Contribution of Unit Managers to the Training of Student Nurses in the Cape Peninsula

R Troskie D Litt et Phil Professor in Ethos and Professional Practice Unisa


Abstrak
Hierdie artikel is op navorsing gebaseer wat in die periode 1993 tot 1996 in die Kaap Peninsula gedoen is.Die doel van die studie was om te bepaal wat die bydrae van eenheidbestuurders in die o p le id in g van k lin ie s e p ra ktika , vir s tu d e n tv e rp le e g k u n d ig e s , in hulle e en he de is.
Die s te e k p ro e f was stu de ntverple eg kun dig es in die vier verpleegkolleges in die Kaap Peninsula en eenheidbestuurders wat werksaam is in die g e s o n d h e id s d ie n s te w at die stu d e n te v ir h ulle k lin ie se p ra ktika akkom m odeer in dieselfde area.Die b e v in d in g e het a a n g e to o n d at die m ee rd erh eid e e n h e id s b e s tu u rd e rs , wanneer die geleentheid hom voordoen, wel studente onderrig.In die algemeen was eenheidsbestuurders voorberei vir h u llle o n d e rrig fu n k s ie , m aar baie studente was nie tevrede met sommige van die kliniese leergeleenthede wat aan hulle gebied is nie.'n Voorbeeld hiervan is by die opstel van verpleegsorgplanne, b e s p re k in g van die p a sië n t se behandeling tydens die oorhandiging van verslag, hulp ten opsigte van besluite wat die versorging van die pasiënt raak en die gee van ondersteuning wanneer studente met probleme van die pasiënt te doen kry.Daar blyk dus 'n behoefte te wees om eenheidsbestuurders op te lei in die verband en in ander aspekte van die student se opleidingsprogram.

Introduction
In South Africa student nurses spend most of their training time in close contact with unit m anagers.It is th erefore important that unit managers carry out their roles and functions in a manner that will ensure student nurses' professional growth.With the introduction of the fouryear co m p re h e n sive co urse (SANC R425:1985) the status of the student nurse remained unchanged.Students were forced to participate actively in unit activities because of a staff shortage.This had a d etrim ental effect on training because students were regarded as part of the workforce (Viljoen 1989:25-26).Because of the multidimensional role of the unit manager and the staff shortage, patient care took priority and student teaching fell behind.Another issue which surfaced when the new programme was implem ented was that unit managers were not well versed in the training c u rric u lu m and needed in-se rvice training.It was difficult for them to assess the students' learning needs and what was expected of them (Jooste 1991:1).Some colleges appointed clinical tutors to accompany students in the different health units.The shortage of tutors made it difficult for one tutor to spend enough time with each student.It is, therefore, wise to use unit managers, empowering them to train students allocated to their units.

Background to the problem
As the foundation of learning to nurse is found in the health service units -be they m id w ifery, g e n e ra l, p s y c h ia try or community health nursing -one cannot overemphasize the importance of the role played by unit managers, for they are responsible for quality patient care, the management of day to day activities and the su p e rvisio n and tra in in g of s u b o rd in a te s .G e rrish (1990:200) describes clinical teaching as the core of nursing practice and states that clinical skills are best taught by practising nurses in the real situation.Lack of time to teach, lack of a knowledge base and te a c h in g s k ills , lack of confidence in their teaching abilities, lack of expert specialist help with teaching and the inability to assess learner needs are some of the problems related to teaching by unit managers (Runciman 1983:68).Bezuidenhout (1988:8) found in a study conducted in the then Transvaal that the fact that student nurses are both learners and workers is frustrating to them.When u n it m an ag ers are yo u n g and inexperienced, students have difficulty approaching them with their problems, as they often see them as som eone w ith o u t status and confid en ce.It is therefore important that unit managers receive support from tutors, to assist them w ith th e ir te a ch in g fu n ctio n (B ezui denhout 1988:8).

Problem Statement
According to Bezuidenhout (1988:2-3) a combination of factors are responsible for problems experienced in the effective provision of independent, professional practitioners.A shortage of well-prepared registered nurses to fulfil their clinical teaching function causes student nurses to feel insecure in their working envi ro n m e n t.These yo u n g a d u lts are expected to perform a variety of duties and to accept responsibility for perfor m ing th em w ith o u t th e nece ssary guidance.The perceived lack of involve ment of unit managers in the clinical teaching of student nurses in the Cape Peninsula gave rise to this study to explore to what extent unit managers are involved with clinical teaching, whether they are sufficiently prepared to take on this role and to meet the learning needs of student nurses.

Statement O f Purpose And Research Questions
The purpose of the study is stated in the questions that guided the study.These questions are the following: • Are unit m anagers sufficiently prepared to provide teaching in the units?
To w ha t e xten t are th e u n it managers involved in the clinical teaching of students in the units?
• To what extent are student nurses satisfied with the type of clinical learning opportunities that are presented to them?

Operational Definitions
Clinical teaching is the practice-oriented teaching given to students in laboratory practice situations and these include the service units (SANC R425:1985).Health service unit refers to a hospital ward or departm ent or a com m unity health centre where health care is given to clients/patients (Hawkins & Weiner 1990:780).Learning opp ortu n ity refers to the possibilities for learning created by the tu to r in the cla s s ro o m and c lin ic a l teaching situations which are used by the student to reach learning objectives (SANC R425:1985).Student nurse refers to an individual who is presently undergoing the required training which has a minimum duration o f fo u r years, to fu lfil S A N C 's requirements to become a registered professional nurse (general, psychiatry and com m unity) and m idwife (SANC R425:1985).Unit manager is synonymous with the nurse who is in charge of a health team w hich cares fo r a s p e cific g ro u p of patients/clients within the boundaries of the unit (Lees 1989:8).

Review of Literature
A review of the literature was done to determine the role of the unit manager in a health service setting in training student nurses.The different learning oppor tu n itie s pre sen t in a p a rtic u la r u nit determine whether the required learning takes place.It is important for students to be in a unit where it is possible to cor relate theory with practice as these two elements should reinforce and comple m ent each o th e r (Jacka & Lewin 1986:573).Unit managers, however, experience role am biguity because of unclear role expectations and uncertainty about work perform ances and beha viours.Sometimes there is conflict be tween what unit managers perceive as their role in relation to teaching and the expectations students have of them.Often the unit manager is expected to perform teaching and m anagem ent duties at the expense of the clinical role (Marson 1984:13-16).Unit managers should, however, be aware that student nurses in their units are not just part of the working force, but have come to the unit to learn their profession.As an expert in her or his field the unit manager is responsible for the professional growth of the student (Jooste & Troskie 1995:13).Feedback on th eir perform ance is a learning/teaching opportunity and should be a true reflection of the student's perfor mance and abilities (Jooste 1991:33-35).The unit managers' attitude to their duties influences the teaching environment in the unit.If unit managers see patient care as a priority they work with the students and teach them as the opportunity arises (Fretwell 1982:99).If their attitude to teaching is positive the learning oppor tunities will be used to teach students.Clinical teaching is the most important function of the unit managers, because it lays the foundation for the improvement and maintenance of nursing standards.Nursing can be effective only if the quality of the professional practice of unit mana gers is good and they are prepared to teach, to manage and to care for their patients effectively.

Methodology
A quantitative descriptive m ethod of research was used because the main objective of the study was to portray a ccu ra te ly the c o n trib u tio n s of unit managers and the frequency with which certain phenomena occur in the training of student nurses.Consent to conduct the study was obtained from the Director-General of Health in the Western Cape Province as well as the nursing colleges, hospitals and community health centres where the research was conducted.

Target population
The p o p u la tio n c o n s is te d o f u nit managers who supervise student nurses in hospitals and community centres in the Cape Peninsula as well as student nurses who are assigned to the different units for their clinical practica.The student nurses were doing the four year course and were in their fourth year of study in the four nursing colleges in the Cape Peninsula.

Sampling
Seven institutions were selected because m ost of the learning institutions and colleges send their students to these hospitals and community centres for their d iffe re n t le a rn in g e x p e rie n c e s .A sampling frame was formed from all the units which are used in the health services that were identified.The units were randomly selected.A total of 117 units from a total of 230 were selected.The student nurses were chosen from fourth year students who were writing their final examination in July and November 1995.A total of 50 student nurses per college were chosen.The total sample size was 200.The unit managers were randomly selected from a total of 455, the sample size being 155.

Reliability and validity
The C ro nb a ch Alpha Coefficients were computed for the e n tire scale, questions 4 to 50, as well as each of the four factors that rotated.A mean ingful comparison o f a lp h a c o e ffi cie n ts a cro ss scales was possi ble and all C ron bach Alpha values w ere ve ry high, which indicates that the constructs are measured reliably.A trial run was also used to test the reliability of the instru ment.
Validity was ensured by the supervisor, clinical tutors and supervisors in the field and a statistician critically evaluating the questionnaires.Discrepancies and errors were corrected as suggested.

Ethical considerations
The p ro s p e c tiv e re sp o n d e n ts w ere informed of the purpose and method of th e rese arch and th u s vo lu n ta ry participation was ensured.All partici pants were ensured that they would remain anonymous.

Method of distribution and return of questionnaires
The different institutions were phoned and appointments were made with the contact persons.The questionnaires were discussed with them after which they agreed to help with the distribution to preselected respondents.Of the 155 questionnaires sent to unit managers 128 (82%) were returned and of the 200 questionnaires to students 146 (77,1%) were returned.

Descriptive profile of the sample
It was found that the age of the unit managers who participated in the study ranged from 24 to 63 years with a mean of 38,7.Of the unit managers 87 percent were between the ages of 30 and 49 years.The m ajority were trained in general nursing and midwifery and few had qualifications in nursing education and nursing administration.
From the analysis it is deduced that the unit managers were of a mature age and that the majority of student nurses were still young as their ages ranged between 19 and 29 years with an average of 23,8 years.It seems that most of them started their training at the age of 19 years.
Are unit managers sufficiently prepared to provide teaching in the units?
The items that rotated in factor 2 which answered the research question on the  To ensure that this is done in the units, regular contact with the nursing colleges is essential and it is encouraging that unit m anagers are aware of the importance of having contact with the college staff.
As unit m anagers are o rg a n isin g and a tte nd in g in-service education programmes and also attend symposia to keep themselves updated on the latest d e ve lo p m e n ts in n ursing education, it would appear that they do in fa ct prepare them selves fo r their teaching function.Coordination with the colleges also receives attention.

I'o what extent are the unit managers involved in the clinical teaching of students in the units?
Factor 1 and factor 3 represent the items related to th e e xten t to w hich u nit m anagers are involved in the clinical teaching of student nurses in the units.The items included in these factors are unit managers' knowledge level of the clinical training needs of student nurses, writing problem-oriented patient records, h a n d in g o ver re p o rts , a s s is tin g in decision making, supporting students when doing procedures and counselling students.A lth o u g h 93,6 p e rc e n t o f the u n it managers indicated that they met the clinical learning needs of the student nurses, a substantial number of students (43%) felt that their clinical learning needs were not met, as shown in table 1.This is of concern because students need to learn from practical experience how to perform certain tasks and need guidance in making decisions.Although 94 percent of the unit managers indicated that they teach student nurses how to write problem-oriented nursing records, this was only supported by 65 percent of the student nurses.With a significant difference of 29 percent it can be a ssum ed th a t s tu d e n ts are not sufficiently involved in writing problemoriented records.This is also supported by a 23 p e rc e n t d iffe re n c e in th e responses to a question about whether students are supported sufficiently when drawing up patient care plans.Support for students when a patient's condition deteriorates is not always available as the significant difference of 42 percent in the unit m an ag ers' and stu de nt nurses' responses indicates.Students faced with such a stressful s itu a tio n need the s u p p o rt o f the u n it m anager.Bezuidenhout (1988:23) indicates that managers have to teach students to observe any untow ard changes in a patient's condition and to act calmly and swiftly, in a caring manner.Students (35,9%) also did not agree that they received the necessary guidance when performing procedures and 32,4 percent did not perceive the unit managers as role models.Table 2 indicates the responses of both unit managers and student nurses to the support given to student nurses when they experience problems.
1 able 2: Qjmparison of student nurses' and unit managers' perception regarding the support given to student nurses when they experience problems To what extent are student nurses satisfied with the type of clinical learning opportunities that are presented to them?
Item s in fa c to r 4 th a t in d ic a te the response as to w hat extent student nurses are satisfied with the type of clinical learning opportunities that are presented to them are the follow ing: orientation of student nurses in the units; setting objectives to enhance learning; providing teaching aids and drawing up a programme for teaching in the units.
Only 50 percent of the student nurses were satisfied that unit managers draw up checklists to ensure that they receive the necessary orientation to the units.Student nurses (82%) were, however, satisfied that unit managers were actively in vo lve d in p re s e n tin g o rie n ta tio n programmes.
In contrast to 89 percent of the unit managers, only 53 percent of the student nurses felt that there were sufficient teaching aids in the units.The difference c o u ld be b eca u se o f d iffe re n t interpretations of the term "teaching aids" by the two groups.Students in general fe lt th a t u n it m an ag ers w ere not sufficiently involved in teaching student nurses.It is encouraging to note that in c o n tra s t w ith d is s a tis fa c tio n w ith evaluation of students' progress, drawing up a teaching programme and involve ment of unit managers with teaching in the units, student nurses are satisfied with demonstrations received in the units.Students (44%) do not feel that they are s a tis fa c to rily in vo lve d in sh a rin g inform ation with the m ultidisciplinary team, they (47%) are not sure of how referrals are made and do not participate in conferences with the other members o f the m u ltid iscip lin a ry team .Unit m an ag ers have to be s k ille d in c o o p e ra tin g w ith e veryon e w ho is concerned with patient care and have to coordinate all the activities in the unit.Fourth year student nurses need to be taught how to do this as they will shortly be the nurse in charge of the unit.

R e a > m n ie n tla ti( m is
The fin d in g s indicate that m ost unit managers who participated in the study are a d e q u a te ly p re pa re d fo r th e ir teaching fu nctio n in the units.It is therefore essential that unit managers should receive ongoing training to keep them informed of new developments in the training of student nurses.Liaison with the college is an essential compo nent of th is p re p a ra tio n .R egular meetings with the college staff should form an integral part of the unit managers' in-service training programme.Student nurses in the study felt that their needs for clinical teaching is not met sufficiently by unit managers.This could result in frustration and students being bored because they are not taught things relevant to their training.Students should be taught how to draw up patient care plans at least once a month or, whenever a patient is adm itted to the unit.On regular ward rounds unit m anagers should accompany student nurses and check patients' records.Student nurses should be assisted in making nursing decisions, according to the patients' condition.Unit managers should work with students more often to be able to evaluate performance and correct and teach on the spot.Other members of the multidisciplinary team should be afforded the o p p o rtu n ity to particip a te in the training of student nurses.Unit managers should act as caring and resourceful mentors and a support system should be put in place for students w ho need professional help.As not all students are satisfied with the manner in which their learning needs are identified and objectives are set to draw up a clinical teaching programme, unit managers should have interviews with students when they come to the units to set their learning objectives with them.This would enable the unit manager to draw up a clinical programme to teach student nurses the aspects relevant to their learning needs.Active participation of u n it m an ag ers in p la n n in g and presenting clinical teaching programmes will enhance learning.Teaching aids such as overhead projectors, chalk boards and pamphlets should be made available to support the teaching process and case studies should be used to guide students in the nursing care of patients.Evaluation of students' progress should play a major role in the unit manager's teaching function.Students should be given the o p p o rtu n ity to inform unit m anagers w hen th ey are ready for e v a lu a tio n .E va lua tion sh o u ld be discussed and measures for improve ment planned with the student.

( C o n c lu s io n
It is apparent from the research findings th a t som e unit m anagers do teach student nurses when they have the opportunity.Unit managers are also prepared for their teaching functions, but need the su pp ort of the colleges to ensure that students' learning needs are met.A reasonable number of student nurses are satisfied with the clinical learning opportunities presented to them.There were, however, a large enough number of the student nurses who were of the opinion that they did not receive the necessary support and guidance from unit managers in the units regarding c lin ic a l p a tie n t care a sp e cts.This warrants attention and rectification.
Two computeV coded questionnaires, one fo r unit m anagers and the other for student nurses, were drawn up and include both closed and open-ended questions.Both these questionnairesCurationis December 1998 45Attending in service have 50 s im ila r items, divided into five sections, to get a nsw ers to the re se a rch q u e s tions.

*FindingsA
factor analysis was done and although six factors rotated, only four were repre sented by a substantial number of items.The four factors will be discussed as they relate to the research questions.The four factors that rotated were as follows: • Factor 2 related to question 1: To what extent are the unit managers involved in clinical teaching of students in the units?• Factor 1 and factor 3 related to question 2: To what extent are the unit managers involved in clinical

Figure 1 :
Figure 1: Preparedness of unit managers for in-service training (unit managers N = 128; student nurses N = 140)

Figure 2 :
Figure 2: The teaching and evaluation function of the unit manager Unit manager (N = 128) Student nurses (N = 140)