«Clinical placements have multiple stakeholders, each with their own set of expectations and requirements, both explicit and implicit. Placement ...»
Understanding the needs of all the stakeholders: Training and
preparation for students and their supervisors
Southern Cross University, Gold Coast, Queensland, Australia
Clinical placements have multiple stakeholders, each with their own set of expectations and requirements, both explicit and
implicit. Placement negotiations happen at many levels and those at the coalface are often unaware of these multiple
expectations. Teaching students and their supervisors to consider the stakeholders more broadly can build their capacity to manage the WIL experiences more skilfully, leading to better outcomes for all.
Two academics who work closely with a range of practice-based learning placements for students in Nursing and Allied health suggest that by developing the ability to consider what advantages and disadvantages there may be in one encounter for all the stakeholders, students and their clinical supervisors are in a strong position to maximise the benefits, limit the disadvantages and increase the satisfaction of the greater number of stakeholders. While this cannot be learnt by rote or ticked off against any particular checklist, social awareness, communication skills and relationship development and maintenance hold the key to success.
Keywords: Multiple stakeholders, social astuteness, WIL, clinical placements, expectations Clinical placements have multiple stakeholders, each with their own set of expectations and requirements, both explicit and implicit. Placement negotiations happen at many levels and those at the coalface are often unaware of these multiple and often, conflicting expectations (Siebert & Costley, 2013; Yap, 2011). Freeman (1984, p. 46) has defined a stakeholder as ‘any group or individual who can affect or is affected by the achievement of the organisation’s objective’. Teaching students and their supervisors to consider the stakeholders more broadly can build their capacity to manage the WIL experiences more skilfully, leading to better outcomes for all. Importantly, successfully managed stakeholder relationships have the potential to benefit the institutions through ongoing and sustained relationships and by providing students with opportunities for employment after graduation.
Clinical placements are integral to preparing healthcare workers to take up positions in the health workforce after graduation. They are a requirement for accreditation for nurses and allied health workers. Clinical placements provide students with opportunities to integrate theory with practice, to develop clinical competence, strengthen confidence and build on their skillsets (Rodger et al., 2008). As clinical placements hold an important position in the health education of nurses and allied health disciplines, much effort is expended ensuring that students are prepared for their placements. Professional development is available to clinical teachers and those who aspire to fulfil these roles. Unfortunately, a number of issues of unmet expectations for both students and hosting facilities are consistently identified in the literature (A. E. Nielsen, Noone, Voss, & Mathews, 2013; C.
Nielsen, Sommer, Larsen, & Bjork, 2013).
Employers often comment that students are ill-equipped to demonstrate agency, intentional motivation to work towards strategic goals (Fortune, Ryan, & Adamson, 2013). Graduates are seen as unprepared for the realities of employment, and unable to cope with the pressures of the work environment (Adamson, Hunt, Harris, & Hummel, 1998). It is necessary to provide learning experiences that help students develop social astuteness, interpersonal influence, networking ability and apparent sincerity (Ferris et al., 2007), while demonstrating the skills and knowledge they have acquired and their understanding of the models and theories that underpin their learning. Harvey, Harris, Harris & Wheeler (2007) argue that politically skilled individuals are better able to manage interprofessional relationships due to their skills in interpreting social information and responding to the information with situationally appropriate behaviours (p.108). This ability to understand social interactions at work helps them to respond to situations effectively, minimising disruption and maximising benefit.
The success of placements is measured on multiple parameters that include the satisfaction of multiple stakeholders: students; the facility; the clinical teachers; the patients/clients; the unit assessors; university and accrediting bodies, to name a few. It includes the strategic objectives of multiple organisations and this makes it crucial not only to identify all the salient stakeholders, but to manage robust relationships with them so these objectives can be managed optimally (Assudani & Kloppenborg, 2010). Students and clinical supervisors need to develop self-management skills, so that social stressors of multiple demands in the workplace can be managed without the intrusion of personal stress that can disrupt effective learning and supervision.
Freeman (2010) argues that instead of viewing stakeholders as disparate in their interests, to manage stakeholders well, they should be seen as “bound together by the jointness of their interests” (p.7). In other words, it is important to understand how the relationships work. It is, therefore, vital to consider what the student placement brings to the relationships that already exist. Clearly this is a complex issue. It is unreasonable to expect students and clinical teachers to understand the complexities of the relationships and interests that exist in the workplaces they enter to spend relatively short periods of time. However, this does not mean that they should ignore their existence. While they may be forgiven for failing to fully understanding these relationships, they may not be forgiven for ignoring their existence.
Mitchell, Agle & Wood (1997) provide some guidance for defining who and what really counts in stakeholder recognition. They categorise stakeholders according to their possession of one, two or all of the following
(1) The stakeholder’s power to influence the institution/s (2) The legitimacy of the stakeholder’s relationship with the institution/s (3) The urgency of the stakeholder’s claim on the institution/s In the case of successful ongoing placements, the needs of and benefits to all stakeholders have been established, either purposefully, or serendipitously, and the efforts to maintain the relationships have become shared across the placement communities. However, it is never wise to rest on one’s laurels, as these relationships are dynamic and the needs and objectives of the parties are likely to shift or change. These relationships are likely to have a life cycle with several stages in which the different priorities exert their influence and demand for attention. The need for vigilant, careful management of these relationships is a constant one.
EXAMPLE FROM THE FIELD
Students from three disciplines were provided placements in a primary health care setting with older adults.
They were afforded the opportunity to interact with adults in residential care, and with adults living independently; managing their own health in the villages attached to the residential care facilities. The facilities had provided placements for nurses in the residential care facility as part of an ongoing agreement, but had not provided placements for either the clinical exercise physiology (CEP) or occupational therapy (OT) students before. In OT terms these were emerging placements, with opportunities to introduce new primary healthcare services and demonstrate their benefits to the placement partners and the participants.
The two emerging placements differed in both the number of students on placement and also the nature and timing of the placements. The CEP students varied in number on any one day from one to eight and their placements were spread across four separate sessions, with ten students provided with placement opportunities over the period. The clinical supervision of these students was shared by two registered clinical exercise physiologists who also work in private practice. These were master students completing placements for accreditation with Exercise Sports Science Association (ESSA).
The OT students were in their final placement before graduation, at the end of a four year undergraduate degree.
Their programme stipulated a placement of ten (10) weeks in a block of time. They were supervised by a registered OT who also worked in private practice. Due to the length and intensity of the placement, the project leader worked with the residential care facility and the managers of the independent living village to scope two projects that would be of benefit to both the students and the placement sites.
The director of nursing in the residential care facility made every effort to ensure that the OT students were made to feel a part of the establishment. Students were accommodated in the office shared by the senior health team.
They were included in staff training and were encouraged to accompany the staff on their rounds. They were also directed to provide professional insight and support in specific cases. The real world task requested by the director of nursing was an audit of the facility from an OT perspective with recommendations for a planned refurbishment of a wing. The second task was an overview of the health status of the residents of the independent living village from the information gathered through the risk and resilience assessments with the participants, providing vital planning information.
NARROW FOCUS ON OWN EXPECTATIONSDespite the clear direction given to the occupational therapy students and the support provided by the facilities, the clinical supervisor and the project leader, the two young women found it difficult to settle in and tackle the tasks. They focused on their fairly narrow interpretation of the assessment requirements for registration, unable to think more broadly about the ways in which the required tasks not only fulfilled those requirements, but also provided valuable on-the-job learning, evidence of two real world tasks and opportunities to develop skills and an understanding of the day to day operations of two different entities, both involved with the health and wellbeing of older adults. They were unable to recognise the multiple stakeholders, and therefore, their needs, and remained focused on their own expectations of the placement. The project leader and the clinical supervisor expended much time and effort trying to expand their understanding of the opportunities and of their responsibilities, working together to motivate the students who exhibited low levels of engagement and poor attitude by the end of the second week.
In an attempt to engage the OT students and to meet their expectations of the placement, the clinical supervisor worked with the students as if they were her clients. She asked them to reflect on their lifestyle habits, health challenges, anxiety and fears of life transitions, personal life goals, mindset and psychological barriers. Under the guidance of the clinical supervisor, each student developed a small personal project that appealed to their own views of what they wanted to achieve on the placement, but which also had benefit for the older adults from independent living: a walking group and a series of health and wellbeing talks. These projects were in addition to the projects negotiated with the placement. This approach appeared to improve the student engagement in terms of the level of energy and commitment they showed in performing the tasks connected to the projects they had each chosen. However, they were less motivated in producing the reports that had been negotiated and promised to the management of the residential care facility and the independent living village. While they had collected most of the data, in each case, for the reports, they baulked at the notion of writing the reports. The project leader took responsibility for these reports and worked with the students and the clinical supervisor to ensure that the reports were completed in time and at the expected professional level.
CONSEQUENCES OF IGNORING A STAKEHOLDER’S INTERESTS
The attitude of the OT students and their inability to see beyond their own needs resulted in a missed opportunity. They failed to demonstrate to the director of nursing that there was sufficient benefit from this placement to consider the services of an occupational therapist on her healthcare team. By contrast, the clinical exercise physiology students, who, granted were not tasked with a deliverable, such as a report, found favour by doing what was expected in terms of assessing the participants, both in the residential care facility and in the independent village. The value of their services was identified and despite clinical exercise physiology not being recognised by the Australian Aged Care Funding Instrument (ACFI) as a fundable service, the director of nursing was keen to introduce clinical exercise physiology into the residential care facility as a pain management and falls prevention strategy.
SUGGESTIONS FROM LESSONS LEARNT
While it may not be fair to compare and contrast the experience of the placements of these two disciplines, there are lessons to be learnt about understanding expectations, managing expectations and understanding the multiple expectations of stakeholders in any one clinical placement situation. Importantly, as a stakeholder, the director of nursing possessed all three attributes of importance (Mitchell et al., 1997); she had the power to influence decision-making regarding employment; the legitimacy of her relationship with the facility and the urgency of her claim to the facility were unquestionable. The students viewed this stakeholder’s needs only in terms of their own assessment requirements, without considering her needs or indeed her influence in terms of the placement.