Faculty are using a variety of teaching methods that place an increased emphasis on adult learning theory and self-directed learning (SDL). An extensive literature review analyzing how varying degrees of SDL were integrated into the nursing curriculum reinforced the view that SDL has many benefits, including increased student confidence, autonomy, motivation, and the development of skills for lifelong learning.1 The purpose of clinical instruction is to give students an opportunity to apply theoretical knowledge to patient care. With limited clinical time, every experience must contribute to the student's ability to master expected content.2 Most faculty make their students' clinical assignments regardless of the student's level in the curriculum; this practice is thought to assure a challenging assignment of patients who require care activities that will best assist the student in meeting the objectives for the clinical rotation.3 In an effort to integrate SDL into the curriculum, I devised a system for student self-selection of clinical patient assignments to enhance learning and satisfaction with the clinical experience. The objectives for the student selecting the clinical assignment were the following:

* Identify individual learning needs

* Select the most appropriate clinical assignments to meet their learning needs within course objectives

* Perform ongoing evaluation of their learning

During clinical orientation, I reviewed with the students the clinical learning objectives for the rotation so that they had a clear understanding of the focus for their clinical rotation and instructed them on the process for the self-selection of clinical assignments. Because assessing one's own strengths is an early step in SDL, I had each student complete a self-assessment that included skills performance, experience with clinical conditions, and goals for the clinical rotation. I reviewed the assessment with each student, providing an opportunity for each to receive personal guidance regarding the self-selection process and how to use the process to meet the goals that he/she had established for the rotation.

To self-select clinical assignments, students went to the clinical facility the morning of their scheduled experience, reviewed the unit data sheet, and spoke with the nurse responsible for the patients whom the student was interested in. Once students chose their 2 patients, they each reviewed the medical records and documented the patient's room number and their initials on the team assignment sheet, which was posted in the nursing station. I was available by telephone, if needed, for questions about the assignment and reviewed the assignments for their appropriateness before the beginning of the clinical experience. Assignments were changed if I felt that the students' learning needs would not be met. I also verified objectives with the staff regarding which activities and clinical objectives the students would be focusing on for each clinical experience.

At the end of each semester, students completed an anonymous survey to evaluate their perspectives regarding selecting their own clinical assignment. Students were asked how many times they participated in self-selection of clinical assignment for that semester, whom they preferred to make their clinical assignment, and if they felt that their learning needs were better met on the days that they chose their own assignment. The final portion asked for their opinions regarding what they liked and disliked about the self-selection process.

When asked for their opinions, students felt that they both enjoyed and benefited from selecting their own assignments. The majority reported that they preferred the self-selection practice because they felt that their individual learning needs were better met when they were allowed to choose the patient assignment; only 2 students did not feel that making their own assignment better met their learning needs and would have preferred the instructor to make assignments. The recurring theme in the student's responses was that they identified patients with conditions and experiences that they needed more exposure to in order to meet their own learning needs and sought patients who met those criteria. Sample comments included the following:

I got to focus on patients who had needs that I had not experienced.

I knew what I needed experience in, so I looked for those opportunities.

I got to practice skills that I had not gotten to perform before.

A second theme I identified from the students' responses was that they felt an increased sense of responsibility and ownership in the learning process. They expressed positive feelings regarding the confidence that the instructor had in their decision making:

Made me feel more independent.

The instructor really trusted me and that made me feel valuable.

There was a feeling of importance in it.

Their views about how much actual choice they felt able to exercise varied. This was because of overall low unit census or patients who left the unit unexpectedly, factors that I could not control. Others said if they were the last one to arrive on the unit, there were fewer patients left to select from. A few stated that they felt anxious at first about picking their own assignment but felt more comfortable with the process as the semester continued, eventually liking it.

One issue that I have to deal with is negative peer perceptions regarding the difficulty level of the chosen assignments. Whereas one expressed fear that she might choose a patient who I would think was "too easy," most students expressed concern over the opinions of their peers:

I did not want anyone to think I chose "easy" patients, especially if they went for testing or did not have many medications.

I do not want people to think I purposely chose an easy assignment[horizontal ellipsis]while it was never said aloud, it was just something we always thought about.

Other students supported these negative perceptions:

People purposely chose simple patients with little or no medications, so it was not really fair and students looked for "easy" assignments to decrease the risk of a clinical failure.

Based on the increasing student self-assurance that came through SDL, I am continuing to allow students to self-select their clinical assignments. Although most students choose challenging assignments that are appropriate to their needs, I counter negative peer perception about other students' self-selected assignments by reviewing all assignments for appropriateness before the beginning of the clinical experience and do change assignments if needed. Using self-directed clinical assignments better facilitated meeting the students' individual learning needs while still within the framework of course objectives and increased the student's satisfaction with the clinical experience.

References