests that providing patient care with clinical nurses developed their sense of self-confidence and responsibility. It is also thought that the development of their sense of responsibility during the internship was because they fulfilled nursing professional roles and responsibilities and had a sense of ownership for the nursing profession.

The present study determined that after the internship, the mean score of the NPVS subscale of "taking action" increased from 18.05 ± 4.00 to 20.06 ± 3.86. The increase in the interns' scores on the subscale of "taking action" suggests that since students develop their cognitive, emotional and psychomotor aspects during the internship as the last step of their education, they want to pursue their profession at a scientifically higher level. Identifying the methods that will help patients to overcome their health problems effectively and taking necessary actions in this regard are very important in terms of effective nursing care and development of the nursing profession.

The present study determined that after the internship, the mean scores of the NPVS subscales of "security" and "autonomy" increased from 14.83 ± 3.42 to 15.88 ± 3.43 and from 14.79 ± 3.90 to 16.28 ± 3.04, respectively. The reason for the increase in the interns' scores on the subscale of "autonomy" may be attributed to the fact that they provided healthcare without assistance from a faculty member, using the knowledge and skills they acquired for fours years during their nursing undergraduate education. In addition, the fact that students stayed for the first time in a hospital for night shifts during the internship may have improved their autonomy. The internship contributes to the ability of students to make nursing decisions and the independence of individuals in their own practices. Autonomy in healthcare practices and decisions is one of the characteristics presenting professional nursing attitude. The fact that autonomy is rated highly by nursing students who have completed an internship will shed light on the development of the nursing profession.

Clinical decision-making in nursing does not only include providing care by understanding patients' clinical status, illnesses, and pathophysiological situations, but also involves identifying their own and their family's physical, social, and emotional difficulties during the care process, understanding their coping skills, and reflecting this situation into their care practices. Practical clinical training activities play an important role in the education of nursing students (Tanner 2006b). In addition, it is important to evaluate students' decision-making skills as a positive assessment of nursing education contributes to their motivation in the nursing profession (Dante et al., 2013). The intern students' pre-test and post-test mean total scores from the CDMNS were determined as 138.98 ± 16.13 and 137.97 ± 16.24, respectively, and no statistically significant difference was found between these scores (p>0.05). The nursing students' mean CDMNS score was found as 124.24 ± 12.713 by Ho et al. (2013). In addition, the mean CDMNS score was determined as 147.9 ± 10.19 by Krumwiede (2010), 147.21 ± 11.05 by Girot (2000), and 144.22 ± 13.71 by Yaman Aktas and Karabulut (2016). Moreover, Durmaz and Dicle (2012) found the mean CDMNS score as 154.78 ± 10.55 in students who received computer-aided simulation training on clinical decision-making skills, and as 157.26 ± 9.29 in students who received laboratory training on vocational skills. The reason why the mean CDMNS score of the intern nursing students was lower in this present study than some other research results may be attributed to the differences in training and application areas, the deficiencies and non-innovative approaches in classical nursing education curriculum, the crowded classes, and the lack of teaching staff.

Conclusion and Recommendations: It was concluded that internships in nursing education positively affected nursing students' professional values, but did not affect their clinical decision-making skills. It is important for nursing students to develop professional values and decision-making skills because these values are an important predictor of quality healtcare and professional development. The factors affecting nurses' professional values while organizing training programs for enabling them to internalize nursing philosophy, and conducting future studies on this subject should be taken into consideration. It is also recommended to repeat this study with nursing students and nursing groups in different fields to create data that will contribute to the professional development of the nursing profession.

Sidebar

Correspondence: Bahar Ciftci, Assistant Professor. Ataturk University, Faculty of Nursing, Department of Nursing Fundamentals, Erzurum, Turkey [email protected]

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