I recently received an e-mail from a clinical faculty member regarding the excellent clinical performance of a junior nursing student:
“I want to let you know about an event that occurred in clinical today. After we returned to the unit from lunch, a student's patient began having difficulty breathing, and a rapid response was called. The student rushed to the room and stayed with her patient during the entire code. The rapid response quickly turned into a code 99 (due to cardiac arrest). I was right outside the door watching as she took vitals, talked with members of the code team, and took her turn doing chest compressions. Unfortunately, the patient did not survive. The nurses on the unit, the charge nurse, and the unit manager, who were all in the code with the nursing student, separately told me how amazing she did!"
Although another student might have timidly remained in the background, this student was an active participant in a stressful situation. The student demonstrated courage, conscientiousness, and excellence. These traits, along with resiliency and endurance, are associated with grit.1 Duckworth and colleagues define grit as “perseverance and passion for long-term goals.”2 Payne has described grit as being “about toughness, hardiness, determination, and tenacity…. Gritty people, gritty nurses, are both goal directed and able to respond to immediate needs, especially nurses in the ED, ICU, or trauma where quick responses are required.”3
GRIT AND SUCCESS
Duckworth and colleagues have studied the importance of grit to success.2 They developed a tool to measure grit and sought to determine if grit was associated with higher levels of education and increased with age.2 Their findings suggest that among adults the same age, the more educated adults are “higher in grit” than the less educated.2 They also found that grit increases during a person's life span.2 This may explain why students in our accelerated second-degree nursing program, who already hold a baccalaureate in another field, experience better outcomes on the nursing licensure exam than traditional four-year students, who are generally younger and do not have previous college experience. This observation is consistent with the findings of several researchers, including McDonald4 and Seldomridge and DiBartolo,5 although others have disputed these results.6, 7
In their report, Duckworth and colleagues also found that grit correlates more with successful outcomes than with intelligence as measured by IQ, noting: “It is possible… that among relatively intelligent individuals, those who are less bright than their peers compensate by working harder and with more determination.”2 This may explain a dynamic I've observed in my students: those who do not easily grasp didactic content but seek to understand it through questioning and by utilizing academic support services are sometimes more successful than their peers who appear to understand the content but do not use these resources. These researchers also found that the most successful people were those focused on a specific, long-term goal.2
CAN GRIT BE TAUGHT?
If grit is associated closely with success, then can it be taught to or fostered in nursing students? Some might say it can't, maintaining that one either has grit or does not. Currently, there is no research validating that grit can be taught. Willingham notes that the question of whether it can be encouraged is complicated and has no simple answer.8
Nonetheless, considering what is known about factors that correlate with grit, some suggestions can be made. According to Willingham, teaching students to be grittier might include “helping students identify what they are passionate about, encouraging them to pursue their passion, teaching them how to find resources to help them pursue their passion, teaching them to learn from failure, teaching them the importance of practice, teaching them when to persist and when to seek a different path if they encounter an obstacle.”8 The question then becomes, how can we incorporate these suggestions into clinical teaching?
Because research suggests an association between grit and long-term goals, nursing instructors may want to incorporate discussions about such goals into their teaching. For example, they can emphasize that mastering the skill and knowledge associated with medication administration will ultimately enable students to be safe practitioners, minimizing the chance that their patients will be harmed as the result of a medication error. Similarly, when a student is passionate about a particular kind of nursing, the instructor can encourage the student to take advantage of additional opportunities in this area. A shadowing experience with an obstetrics nurse, for instance, could be arranged for a student who is drawn to this type of nursing. Some schools offer electives, such as classes focused on nurses’ roles in the operating room (OR) or in holistic care. Instructors can encourage students to seek summer internships in nursing fields that interest them.
Duckworth and colleagues noted that people with the most grit focused their efforts on a long-term goal rather than on broad interests.2 Paraphrasing Benjamin Franklin, these researchers noted that “the goal of an education is not just to learn a little about a lot but also a lot about a little.”2 Nursing students would do well to heed this advice. Though university orientation programs encourage college students to become involved in a variety of activities, it's also essential to remind nursing students not to overextend themselves. Nursing is a difficult major. It's reasonable to advise nursing students to commit to only one or two extracurricular activities while focusing on the primary goal of becoming a nurse.
Because research indicates that resilience is a characteristic of grit, McCabe suggests that exposing students to difficult work experiences may “lead to the ability to recover more quickly at the next encounter and have a sense of toughness—being up for the challenge.”9 One way to do this, according to McCabe, is to assign students to patients who may prove to be challenging.9 Instructors sometimes want to shield students from patients who may be unkind toward students or ungrateful for their assistance, but caring for such patients may help students to develop resilience. This requires thoughtful encouragement from the instructor; facing such an assignment without an instructor's support, for instance, could backfire and cause a student to withdraw from nursing altogether. By contrast, successfully caring for more challenging patients can help students to gain a sense of pride in their work, as well as resilience. DeSteno notes that pride can promote students’ efforts to develop valuable skills.10 Therefore, it's important that instructors help students learn from any failure they experience. It can be helpful to remind nursing students, for instance, that many will fail a course or two, but students who persist can still become successful nurses.
Grit can also be a topic of discussion in a postclinical conference. Explain the characteristics of a “gritty” person to students. In a reflective writing assignment, ask students to ponder their own background and experiences and then to identify whether they think they have grit. Ask them if they have identified a goal—working in a specific field of nursing, for example—and suggest how they can gain experience in that area. Ask students to discuss incidents in which they've witnessed nurses exhibiting grit. McCabe suggests that clinical instructors talk about nurses who've exemplified grit and model the characteristics of grit for their students.9
It can be especially challenging when nursing students are anxious and faint after observing or participating in stressful situations. As a clinical instructor, I've seen students faint while observing a circumcision, inserting a Foley catheter, and even during morning report. Stress-induced syncope may have associated symptoms of tremor, diaphoresis, pallor, and, in rare instances, seizures. The episode can be very concerning: the student's eyes may roll upward, and she or he may experience bradycardia. Fainting episodes can indicate a serious condition, so further investigation is always warranted if they occur frequently or during a variety of situations.
Clinical instructors can be a positive influence on students who are prone to fainting because of anxiety. Suggestions for how to help students overcome their anxiety and develop confidence and grit when managing stressful conditions include the following:
- Remind students to eat breakfast. It's seldom known if students faint because of low blood glucose levels or the stressfulness of a procedure—or some combination of the two. Often, however, students who faint report that they haven't had breakfast. Marchiondo suggests that an increase in dietary salt and fluid intake, if not contraindicated, can help.11
- Recommend strategies to avert fainting. These include muscle tension techniques, such as tightening the thighs, abdominal muscles, and buttocks to reduce the risk of vasovagal syncope.11 Tell students to momentarily look away from a procedure if it bothers them, and focus on their breathing, maintaining slow and steady respirations.
- Discuss with students how they can manage stressful situations. This can be done in a postclinical conference, when you can also share any personal stories you may have. For example, I frequently tell students about my experience with fainting when I was a student. I fainted three times in the OR, as well as when my blood was being drawn. I've shared with students the fear I felt at that time, when I thought I might not be able to become a nurse. I explain that a kind clinical instructor helped me to overcome this obstacle. She had been watching me, and she'd noticed that I would almost stop breathing when I was in what I perceived to be an anxiety-provoking setting. By following her suggestion to focus on my breathing, I eventually found that no nursing or surgical procedure left me feeling faint, and I became a successful intensive care nurse.
- Encourage students to use reflective writing to analyze anxiety-provoking situations, the ways in which they react to these situations, and how these situations can be handled differently.
- Be an approachable instructor.
CLINICAL INSTRUCTORS MAKE A DIFFERENCE
Grit is an essential component of a great nurse. Hardy, tenacious, tough nurses are the result of experience and knowledge. Duckworth points out the need for further research to help educators understand how to build grit while also offering a few suggestions: “We need to take our best ideas, our strongest intuitions, and we need to test them. We need to measure whether we've been successful, and we have to be willing to fail, to be wrong, to start over again with lessons learned. In other words, we need to be gritty about getting our kids grittier.”12
Clinical instructors play a key role in preparing nursing students for the many challenges they will face as nurses. This includes helping them to overcome anxiety and learn from failure; supporting them in difficult circumstances; and assuring them that, with experience, they will be able to face the most demanding situations.