The challenges of practice learning in the light of the
Francis reportsProfessor Helen Allan
Department Health SciencesUniversity of York
Research based talk
ā¢ Nurse researcher & teacherā¢ Clinical nurse 23 yearsā¢ Method [ethnography] gives in-depth
data on realities of practice:ā āIām a nurse researcher. Did someone
tell you I was coming?āā āOh greatā (ward sister)ā āI can work while I researchāā Oh GREAT! Hereās a bay!ā
Francis report (2013)
ā¢ Key messages for education ā¢ Not as comfortable reading as Willisā
report, but some misunderstandings:ā Compassion not taughtā Recruitment & selection inadequate
ā¢ āThe NHS no longer appears to be a learning organisationā (Melia 2000)
Challenges to practice learning
ā¢ Where is the Leadership for Learning in nursing & midwifery?
ā¢ Using 3 projects over 8 years:ā New role of the ward managerā Transitioning to newly qualified statusā Midwives & complaints
ā¢ Discuss challenges of practice learning in terms macro, meso & micro levels in the organisation of learning in health care
Macro
ā¢ Structural reconfiguration of service delivery ā Internal marketā Foundation status
ā¢ Structural reconfiguration nursing educationā P2Kā Fitness for Practiceā UKCC 2000 national competenciesā All graduate registrationā Move into HEIs
ā¢ Market mechanism for nurse educationā Purchaser/provider split i.e.: splitting off of nursing
practice from education (Allan et al 2009; Smith & Allan 2011)
Meso
ā¢ Role changes in serviceā Ward managersā Mentors
ā¢ Role changes in educationā REFā Link lecturersā Lecturer roles (not tutors)ā Student status
ā¢ New relationships between nursing education & practiceā Geographically ā Contractually
Micro
ā¢ Changing expectations of mentors & studentsā Learning contractsā Supernumerary statusā Competencies
Projects
1. Study into Leadership for Learning ā General Nursing Council Trust for England & Wales 2008/10
2. Academic award and recontextualising knowledge - Centre for Research in Nursing & Midwifery Education 2011/14
3. Responding Effectively to Service usersā and Practitionersā perspectives ON care concerns: challenging Sustainable responses through collaborative Educational action research (RESPONSE) - Centre for Research in Nursing & Midwifery Education 2011/14
Methodologies ā broadly qualitative in-depth case studies
1. Ethnographic case studies ā 4 sites1. 60 Interviews & participant observation [160 hours
obs]2. On-line survey [937 responses]
2. Ethnographic case studies ā 3 sites1. 50 Interviews & participant observation [198 hours
obs]2. Preceptor tool
3. Action research 1 site 2 yrs 1. Postal survey ā 40 responses2. Supervision groups ā 7 midwives3. Communications training ā 4 midwives
Leadership for Learning study ā āFeeling part of the teamā
ā¢ Extract from notes (17/01/07 Site 1 day surgery morning shift; 3rd year, part-time student) ā āAt coffee student described how she felt they were told to be
assertive and self-empowered in college and to be agents of change yet the NHS and nursing was hierarchical and bullying and I feel like Iām in the playground again. On ICU, nobody had said goodbye to her when she left, too busy doing internet shopping, obsessing about off duty and character assassination of anyone coming into the unit. She felt that staff referred to the students as āthe studentā and staff didnāt bother to learn their names; rarely felt part of the team. She used the word āburdenā to describe how the mentoring relationship in the clinical areasā
ā¢ Structure of course leads to not feeling settled ā āChopping and changing placements, you learn to learnā āFeel
students are seen as stupid, clumsy, and that weāll make mistakesā She resented this and felt nursing had to change.
āDoing things fasterā
ā¢ Extract from notes (17/01/07 Site 1 day surgery morning shift) ā coffee break with student nurse whose 1st placement
was care home ā¢ āI asked what sheād learnt in the care home. She said
immediately āconfidenceā as sheād never done carework before and she felt she did all that there; sheād learnt confidence in meeting people, making relationships with them, getting to know them. And in surgery, these skills had given her confidence to cope with the faster pace and higher turnover.ā
ā¢ Later that shift during coffee break, āVery busy, short stay, patient turnover is high ā have to be out in 23 hours. Student commented that having to work in bay with 6 patients on Ā½ hourly obs. was difficult āhow do you keep up? You learn to do things fasterā.ā
āThe blind leading the blindā
ā¢ Extract from notes 23/01/07 mixed surgical morning shift with 3rd year student )
ā āStaff nurse and student allocated a bay and a transfer to bay from side room; staff nurse went straight away to do drugs asking student to move patient (very sick man) with HCA. Man needed to change to 40 % O2 from nasal cannula; sounded as if he had a chest infection; student went to fetch mask. Came back with no tubing; went to find some; came back with wrong tubing; came back with correct tubing and then started fitting mask and tubing. Hadnāt done so before, neither had HCA. There was a degree of fluster and patient got more breathless; HCA suggested turning up O2. Student went to ask sister who said yes and came back and turned up O2. I asked her if she felt okay and understood the reason for turning up O2. She said no; I explained rationale.ā This went on for some time before the patient was successfully settled in his new bed; the staff nurse did not appear to supervise student with a very sick patient neither did the sister.
ā A similar situation arose when the staff nurse asked the student to do an ECG which she knew how to do. However then the staff nurse came in and the student asked her a question about ST elevation which she was unable to answer; student asked staff nurse how to stop trace interference; staff nurse didnāt know and it felt like the blind leading the blind.ā
Challenge no. 1
ā¢ Reality of practice learning in busy NHSā Reality shock
ā¢ 1st priority is safety of patientsā Is learning always ethical?
ā¢ Supernumerary status ā Onus on student
ā¢ Re-aligning practice & education at macro and micro levelā Uncoupling ā Supporting mentorsā Link lecturer role
AaRK ā what is practice learning as NQN?
ā¢ Transition to newly qualified āreality shockā¢ Iāve learnt the hard way reallyā¢ they lack[ing] confidence if you like, not necessarily
knowledge
ā¢ Learning largely invisible and unsupportedā¢ The knowledge was there I just didnāt feel that it was
there and I didnāt feel that I knew enough but then when I started talking about it and doing it and pulling things you know from wherever it was stored I thought āwow, I do know thisā, you know, āwow, where did that come fromā, I do know what it is to be a nurse ā¦ you look at yourself in the mirror and think āI can do this, I am a nurseā, you know I am a good nurse
Challenge no. 2 ā learning as NQN
ā¢ Support after qualifyingā Preceptorship keyā Need to develop āassumedā skill
ā¢ Recontextualisation of learningā Hidden curriculum & invisible learning
ā¢ Expectations in teams and at management level of NQNsā Hit the ground running
RESPONSE ā responding to complaints by āno longer assumingā
ā¢ "There are a couple of things that I have noticed I have changed on my practice. The first one is that I no longer assume that patients or even colleagues understand what I say in the way I mean to say it. I am constantly "checking for clues" (i.e. non verbal communication) to ensure that they understand exactly what I need them to.
The second one is related to my ability to show empathy particularly to patients when their expectations are not met. I found quite helpful to verbalise more accurately my thought process. For instance, if someone has been waiting for an obstetric review for a long period of time and they complaint loudly. I find that patients (or patient's relatives) seem to calm down faster if they hear me saying something like "Oh dear! you must be tired by now. I'm very sorry about this. Let me find out why this has happened and see what we can do to fix this".I really appreciated that session and I wish we had something like this in other hospitals. I would love to know about the conclusions of your study when you finish."
āPaying more attentionā
ā¢ "I think that I now pay more attention to the words that I use, in particular with patients and visitors however I'm not sure if this was due to a incident in practice which may have facilitated this change. I also think that the training has made me think more about communication in general in all aspects of my work including answering door bells, speaking to doctors. I have learnt not to assume that the reason for patients being angry/frustrated is always due to lack of information, rather than considering alternatives and asking the family directly about their concerns.
āStop and thinkā
ā¢ "Following the training I have really taken the time to think about how I communicate with patients and have become aware of how many closed questions I ask. I have tried to ask more open ended questions, and have been trying to consider how I communicate with patients, including non-verbal communication. The training definitely helped me communicate with people from who don't speak English very well.
I think I have become a little more confident, and found the session very useful to stop and think about what and how I say.
Challenge no.3 ā learning & service development
ā¢ How do we learn in practice to develop practice?ā Busy-ness of NHS ā hard to engage in
practice and service developmentā Totalising systems (Goodman 2012)
Compassionate individualised midwifery care within a ātotalā health care institution: a possibility or a paradox? (Allan et al in review)
ā Stop, think, pay attention and donāt assume
Conclusions
ā¢ There is huge willingness to learn among ward staff
ā¢ Expectations that staff will learn by trust managers & desire to facilitate that
ā¢ There is tension between patient and learning functions of NHS
ā¢ āThe NHS no longer appears to be a learning organisationā (Melia 2000)
ā¢ Recoupling of NHS and HEIs
ā¢ Allan H T, Smith P A, OāDriscoll M (2011) Experiences of supernumerary status and the hidden curriculum in nursing: a new twist in the theory-practice gap? Journal Clinical Nursing: 20: 847ā855
ā¢ OāDriscoll M Allan H T Smith P (2010) Still looking for leadership ā who is responsible for students nursesā learning in practice? Nurse Education Today 30(3): 212-218
ā¢ Smith P, Allan H T (2010) We should be able to bear our patients in our teaching in some wayā theoretical perspectives on how nurse teachers manage their emotions to negotiate the split between education and caring practice. Nurse Education Today. 30(3): 218-223
ā¢ Evans K,Guile D, Harris J & Allan H T (2010) Putting knowledge to work: a new approach. Nurse Education Today. 30(3): 245-251
ā¢ OāDriscoll M Allan H T Smith P (2010) Still looking for leadership ā who is responsible for students nursesā learning in practice? Nurse Education Today 30(3): 212-218
ā¢ Odelius , Allan H T Hunter B Bryan K Gallagher A & Knibb, W (2012) Reflecting on action research exploring informal complaints management by nurses & midwives in an acute NHS trust. Int. Journal Practice Development 2, 2.