Another student responding to the Carnegie-NSNA survey reported her difficulty in trying to integrate her learning: “While the program does require clinical write-ups, which require applying classroom content, I feel like I’m on my own in integrating the information we’re taught. I spend quite a bit of time in independent study trying to fill in holes and gaps in my education that are revealed as I struggle in the clinical setting.”

As the student comment that opens Part Three suggests, connections between the classroom and the clinical setting go a long way toward helping students grasp the knowledge on which their patients will depend. Students note that when their clinical instructor also teaches the course, the course objectives and content benefit from “direct clinical setting examples”: “The teacher will say, ‘Remember, we talked about this subject in class…here is a prime example of that lecture in the clinical setting.’” Yet students also recognize when their program makes a concerted effort to draw classroom and clinical together; as one student observed, “They try to…give us bits and pieces and work altogether and make sure that they’re all on the same track and trying to complement what we’re learning in one class to another. So it’s all tied together.” However, “Until faculty integrates content, we cannot expect students to do so,” asserted one nursing educator.

Of course, dual clinical and classroom teaching assignments facilitate integration. “Classroom faculty [in our institution],” one faculty member explained on the Carnegie-NLN survey, “are also the clinical faculty augmented by some adjunct faculty. We know exactly where the students are contentwise and select learning experiences accordingly.” “It’s helpful when you are the classroom teacher going into clinicals,” said another faculty member. “Sometimes it is easier to relate to theory in clinical because the client is right in [the student’s] face.” Another teacher noted that in clinical she tries to place her students “with patients who have the disease process we are currently discussing in class.” Day notes, “If the students are struggling in clinical, I can return to the classroom and clarify content, perhaps present it in a different way.”

Despite the hard work of teaching in the classroom and practicing in the clinical setting, the reward is being able to bring currency about practice to their students, as one faculty member notes: “Because I work sixteen hours a month in a local hospital plus donate time to a local free medical clinic, I can integrate a lot of true and timely situations into my teaching. I also am not only lecturing about the problems in health care and the nursing shortage; I am living them out.”

Even when the faculty have separate classroom and clinical assignments, it is possible to bridge the divide. One faculty member described her program’s policy: “Clinical experiences emphasize content taught in the classroom. Each adjunct clinical faculty is given the classroom content and appropriate postconference topics to mesh with classroom content. Some clinical experiences are also timed to match content in the classroom.” One school’s clinical and classroom faculty meet every other week to discuss classroom and clinical integration and the clinical learning, including difficulties of particular students. This program was unique among the nine we visited. Clinical faculty receive extensive orientation and instruction prior to and during teaching. In addition, clinical faculty are reimbursed for time spent in the biweekly team meeting and required in-service classes on clinical instruction. This school makes a concerted effort to bring the clinical and classroom teachers together to share the responsibility for students’ integrative learning. The teachers’ development is highly valued by the service sector because it prepares staff nurses for teaching within the health care setting.

Where such policies are not in effect, however, as the clinical teacher’s comments suggest, “Those who teach in clinical settings and those in classrooms need to know what each is doing…. All clinical instructors have access to classroom content via textbook and Web supplement.” Using such information, she brings the classroom into postclinical conferences: “[I say] ‘Last week in class, you discussed the problem X that your patient has. How does your patient compare with what you learned in class?’ Or, ‘Your patient had X. You will be talking about this next week in class. Think about your patient again during class.’” She continued: “Not all faculty do this. Some [clinical] faculty [members] aren’t even aware of what topics were covered in classes the previous week. I created a one-page grid of all topics in all classes by the week for myself and have shared it with other faculty. Seeing the information on one page is very helpful when making clinical assignments and knowing what skills or information students have or have not had in class.”

Another instructor pointed out that “clinical instructors meet to discuss clinical learning and also discuss clinical situations by e-mail during the weeks of clinical experience.” This comment illustrates that the flow of information needs to go from clinical to classroom and vice versa. School policies can help teachers better integrate classroom and clinical teaching. For example, one faculty member spoke with admiration about how the clinical faculty in her program receives “a weekly run-down of the kind of things that are going on in each course.” She pointed to the example of students learning about communication and cultural differences, and how knowing about this can be very important in clinical situations, noting that students “can think not only about the fact that they are learning about burn injuries but they’re also learning how to communicate with a specific person [across cultural boundaries and languages] about their injuries and concerns.”

Despite such avowed commitment to integration, all too often nursing education is approached as if it has two discrete elements. As a student comment on the Carnegie-NSNA survey noted, “It is as if the classroom content was a different program.”