Improving student nurses’ aged care understandings through a supported placement E. Lea1 BA(Hons), PhD, A. Marlow2 RN, MN, M. Bramble3 RN, BN(Hons), BEc, PhD, GradCertStratMarketing, S. Andrews4,5 RN, BN(Hons), PhD, C. Eccleston5 BSc(Hons), PhD, F. McInerney6 RN, BAppSci, MA, PhD & A. Robinson7 RN, DipAppSc(Nurs), BAppSc(Nurs Ed), MNS, PhD 1 Research Fellow, School of Health Sciences, Wicking Dementia Research and Education Centre, 2 Director, Professional Experience, Faculty of Health, 3 Adjunct Senior Lecturer, School of Health Sciences, 4 NHMRC TRIP Fellow, 5 Research Fellow, 7 Co-Director, Wicking Dementia Research and Education Centre, & Professor, Aged Care Nursing, School of Health Sciences, University of Tasmania, Hobart, Tas., 6 Professor, Aged Care, School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Australian Catholic University/Mercy Health, Melbourne, Vic., Australia
LEA E., MARLOW A., BRAMBLE M., ANDREWS S., ECCLESTON C., MCINERNEY F. & ROBINSON A. (2015) Improving student nurses’ aged care understandings through a supported placement. International Nursing Review 62, 28–35 Aim: The study aimed to identify the potential for aged care placements to deliver benefits for second year nursing students when conducted within a supportive framework with debriefing and critical reflection opportunities. Background: Given the ageing population and complex care needs of aged care facility residents, exacerbated by the high prevalence of dementia, the healthcare workforce’s ability to meet older people’s care needs is paramount. Yet research shows that nursing students are disengaged from aged care. Methods: Using a quasi-experimental mixed method design within an action research framework, 40 students were allocated a 3-week supported placement in 2011–2012 at one of the two intervention residential aged care facilities in Tasmania, Australia. Staff formed mentor action research groups in each facility and participated in a pre-placement capacity-building programme. Thirty-nine students were placed across 14 control facilities. Data were collected via meetings with students and pre-post placement questionnaires on placement experiences, attitudes and dementia knowledge. Results: The intervention facility placement programme led to mentors and students being well prepared for the placement and to students experiencing enhanced teaching and learning derived from high levels of mentor support and increased autonomy. Students’ knowledge, understanding and attitudes around aged care and dementia improved.
Correspondence address: Andrew Robinson, School of Health Sciences and Wicking Dementia Research and Education Centre, University of Tasmania, Private Bag 121, Hobart, Tas. 7001, Australia; Tel: +61-(0)3-6226-4735; Fax: +61-(0)3-6226-4880; E-mail: [email protected].
Funding source The project received funding from the School of Nursing and Midwifery (now Health Sciences), School of Medicine, and the Wicking Dementia Research and Education Centre, University of Tasmania; Health Workforce Australia; and the Australian Government Department of Health and Ageing (now Social Services). Conflict of interest No conflict of interest has been declared by the authors.
© 2014 International Council of Nurses
28
bs_bs_banner
Nursing Education
Improving student nurses’ aged care understandings
29
Discussion: Mentors working together within an action research framework can provide a supported residential aged care placement for nursing students that improves students’ aged care attitudes and understandings. Conclusion and Implications for Nursing and Health Policy: Provision of quality, supported aged care student placements is vital to prepare a new generation of nurses who will have to deal with the complex chronic healthcare needs associated with an ageing population. Key words: Action Research, Australia, Clinical Placements, Dementia, Mentors, Mixed Methods, Nurse Education, Nursing Students, Quasi-Experimental Design, Residential Aged Care Facilities
Background Consistent with international trends, Australia is experiencing an increase in the proportion of the population aged over 65, expected to rise from 14% in 2012 to 22% in 2061 (Australian Bureau of Statistics 2013). Worldwide, there are likely to be two billion people aged over 60 by 2050 (World Health Organization 2012). This demographic shift, alongside an increased proportion of people with chronic health conditions such as dementia (World Health Organization 2012), has impacted resident care provision in residential aged care facilities (RACFs) or nursing homes. Residents are presenting for admission at a later age, the proportion requiring higher care levels is increasing (Forder & Fernandez 2011), and a high proportion of RACF residents have dementia (Australian Institute of Health and Welfare 2012; Caffrey et al. 2012). For example, 52% of Australian RACF residents have a diagnosis of dementia (Australian Institute of Health and Welfare 2012). In recognition of these issues, there has been an increased focus in the literature on the importance of quality dementia care for RACF residents (Andrews et al. 2009; McVey et al. 2014). In the context of an ageing population and the increasingly complex care needs of RACF residents, the ability of the healthcare workforce to meet older people’s care needs is paramount. Yet research has shown that nursing students are disengaged from aged care, which is viewed as an unattractive career option (Neville et al. 2014; Stevens 2011). Student placements in this setting are regarded as being of limited clinical relevance, with students strongly focused on technical challenges that they perceive as more aligned with hospital settings (Abbey et al. 2006; Grealish et al. 2013; Holroyd et al. 2009). These perceptions may partially derive from contemporary nursing education that gives precedence to medical and acute models of care (Grealish et al. 2013; Holroyd et al. 2009). This contrasts with increasing recognition in the aged care sector of the importance of holistic and psychosocial models of care, including quality of life and resident-centred care (White-Chu et al. 2009).
© 2014 International Council of Nurses
These factors suggest the need for nursing students to better prepare for the 21st century healthcare challenges they will face when they enter the workforce. Theoretically, clinical placements in RACFs present one possibility for improving students’ preparation by developing their understanding of aged care, including holistic and psychosocial models of care, and the key public health issue of dementia. The placement is significant because evidence indicates that this experience helps shape student attitudes to aged care and represents a key determinant of student career decision-making (Abbey et al. 2006; King et al. 2013). Therefore, it is imperative that nursing students exposed to a clinical placement in a RACF have a positive, high quality experience. Research shows that placement of students in environments ‘enriched’ to provide a positive learning experience with friendly, supportive staff is more likely to result in positive attitudes towards aged care (Brown et al. 2008). For example, students’ anxieties related to the unfamiliar environment of residential aged care are ameliorated by a comprehensive orientation and well-structured programme to support effective learning and teaching, which, in turn, improves their perceptions of aged care (Robinson et al. 2008b). However, many students have a poor placement experience, with research indicating that ‘standard’ aged care placement experiences are likely to develop or strengthen negative student views on aged care (Abbey et al. 2006; Robinson et al. 2007).
Aim This paper focuses upon an approach to improve nursing student placement experiences in residential aged care, with a view to better prepare graduates for future healthcare challenges. The Wicking Teaching Aged Care Facilities Program (TACFP) aims to provide students with an improved learning environment that delivers a positive placement experience (Robinson et al. 2013). This paper identifies the potential for such supportive placements to deliver benefits for second year nursing students. The
30
E. Lea et al.
focus is on provision of a welcoming environment, an improved understanding of dementia and attitudinal change to aged care.
Methods Study design
The Wicking TACFP builds on an evidence-based best practice model of quality aged care placements (Robinson et al. 2008a), key components of which include appropriate preparation of staff to mentor students and adequate on-site support. Uniquely, the Wicking TACFP activates this model within a framework that includes opportunities for students to debrief and engage in critical reflection (Robinson et al. 2008a). The intent is to encourage student learning and teaching, so they experience a well-supported placement and develop their understanding of both aged care and dementia. Evaluation of students’ experiences of the placements occurred through a quasi-experimental mixed method design within an action research framework. Qualitative data were collected from students placed at intervention RACFs, whereas prepost placement questionnaire data were collected from students placed at control and intervention RACFs. Setting
Two independent RACFs in the Australian state of Tasmania (which shares the aged and healthcare systems in place elsewhere in Australia) volunteered to participate in the Wicking TACFP. The data for this paper were collected from students in semester 2 of 2011 and semester 1 of 2012 at these two intervention RACFs and from 14 control RACFs. Intervention RACFs had 141–175 beds and included high and low care residents (57% high care); control facilities were generally smaller, with size ranging from 53 to 143 beds (average of 82 beds), and a similar resident mix (59% high care). Intervention facilities were located in the two main Tasmanian cities, as were all control facilities, with the exception of two, which were located within 30-min drive. To foster the process of student learning and teaching, a group of RACF staff was recruited to act as mentors to students and form a mentor group in each intervention facility. However, as aged care nurses and care staff often exhibit a limited capacity to implement evidence-based practice (Andrews et al. 2012; Elliott et al. 2012; Lea et al. 2012), mentors participated in a range of organizational development and capacity-building activities. This was consistent with both the best practice model of aged care placements (Robinson et al. 2008a) and an action research approach of collaboration to identify and take action on issues (Kemmis & McTaggart 1986). Established as a functional and identifiable cohort, members of the mentor group
© 2014 International Council of Nurses
took responsibility for developing rosters, the assignment of students to staff over the course of the placement, the scheduling of education sessions, development of facility-specific information packages and implementing a comprehensive orientation programme. Prior to the students’ arrival, mentors also participated in training around mentorship and dementia. Supporting this process were university-based project officers and nursing academics (Robinson et al. 2013). The action research mentor group at each intervention RACF involved 10–12 staff members (the number fluctuated depending upon additional recruitment/withdrawals; 32 mentors joined the group before the end of semester 1 of 2012). These groups were composed largely of registered nurses (RNs; 46.9%), enrolled nurses (ENs; 25.0%) and care workers (25.0%). Half (50.0%) had worked in aged care for over ten years, whereas 12.5% had worked in aged care for less than one year. A senior RN (mentor leader) was identified by RACF managers to lead each group. Participants
Participants were two second year nursing student cohorts from a single university allocated to a 3-week professional experience placement at one of the two intervention facilities (ten students/ facility/semester, n = 40). Included were 39 control students who undertook ‘standard’ placements across 14 other RACFs (19–20 students in total per semester). Students were allocated to a placement on the basis of their regional preferences and prior placement history. Ten intervention students were assigned to each RACF placement, consistent with the TACFP protocol (Robinson et al. 2013). Control students were allocated based upon the RACFs’ usual allocation practices. This varied from one to six students per facility (average of two). Student demographics are presented in Table 1. Preparation for practice: structure of students’ course
The structure and content of the nursing students’ course provides an important context for students’ attitude to aged care Table 1 Second year nursing student demographics (no significant difference at P < 0.05 between intervention and control groups) Nursing students
Gender Female Age – mean (SD, range) Country of birth Australia
Intervention n = 40
Control n = 39
77.5% (31) 26 (±6.5, 19–42)
92.3% (36) 25 (±6.7, 20–43)
82.5% (33)
89.2% (33)
Improving student nurses’ aged care understandings
placements. The second year of the three-year Bachelor of Nursing degree builds on studies undertaken in first year, allowing students to develop their nursing practice, knowledge and skills. However, students do not engage with specific theory pertaining to the care of older people or dementia until their second year placement experience. Structure of student placement in intervention facilities
Intervention students participated in a supported 3-week professional experience placement, as outlined in the evidencebased model of quality clinical aged care placements (Robinson et al. 2008a) introduced earlier. The model outlines a process related to placement preparation. This preparation is coherent across RACFs, yet encompasses a degree of flexibility to allow adaptation to the local situation at each facility. Central operational steps involved in placement preparation include site visits by students prior to placement, elucidation of expectations of mentorship and delivery of a toolkit for mentors containing details such as liaison plans, objectives and scope of the placement, and students’ prior learning experiences. Throughout the placement, mentors and students participated in weekly separate but parallel meetings with a facilitated feedback loop (Robinson & Cubit 2005). These meetings allowed opportunities for critical reflection, for mentors and students to obtain a sense of each other’s perceptions, and for augmenting collaboration both within and between the groups. Within the formal placement structure, students also attended a 2-h workshop on the dementia trajectory and related care needs. Data collection and analysis Qualitative
Qualitative data reported here were those collected from 12 intervention student feedback meetings held weekly during the placements. These semi-structured meetings, facilitated by a project officer using a list of topics to guide discussions (e.g. ‘involvement in clinical activities’, ‘accounts of interacting with residents’, ‘working with people with dementia’), allowed students to discuss placement experiences and share issues and concerns. Meetings were audio-recorded and transcribed. Qualitative thematic analysis of transcripts (Hansen 2006) was used to identify key themes and issues related to student experiences. Emergent themes were discussed with a research team with qualitative research experience in the RACF environment. Exemplifier quotes illustrate these key themes, coded by intervention facility A or B and a unique number for each student at each facility.
© 2014 International Council of Nurses
31
Quantitative
Students (intervention and control) completed questionnaires before, during (end of week 1) and after placement to gather information on demographics (Robinson et al. 2007), welcome into the facility (Robinson et al. 2007), pre-post dementia knowledge (Toye et al. 2014) and clinical learning experiences of the placement (Chan 2001). Welcome into the facility was assessed at the end of week 1 (‘When you arrived in the aged care facility were you made to feel comfortable and welcome?’ using a four-point Likert scale ranging from ‘very welcome’ to ‘very unwelcome’). Placement clinical learning experiences were assessed using the following two activity-related items with a four-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’: ‘The mentors often planned interesting activities’ and ‘I did the same type of tasks in every shift’ (Chan 2001). Dementia knowledge was assessed using the 21-item validated Dementia Knowledge Assessment Tool Version 2 (D-KAT2) (Toye et al. 2014). This tool was chosen because it assesses knowledge of dementia and dementia care in general, rather than knowledge of a specific type of dementia (e.g. Alzheimer’s disease), and is accessible to respondents from a range of backgrounds (i.e. not specialist knowledge). Example items include ‘Dementia is likely to limit life expectancy’ and ‘Difficulty swallowing occurs in late stage dementia’. Good internal consistency was achieved for the D-KAT2 using the TACFP sample (Cronbach’s alpha = 0.781). Questionnaire data were analysed using IBM SPSS Statistics (version 20.0, Armonk, NY, USA). Descriptive analyses were completed, with total correct scores calculated for the D-KAT2 (possible range: 0–21). The non-parametric Wilcoxon signedrank test was used to compare pre-post placement scores, and Mann–Whitney U to compare control and intervention group responses. Ethics
The study was independently reviewed and approved by the University of Tasmania Human Research Ethics Committee (No. H11576) in accordance with ethical guidelines (National Health and Medical Research Council et al. 2007). Students attended information sessions to facilitate their understanding of the study terms prior to providing written consent to participate.
Results The findings indicated that the structure of the placement and provision of opportunities for progressively increasing student autonomy worked to support students’ experience of a productive environment for learning and teaching.
32
E. Lea et al.
Enhanced preparation: students feeling welcome and supported
A key focus of the evidence-based best practice model of quality clinical placements involves preparing the students for what may well be a quite confronting placement experience (Robinson & Cubit 2007). Intervention students indicated during their weekly feedback meetings that the pre-placement site visit had been ‘a great opportunity’ [B01] and ‘helpful because you knew what you were going to have to do over the three weeks’ [B18]. This worked to allay placement fears as one student commented: ‘I knew exactly where I had to go [and] who was going to be there . . . that really helped’ [B07]. Another student appreciated the opportunity to ask questions, contrasting this with a previous placement: It was good to have that opportunity to ask questions before, because with my previous prac[ticum] we went straight into it and had to ask questions after. [A18] The best practice model also highlights the importance of students feeling welcome to the RACF on their arrival (Robinson et al. 2008b). Evaluation findings indicated that both intervention RACFs had the capacity to provide a supportive, welcoming environment for students. For example, intervention students reported via end-week 1 questionnaires that they felt welcomed into the facilities more so than the control students in other facilities (77.5% of intervention vs. 42.1% of control students felt ‘very welcome’; U = 491.0, Z = −3.172, P = 0.002). In the feedback meetings, intervention students explicated what this meant in practice. For example, they noted that staff knew they were coming (‘it seemed like everyone was informed’ [B20]) and had made preparations in advance: ‘it was good to know that the programs were structured in before we got here; it makes everything a lot easier . . .’ [B11]. As the placements progressed, intervention students indicated that they felt supported by mentors. For example, the students variously described their mentors as ‘really friendly’ [B15] and ‘lovely and supportive and let us get involved’ [B14]. One student reported that the mentors ‘were always there if you need them to be, which was good’ [A14], whereas another noted it was ‘good to know that the carers and nurses . . . know you’re there to learn and that they’re there to teach you’ [B12]. Another student contrasted their current TACFP placement with previous placements where the staff they worked with ‘assumed we knew how to do everything [even when] I’d never seen the procedures done’ [A18]. This student went on to note that mentors on the current placement were ‘more aware that we’re students, here to learn the procedures before we’re happy to do them – that is much, much better’ [A18]. Students identified a desire to have increasing opportunities to practise more autonomously as the placement progressed:
© 2014 International Council of Nurses
‘we love a challenge’ [B09]. Through the feedback loop referred to previously, students were able to inform the mentors of their desire to have progressively increasing autonomy. Their comments suggest that the mentors did indeed support them to assume increasing autonomy in their practice. For example, in the first placement week, a student recounted that she appreciated mentors ‘stepping back and letting you do things’ [B15]. By the second week, this student reported: This week I’ve been really independent and that was fantastic. I did my own resident care . . . I felt like a nurse for five minutes and that was so cool. [B15] By the final week, students reported ‘we’ve been a lot more independent this week’ [A19]. One student described how mentors ‘trusted me enough to [let me] initiate what I was doing’ [B20], whereas another recounted how she and her colleagues had ‘checked the blood sugar levels by ourselves’ [A19]. Progressively increasing autonomy supported students to build their clinical confidence, as epitomized by the comment: ‘it’s the first time I felt like I knew what I was doing, in all placements, first time ever, which is awesome’ [B15]. Indeed, postplacement questionnaires demonstrated that in comparison to control students, intervention students reported that their mentors provided them with a variety of learning opportunities. For example, data illustrated a significant difference between these students and controls in terms of ‘agree’/‘strongly agree’ responses to the question: ‘The mentors often planned interesting activities’ (85.0% of intervention vs. 33.3% of control; U = 92.0, Z = 2.787, P = 0.009). Their responses also reveal a significant difference with respect to ‘agree’/‘strongly agree’ responses to the question: ‘I did the same type of tasks in every shift’ (42.1% of intervention vs. 77.8% of control students; U = 107.0, Z = 2.324, P = 0.03). These responses imply that the structured programme in the intervention facilities provided the students with a variety of experiences that supported learning and teaching. Improved understanding of dementia and aged care
The diversity of experiences for students, where mentors thought of ‘interesting activities’, together with participation in the dementia education workshop, opened up opportunities for the intervention students to develop their knowledge of dementia. This was important because feedback meeting data indicated that students’ pre-existing experience of caring for people with dementia was limited: ‘I’ve never done anything with dementia care at all’ [B15]. This meant that the ‘fascinating’ [B04] dementia workshop was ‘really appreciated’ [B15]. One student noted:
Improving student nurses’ aged care understandings
It [the workshop] will help me deal with someone with dementia a lot better, a lot easier, because I [better understand] where they [residents with dementia] are coming from. [B11] Other students reported that the workshop ‘helped us to get to know them [residents with dementia]’ [A14] so when they began to work with residents ‘we had an understanding of what was going on and how to tailor [our] behaviour [to] people with dementia’ [B09]. Students recounted that the opportunity to work with residents with dementia – opportunities strategically facilitated by their mentor – led to their developing new insights into care provision and enhanced understandings of dementia. Reflective of mentors’ focus on giving students access to ‘interesting activities’, they reported learning techniques and communication strategies to work effectively with these residents, such as ‘getting to know their personalities because you can’t approach them all the same way’ [A15]. Not infrequently, students’ impressions of residents with dementia changed. For example, early in the placement, one student described residents with dementia as ‘all just lost’, yet recounted later in the placement that ‘when you spend some time with them or get to know them, I’ve really loved it’ [A15]. Supporting these qualitative findings, the D-KAT2 questionnaire (Toye et al. 2014) data indicated a significant improvement in the two cohorts of intervention students’ dementia knowledge when compared to controls (pre-placement M = 14.1, SD = 3.3, post-placement M = 17.6, SD = 2.3; Z = −4.815, P = 0.001). While the mean D-KAT2 score also increased for control students (from M = 13.6, SD = 3.2 to M = 15.4, SD = 2.6; Z = −3.600, P = 0.001), intervention students had a significantly higher score than control students at post-placement (U = 312.5, Z = −3.67, P = 0.001; no significant difference at pre-placement). The qualitative data demonstrated that new understandings of dementia together with a diversity of placement experiences supported students to develop their understandings of appropriate care for older people. Students recognized the importance of holistic care, noting that care is ‘more based on the person’s feelings . . . it’s less clinical . . . you need to just make them [residents] as comfortable as you can’ [A14]. Improved awareness of palliative approaches was cited as an important placement outcome that they had not been exposed to in their nursing studies: ‘you go to uni[versity] and learn that when you’re a nurse you want to save everyone’s life and make people better and here, that’s not what it’s really about’ [A15]. Interestingly, some students indicated in the feedback meetings that their attitude to aged care and to working in RACFs improved as the placement progressed. For example, one student explained how the placement had ‘changed my
© 2014 International Council of Nurses
33
perspective; I thought I’d never go into aged care but now . . . I’d definitely consider it’ [B18]. Other intervention students concurred, showing that most students were positive about their placement overall: ‘[it has been] a really good experience’ [B13]; ‘I’ve been having a great time’ [A13].
Discussion The TACFP aims to improve students’ attitudes and knowledge around aged care by provision of a quality placement experience. Some of the key factors that improve the placement experience found in this study are reported as important in the literature, such as welcome and orientation (Robinson et al. 2008b), supportive staff (Levett-Jones et al. 2009) and a supportive learning environment (Brown et al. 2008; Henderson et al. 2008). The TACFP intends to differ from ‘standard’ aged care placements by building on an evidence-based best practice model of quality clinical aged care placements (Robinson et al. 2008a) and by engaging mentors to support students within an action research framework. This model specifies the need to plan well in advance for student placements by preparing facility staff to act as mentors, and to provide a supportive environment including welcome and orientation activities, debriefing and the opportunity for critical reflection for mentors and students (Robinson et al. 2008a). The findings reported here show the success of this approach, with intervention students having an improved experience compared with control (‘standard’ placement) students as a result of their mentors’ involvement in the action research group. This is highlighted particularly by mentors and intervention students being well-prepared for the placement and the teaching and learning benefits for students derived from high levels of mentor support. The mentor’s role in supporting students, particularly as it pertains to RNs, is addressed in the literature and in nursing competency standards (Andrews et al. 2010; Levett-Jones et al. 2009; Nursing and Midwifery Board of Australia 2006). However, there is little in the literature that addresses the role that care workers and ENs play in mentoring nursing students in RACFs, an environment where these staff predominate (King et al. 2012; The National Care Forum 2013). Significantly, based upon the student feedback, the action research approach utilized in this study appears to have improved the mentorship ability of a range of staff. The supported placement provided students with teaching and learning benefits around both improved understanding of the importance of a holistic focus to care, which is recognized as a crucial component to quality dementia care (White-Chu et al. 2009), and satisfaction with their learning activities. For example, the findings suggest that in intervention facilities, the structured programme provided students with a range of experiences that facilitated learning and teaching, and meant
34
E. Lea et al.
that students did not find themselves engaged in the limited repertoire of routine activities and tasks that often characterize aged care placements (Brown et al. 2008; Henderson et al. 2008). In particular, the TACFP had successful outcomes related to knowledge of dementia. Students initially (pre-placement) had deficiencies in their understanding of dementia, which has also been reported elsewhere (Kwok et al. 2011; Robinson & Cubit 2007; Scerri & Scerri 2013), and may be linked to limited or variable aged care and dementia-specific content in higher education undergraduate healthcare courses internationally (All-Party Parliamentary Group 2012; Duggan et al. 2013; Tullo & Gordon 2013). The supported placement the intervention students received in this study was able to improve these dementia knowledge deficiencies, more so than for the control students. Together, these outcomes highlight the potential for second year nursing students to learn and develop from a quality aged care placement, which is particularly important given the link between a positive aged care placement and student attitudes to aged care, as well as their desire to work in the sector (Brown et al. 2008). This not only has likely longterm benefits for the aged care sector in terms of improved recruitment and retention but also for the quality of the future healthcare workforce. The healthcare workforce needs to be prepared to deal with the ageing population and the escalation of chronic diseases, including dementia, which characterize the 21st century health needs (World Health Organization 2012). Limitations and further research
A limitation of the research is the study size and the implications this has for generalization. However, due to the resourceintensive nature of this project, it was not possible to increase the sample size at this project stage. Subsequent stages of the project will consolidate the programme across additional second year nursing student placements.
Conclusion and Implications for Nursing and Health Policy This research shows that an enriched, supported professional experience placement in aged care, which employs an action research framework to build capability among mentors to support students and an opportunity for students to debrief and critically reflect, provides second year nursing students with an improved placement experience over ‘standard’ aged care placements. Such placements enable nursing students to feel welcome, experience satisfaction with learning activities, and improve their attitudes to and understanding of aged care, effectively enhancing students’ exposure to education in areas such as dementia and facilitating their learning about holistic care practices. Employing a strategic approach to facilitation of
© 2014 International Council of Nurses
teaching and learning via mentor support to provide a quality placement in residential aged care will potentially prepare students more completely for their future role as nurses. This applies not only to those who will work in the aged care sector but also in the acute or community sectors, where nurses will be required to manage the complex chronic healthcare needs associated with an ageing population.
Acknowledgements The authors thank the aged care facility and university staff and students involved with the project.
Author contributions EL, AM, SA, FM and AR contributed to study conception/ design; EL, MB, SA, CE and AR contributed to data collection/ analysis; EL and AR drafted the manuscript, whereas all other authors critically revised it for important intellectual content; CE provided statistical expertise; all authors approved the final version.
References Abbey, J., et al. (2006) Clinical placements in residential aged care facilities: the impact on nursing students’ perception of aged care and the effect on career plans. Australian Journal of Advanced Nursing, 23 (4), 14–19. All-Party Parliamentary Group (2012) Unlocking Diagnosis: All-Party Parliamentary Group Report 2012. British Government, London. Andrews, M., et al. (2010) Implementation and sustainability of the nursing and midwifery standards for mentoring in the UK. Nurse Education in Practice, 10, 251–255. Andrews, S., McInerney, F. & Robinson, A. (2009) Realizing a palliative approach in dementia care: strategies to facilitate aged care staff engagement in evidence-based practice. International Psychogeriatrics, 21 (1), S64–S68. Andrews, S., et al. (2012) Reducing staff isolation and developing evidenceinformed practice in the aged care environment through an action research approach to falls prevention. Advances in Nursing Science, 35 (1), 3–13. Australian Bureau of Statistics (2013) Population Projections Australia, 2012 (Base) to 2101 (Cat. No. 3222.0). ABS, Canberra. Australian Institute of Health and Welfare (2012) Residential Aged Care in Australia 2010–2011: A Statistical Overview. Aged Care Statistics Series No. 36. AIHW, Canberra. Brown, J., et al. (2008) Transforming students’ views of gerontological nursing: realising the potential of ‘enriched’ environments of learning and care: a multi-method longitudinal study. International Journal of Nursing Studies, 45 (8), 1214–1232. Caffrey, C., et al. (2012) Residents Living in Residential Care Facilities: United States, 2010. National Center for Health United States, Hyattsville, MD. Chan, D. (2001) Development of an innovative tool to assess hospital learning environments. Nurse Education Today, 21 (8), 624–631.
Improving student nurses’ aged care understandings
Duggan, S., Mitchell, E.A. & Moore, K.D. (2013) ‘With a bit of tweaking. . .we could be great’. An exploratory study of the perceptions of students on working with older people in a preregistration BSc (Hons) Nursing course. International Journal of Older People Nursing, 8, 207– 215. Elliott, K.J., et al. (2012) Building capacity and resilience in the dementia care workforce: a systematic review of interventions targeting worker and organizational outcomes. International Psychogeriatrics, 24 (6), 882– 894. Forder, J. & Fernandez, J.-L. (2011) Length of Stay in Care Homes. Bupa Care Services, PSSRU, Canterbury. Grealish, L., et al. (2013) Promoting student learning and increasing organizational capacity to host students in residential aged care: a mixed method research study. Nurse Education Today, 33, 714–719. Hansen, E.C. (2006) Successful Qualitative Health Research – A Practical Introduction. Allen and Unwin, Sydney, NSW. Henderson, J., et al. (2008) Older people have lived their lives: first year nursing students’ attitudes towards older people. Contemporary Nurse, 30 (1), 32–45. Holroyd, A., et al. (2009) Attitudes toward aging: implications for a caring profession. Journal of Nursing Education, 48 (7), 374–380. Kemmis, S. & McTaggart, R. (1986) The Action Research Planner. Deakin University Press, Geelong, Vic. King, B.J., Roberts, T.J. & Bowers, B.J. (2013) Nursing student attitudes towards and preference for working with older adults. Gerontology and Geriatrics Education, 34 (3), 272–291. King, D., et al. (2012) The Aged Care Workforce, 2012. Australian Government Department of Health and Ageing, Canberra. Kwok, T., Lam, K., Yip, A. & Ho, F. (2011) Knowledge of dementia among undergraduates in the health and social care professions in Hong Kong. Social Work in Mental Health, 9 (4), 287–301. Lea, E., et al. (2012) Beyond the ‘tick and flick’: facilitating best practice falls prevention through an action research approach. Journal of Clinical Nursing, 21 (13–14), 1896–1905. Levett-Jones, T., Lathlean, J., Higgins, I. & McMillan, M. (2009) Staffstudent relationships and their impact on nursing students’ belongingness and learning. Journal of Advanced Nursing, 65 (2), 316– 324. McVey, P., McKenzie, H. & White, K. (2014) A community-of-care: the integration of a palliative approach within residential aged care facilities in Australia. Health and Social Care in the Community, 22 (2), 197–209. National Health and Medical Research Council, Australian Research Council & Australian Vice-Chancellors’ Committee (2007) National Statement on Ethical Conduct in Human Research. NHMRC, ARC, AVCC, Canberra.
© 2014 International Council of Nurses
35
Neville, C., Dickie, R. & Goetz, S. (2014) What’s stopping a career in gerontological nursing? Literature review. Journal of Gerontological Nursing, 40 (1), 18–27. Nursing and Midwifery Board of Australia (2006) National Competency Standards for the Registered Nurse. Nursing and Midwifery Board of Australia, Melbourne. Available at: http://www.nursingmidwiferyboard .gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx) (accessed 5 June 2014). Robinson, A. & Cubit, K. (2005) Student nurses’ experiences of the body in aged care. Contemporary Nurse, 19 (1–2), 41–51. Robinson, A. & Cubit, K. (2007) Caring for older people with dementia in residential care: nursing students’ experiences. Journal of Advanced Nursing, 59 (3), 255–263. Robinson, A., Andrews-Hall, S. & Fassett, M. (2007) Living on the edge: issues that undermine the capacity of residential aged care providers to support student nurses on clinical placement. Australian Health Review, 31 (3), 368–378. Robinson, A., et al. (2008a) Modelling Connections in Aged Care: Development of an Evidence-Based/Best Practice Model to Facilitate Quality Clinical Placements in Aged Care. Report on Stages 1–3 (Amended). School of Nursing and Midwifery, University of Tasmania, Hobart. Robinson, A., et al. (2008b) Attracting students to aged care: the impact of a supportive orientation. Nurse Education Today, 28 (3), 354–362. Robinson, A., et al. (2013) Teaching Aged Care Facilities: Implementing Interprofessional Prevocational Education and Practice in Residential Aged Care. Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania. Scerri, A. & Scerri, C. (2013) Nursing students’ knowledge and attitudes towards dementia – a questionnaire study. Nurse Education Today, 33 (9), 962–968. Stevens, J. (2011) Student nurses’ career preferences for working with older people: a replicated longitudinal survey. International Journal of Nursing Studies, 48 (8), 944–951. The National Care Forum (2013) Personnel Statistics Report: Survey of NCF Member Organisations. NCF, Coventry. Toye, C., et al. (2014) Dementia knowledge assessment tool version two: development of a tool to inform preparation for care planning and delivery in families and care staff. Dementia: The International Journal of Social Research and Practice, 13 (2), 248–256. Tullo, E. & Gordon, A. (2013) Teaching and learning about dementia in UK medical schools: a national survey. BMC Geriatrics, 13, 29. White-Chu, E.F., et al. (2009) Beyond the medical model: the culture change revolution in long-term care. Journal of the American Medical Directors Association, 10, 370–378. World Health Organization (2012) Dementia: A Public Health Priority. World Health Organization, Geneva.
Copyright of International Nursing Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
LEA E., MARLOW A., BRAMBLE M., ANDREWS S., ECCLESTON C., MCINERNEY F. & ROBINSON A. (2015) Improving student nurses’ aged care understandings through a supported placement. International Nursing Review 62, 28–35 Aim: The study aimed to identify the potential for aged care placements to deliver benefits for second year nursing students when conducted within a supportive framework with debriefing and critical reflection opportunities. Background: Given the ageing population and complex care needs of aged care facility residents, exacerbated by the high prevalence of dementia, the healthcare workforce’s ability to meet older people’s care needs is paramount. Yet research shows that nursing students are disengaged from aged care. Methods: Using a quasi-experimental mixed method design within an action research framework, 40 students were allocated a 3-week supported placement in 2011–2012 at one of the two intervention residential aged care facilities in Tasmania, Australia. Staff formed mentor action research groups in each facility and participated in a pre-placement capacity-building programme. Thirty-nine students were placed across 14 control facilities. Data were collected via meetings with students and pre-post placement questionnaires on placement experiences, attitudes and dementia knowledge. Results: The intervention facility placement programme led to mentors and students being well prepared for the placement and to students experiencing enhanced teaching and learning derived from high levels of mentor support and increased autonomy. Students’ knowledge, understanding and attitudes around aged care and dementia improved.
Correspondence address: Andrew Robinson, School of Health Sciences and Wicking Dementia Research and Education Centre, University of Tasmania, Private Bag 121, Hobart, Tas. 7001, Australia; Tel: +61-(0)3-6226-4735; Fax: +61-(0)3-6226-4880; E-mail: [email protected].
Funding source The project received funding from the School of Nursing and Midwifery (now Health Sciences), School of Medicine, and the Wicking Dementia Research and Education Centre, University of Tasmania; Health Workforce Australia; and the Australian Government Department of Health and Ageing (now Social Services). Conflict of interest No conflict of interest has been declared by the authors.
© 2014 International Council of Nurses
28
bs_bs_banner
Nursing Education
Improving student nurses’ aged care understandings
29
Discussion: Mentors working together within an action research framework can provide a supported residential aged care placement for nursing students that improves students’ aged care attitudes and understandings. Conclusion and Implications for Nursing and Health Policy: Provision of quality, supported aged care student placements is vital to prepare a new generation of nurses who will have to deal with the complex chronic healthcare needs associated with an ageing population. Key words: Action Research, Australia, Clinical Placements, Dementia, Mentors, Mixed Methods, Nurse Education, Nursing Students, Quasi-Experimental Design, Residential Aged Care Facilities
Background Consistent with international trends, Australia is experiencing an increase in the proportion of the population aged over 65, expected to rise from 14% in 2012 to 22% in 2061 (Australian Bureau of Statistics 2013). Worldwide, there are likely to be two billion people aged over 60 by 2050 (World Health Organization 2012). This demographic shift, alongside an increased proportion of people with chronic health conditions such as dementia (World Health Organization 2012), has impacted resident care provision in residential aged care facilities (RACFs) or nursing homes. Residents are presenting for admission at a later age, the proportion requiring higher care levels is increasing (Forder & Fernandez 2011), and a high proportion of RACF residents have dementia (Australian Institute of Health and Welfare 2012; Caffrey et al. 2012). For example, 52% of Australian RACF residents have a diagnosis of dementia (Australian Institute of Health and Welfare 2012). In recognition of these issues, there has been an increased focus in the literature on the importance of quality dementia care for RACF residents (Andrews et al. 2009; McVey et al. 2014). In the context of an ageing population and the increasingly complex care needs of RACF residents, the ability of the healthcare workforce to meet older people’s care needs is paramount. Yet research has shown that nursing students are disengaged from aged care, which is viewed as an unattractive career option (Neville et al. 2014; Stevens 2011). Student placements in this setting are regarded as being of limited clinical relevance, with students strongly focused on technical challenges that they perceive as more aligned with hospital settings (Abbey et al. 2006; Grealish et al. 2013; Holroyd et al. 2009). These perceptions may partially derive from contemporary nursing education that gives precedence to medical and acute models of care (Grealish et al. 2013; Holroyd et al. 2009). This contrasts with increasing recognition in the aged care sector of the importance of holistic and psychosocial models of care, including quality of life and resident-centred care (White-Chu et al. 2009).
© 2014 International Council of Nurses
These factors suggest the need for nursing students to better prepare for the 21st century healthcare challenges they will face when they enter the workforce. Theoretically, clinical placements in RACFs present one possibility for improving students’ preparation by developing their understanding of aged care, including holistic and psychosocial models of care, and the key public health issue of dementia. The placement is significant because evidence indicates that this experience helps shape student attitudes to aged care and represents a key determinant of student career decision-making (Abbey et al. 2006; King et al. 2013). Therefore, it is imperative that nursing students exposed to a clinical placement in a RACF have a positive, high quality experience. Research shows that placement of students in environments ‘enriched’ to provide a positive learning experience with friendly, supportive staff is more likely to result in positive attitudes towards aged care (Brown et al. 2008). For example, students’ anxieties related to the unfamiliar environment of residential aged care are ameliorated by a comprehensive orientation and well-structured programme to support effective learning and teaching, which, in turn, improves their perceptions of aged care (Robinson et al. 2008b). However, many students have a poor placement experience, with research indicating that ‘standard’ aged care placement experiences are likely to develop or strengthen negative student views on aged care (Abbey et al. 2006; Robinson et al. 2007).
Aim This paper focuses upon an approach to improve nursing student placement experiences in residential aged care, with a view to better prepare graduates for future healthcare challenges. The Wicking Teaching Aged Care Facilities Program (TACFP) aims to provide students with an improved learning environment that delivers a positive placement experience (Robinson et al. 2013). This paper identifies the potential for such supportive placements to deliver benefits for second year nursing students. The
30
E. Lea et al.
focus is on provision of a welcoming environment, an improved understanding of dementia and attitudinal change to aged care.
Methods Study design
The Wicking TACFP builds on an evidence-based best practice model of quality aged care placements (Robinson et al. 2008a), key components of which include appropriate preparation of staff to mentor students and adequate on-site support. Uniquely, the Wicking TACFP activates this model within a framework that includes opportunities for students to debrief and engage in critical reflection (Robinson et al. 2008a). The intent is to encourage student learning and teaching, so they experience a well-supported placement and develop their understanding of both aged care and dementia. Evaluation of students’ experiences of the placements occurred through a quasi-experimental mixed method design within an action research framework. Qualitative data were collected from students placed at intervention RACFs, whereas prepost placement questionnaire data were collected from students placed at control and intervention RACFs. Setting
Two independent RACFs in the Australian state of Tasmania (which shares the aged and healthcare systems in place elsewhere in Australia) volunteered to participate in the Wicking TACFP. The data for this paper were collected from students in semester 2 of 2011 and semester 1 of 2012 at these two intervention RACFs and from 14 control RACFs. Intervention RACFs had 141–175 beds and included high and low care residents (57% high care); control facilities were generally smaller, with size ranging from 53 to 143 beds (average of 82 beds), and a similar resident mix (59% high care). Intervention facilities were located in the two main Tasmanian cities, as were all control facilities, with the exception of two, which were located within 30-min drive. To foster the process of student learning and teaching, a group of RACF staff was recruited to act as mentors to students and form a mentor group in each intervention facility. However, as aged care nurses and care staff often exhibit a limited capacity to implement evidence-based practice (Andrews et al. 2012; Elliott et al. 2012; Lea et al. 2012), mentors participated in a range of organizational development and capacity-building activities. This was consistent with both the best practice model of aged care placements (Robinson et al. 2008a) and an action research approach of collaboration to identify and take action on issues (Kemmis & McTaggart 1986). Established as a functional and identifiable cohort, members of the mentor group
© 2014 International Council of Nurses
took responsibility for developing rosters, the assignment of students to staff over the course of the placement, the scheduling of education sessions, development of facility-specific information packages and implementing a comprehensive orientation programme. Prior to the students’ arrival, mentors also participated in training around mentorship and dementia. Supporting this process were university-based project officers and nursing academics (Robinson et al. 2013). The action research mentor group at each intervention RACF involved 10–12 staff members (the number fluctuated depending upon additional recruitment/withdrawals; 32 mentors joined the group before the end of semester 1 of 2012). These groups were composed largely of registered nurses (RNs; 46.9%), enrolled nurses (ENs; 25.0%) and care workers (25.0%). Half (50.0%) had worked in aged care for over ten years, whereas 12.5% had worked in aged care for less than one year. A senior RN (mentor leader) was identified by RACF managers to lead each group. Participants
Participants were two second year nursing student cohorts from a single university allocated to a 3-week professional experience placement at one of the two intervention facilities (ten students/ facility/semester, n = 40). Included were 39 control students who undertook ‘standard’ placements across 14 other RACFs (19–20 students in total per semester). Students were allocated to a placement on the basis of their regional preferences and prior placement history. Ten intervention students were assigned to each RACF placement, consistent with the TACFP protocol (Robinson et al. 2013). Control students were allocated based upon the RACFs’ usual allocation practices. This varied from one to six students per facility (average of two). Student demographics are presented in Table 1. Preparation for practice: structure of students’ course
The structure and content of the nursing students’ course provides an important context for students’ attitude to aged care Table 1 Second year nursing student demographics (no significant difference at P < 0.05 between intervention and control groups) Nursing students
Gender Female Age – mean (SD, range) Country of birth Australia
Intervention n = 40
Control n = 39
77.5% (31) 26 (±6.5, 19–42)
92.3% (36) 25 (±6.7, 20–43)
82.5% (33)
89.2% (33)
Improving student nurses’ aged care understandings
placements. The second year of the three-year Bachelor of Nursing degree builds on studies undertaken in first year, allowing students to develop their nursing practice, knowledge and skills. However, students do not engage with specific theory pertaining to the care of older people or dementia until their second year placement experience. Structure of student placement in intervention facilities
Intervention students participated in a supported 3-week professional experience placement, as outlined in the evidencebased model of quality clinical aged care placements (Robinson et al. 2008a) introduced earlier. The model outlines a process related to placement preparation. This preparation is coherent across RACFs, yet encompasses a degree of flexibility to allow adaptation to the local situation at each facility. Central operational steps involved in placement preparation include site visits by students prior to placement, elucidation of expectations of mentorship and delivery of a toolkit for mentors containing details such as liaison plans, objectives and scope of the placement, and students’ prior learning experiences. Throughout the placement, mentors and students participated in weekly separate but parallel meetings with a facilitated feedback loop (Robinson & Cubit 2005). These meetings allowed opportunities for critical reflection, for mentors and students to obtain a sense of each other’s perceptions, and for augmenting collaboration both within and between the groups. Within the formal placement structure, students also attended a 2-h workshop on the dementia trajectory and related care needs. Data collection and analysis Qualitative
Qualitative data reported here were those collected from 12 intervention student feedback meetings held weekly during the placements. These semi-structured meetings, facilitated by a project officer using a list of topics to guide discussions (e.g. ‘involvement in clinical activities’, ‘accounts of interacting with residents’, ‘working with people with dementia’), allowed students to discuss placement experiences and share issues and concerns. Meetings were audio-recorded and transcribed. Qualitative thematic analysis of transcripts (Hansen 2006) was used to identify key themes and issues related to student experiences. Emergent themes were discussed with a research team with qualitative research experience in the RACF environment. Exemplifier quotes illustrate these key themes, coded by intervention facility A or B and a unique number for each student at each facility.
© 2014 International Council of Nurses
31
Quantitative
Students (intervention and control) completed questionnaires before, during (end of week 1) and after placement to gather information on demographics (Robinson et al. 2007), welcome into the facility (Robinson et al. 2007), pre-post dementia knowledge (Toye et al. 2014) and clinical learning experiences of the placement (Chan 2001). Welcome into the facility was assessed at the end of week 1 (‘When you arrived in the aged care facility were you made to feel comfortable and welcome?’ using a four-point Likert scale ranging from ‘very welcome’ to ‘very unwelcome’). Placement clinical learning experiences were assessed using the following two activity-related items with a four-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’: ‘The mentors often planned interesting activities’ and ‘I did the same type of tasks in every shift’ (Chan 2001). Dementia knowledge was assessed using the 21-item validated Dementia Knowledge Assessment Tool Version 2 (D-KAT2) (Toye et al. 2014). This tool was chosen because it assesses knowledge of dementia and dementia care in general, rather than knowledge of a specific type of dementia (e.g. Alzheimer’s disease), and is accessible to respondents from a range of backgrounds (i.e. not specialist knowledge). Example items include ‘Dementia is likely to limit life expectancy’ and ‘Difficulty swallowing occurs in late stage dementia’. Good internal consistency was achieved for the D-KAT2 using the TACFP sample (Cronbach’s alpha = 0.781). Questionnaire data were analysed using IBM SPSS Statistics (version 20.0, Armonk, NY, USA). Descriptive analyses were completed, with total correct scores calculated for the D-KAT2 (possible range: 0–21). The non-parametric Wilcoxon signedrank test was used to compare pre-post placement scores, and Mann–Whitney U to compare control and intervention group responses. Ethics
The study was independently reviewed and approved by the University of Tasmania Human Research Ethics Committee (No. H11576) in accordance with ethical guidelines (National Health and Medical Research Council et al. 2007). Students attended information sessions to facilitate their understanding of the study terms prior to providing written consent to participate.
Results The findings indicated that the structure of the placement and provision of opportunities for progressively increasing student autonomy worked to support students’ experience of a productive environment for learning and teaching.
32
E. Lea et al.
Enhanced preparation: students feeling welcome and supported
A key focus of the evidence-based best practice model of quality clinical placements involves preparing the students for what may well be a quite confronting placement experience (Robinson & Cubit 2007). Intervention students indicated during their weekly feedback meetings that the pre-placement site visit had been ‘a great opportunity’ [B01] and ‘helpful because you knew what you were going to have to do over the three weeks’ [B18]. This worked to allay placement fears as one student commented: ‘I knew exactly where I had to go [and] who was going to be there . . . that really helped’ [B07]. Another student appreciated the opportunity to ask questions, contrasting this with a previous placement: It was good to have that opportunity to ask questions before, because with my previous prac[ticum] we went straight into it and had to ask questions after. [A18] The best practice model also highlights the importance of students feeling welcome to the RACF on their arrival (Robinson et al. 2008b). Evaluation findings indicated that both intervention RACFs had the capacity to provide a supportive, welcoming environment for students. For example, intervention students reported via end-week 1 questionnaires that they felt welcomed into the facilities more so than the control students in other facilities (77.5% of intervention vs. 42.1% of control students felt ‘very welcome’; U = 491.0, Z = −3.172, P = 0.002). In the feedback meetings, intervention students explicated what this meant in practice. For example, they noted that staff knew they were coming (‘it seemed like everyone was informed’ [B20]) and had made preparations in advance: ‘it was good to know that the programs were structured in before we got here; it makes everything a lot easier . . .’ [B11]. As the placements progressed, intervention students indicated that they felt supported by mentors. For example, the students variously described their mentors as ‘really friendly’ [B15] and ‘lovely and supportive and let us get involved’ [B14]. One student reported that the mentors ‘were always there if you need them to be, which was good’ [A14], whereas another noted it was ‘good to know that the carers and nurses . . . know you’re there to learn and that they’re there to teach you’ [B12]. Another student contrasted their current TACFP placement with previous placements where the staff they worked with ‘assumed we knew how to do everything [even when] I’d never seen the procedures done’ [A18]. This student went on to note that mentors on the current placement were ‘more aware that we’re students, here to learn the procedures before we’re happy to do them – that is much, much better’ [A18]. Students identified a desire to have increasing opportunities to practise more autonomously as the placement progressed:
© 2014 International Council of Nurses
‘we love a challenge’ [B09]. Through the feedback loop referred to previously, students were able to inform the mentors of their desire to have progressively increasing autonomy. Their comments suggest that the mentors did indeed support them to assume increasing autonomy in their practice. For example, in the first placement week, a student recounted that she appreciated mentors ‘stepping back and letting you do things’ [B15]. By the second week, this student reported: This week I’ve been really independent and that was fantastic. I did my own resident care . . . I felt like a nurse for five minutes and that was so cool. [B15] By the final week, students reported ‘we’ve been a lot more independent this week’ [A19]. One student described how mentors ‘trusted me enough to [let me] initiate what I was doing’ [B20], whereas another recounted how she and her colleagues had ‘checked the blood sugar levels by ourselves’ [A19]. Progressively increasing autonomy supported students to build their clinical confidence, as epitomized by the comment: ‘it’s the first time I felt like I knew what I was doing, in all placements, first time ever, which is awesome’ [B15]. Indeed, postplacement questionnaires demonstrated that in comparison to control students, intervention students reported that their mentors provided them with a variety of learning opportunities. For example, data illustrated a significant difference between these students and controls in terms of ‘agree’/‘strongly agree’ responses to the question: ‘The mentors often planned interesting activities’ (85.0% of intervention vs. 33.3% of control; U = 92.0, Z = 2.787, P = 0.009). Their responses also reveal a significant difference with respect to ‘agree’/‘strongly agree’ responses to the question: ‘I did the same type of tasks in every shift’ (42.1% of intervention vs. 77.8% of control students; U = 107.0, Z = 2.324, P = 0.03). These responses imply that the structured programme in the intervention facilities provided the students with a variety of experiences that supported learning and teaching. Improved understanding of dementia and aged care
The diversity of experiences for students, where mentors thought of ‘interesting activities’, together with participation in the dementia education workshop, opened up opportunities for the intervention students to develop their knowledge of dementia. This was important because feedback meeting data indicated that students’ pre-existing experience of caring for people with dementia was limited: ‘I’ve never done anything with dementia care at all’ [B15]. This meant that the ‘fascinating’ [B04] dementia workshop was ‘really appreciated’ [B15]. One student noted:
Improving student nurses’ aged care understandings
It [the workshop] will help me deal with someone with dementia a lot better, a lot easier, because I [better understand] where they [residents with dementia] are coming from. [B11] Other students reported that the workshop ‘helped us to get to know them [residents with dementia]’ [A14] so when they began to work with residents ‘we had an understanding of what was going on and how to tailor [our] behaviour [to] people with dementia’ [B09]. Students recounted that the opportunity to work with residents with dementia – opportunities strategically facilitated by their mentor – led to their developing new insights into care provision and enhanced understandings of dementia. Reflective of mentors’ focus on giving students access to ‘interesting activities’, they reported learning techniques and communication strategies to work effectively with these residents, such as ‘getting to know their personalities because you can’t approach them all the same way’ [A15]. Not infrequently, students’ impressions of residents with dementia changed. For example, early in the placement, one student described residents with dementia as ‘all just lost’, yet recounted later in the placement that ‘when you spend some time with them or get to know them, I’ve really loved it’ [A15]. Supporting these qualitative findings, the D-KAT2 questionnaire (Toye et al. 2014) data indicated a significant improvement in the two cohorts of intervention students’ dementia knowledge when compared to controls (pre-placement M = 14.1, SD = 3.3, post-placement M = 17.6, SD = 2.3; Z = −4.815, P = 0.001). While the mean D-KAT2 score also increased for control students (from M = 13.6, SD = 3.2 to M = 15.4, SD = 2.6; Z = −3.600, P = 0.001), intervention students had a significantly higher score than control students at post-placement (U = 312.5, Z = −3.67, P = 0.001; no significant difference at pre-placement). The qualitative data demonstrated that new understandings of dementia together with a diversity of placement experiences supported students to develop their understandings of appropriate care for older people. Students recognized the importance of holistic care, noting that care is ‘more based on the person’s feelings . . . it’s less clinical . . . you need to just make them [residents] as comfortable as you can’ [A14]. Improved awareness of palliative approaches was cited as an important placement outcome that they had not been exposed to in their nursing studies: ‘you go to uni[versity] and learn that when you’re a nurse you want to save everyone’s life and make people better and here, that’s not what it’s really about’ [A15]. Interestingly, some students indicated in the feedback meetings that their attitude to aged care and to working in RACFs improved as the placement progressed. For example, one student explained how the placement had ‘changed my
© 2014 International Council of Nurses
33
perspective; I thought I’d never go into aged care but now . . . I’d definitely consider it’ [B18]. Other intervention students concurred, showing that most students were positive about their placement overall: ‘[it has been] a really good experience’ [B13]; ‘I’ve been having a great time’ [A13].
Discussion The TACFP aims to improve students’ attitudes and knowledge around aged care by provision of a quality placement experience. Some of the key factors that improve the placement experience found in this study are reported as important in the literature, such as welcome and orientation (Robinson et al. 2008b), supportive staff (Levett-Jones et al. 2009) and a supportive learning environment (Brown et al. 2008; Henderson et al. 2008). The TACFP intends to differ from ‘standard’ aged care placements by building on an evidence-based best practice model of quality clinical aged care placements (Robinson et al. 2008a) and by engaging mentors to support students within an action research framework. This model specifies the need to plan well in advance for student placements by preparing facility staff to act as mentors, and to provide a supportive environment including welcome and orientation activities, debriefing and the opportunity for critical reflection for mentors and students (Robinson et al. 2008a). The findings reported here show the success of this approach, with intervention students having an improved experience compared with control (‘standard’ placement) students as a result of their mentors’ involvement in the action research group. This is highlighted particularly by mentors and intervention students being well-prepared for the placement and the teaching and learning benefits for students derived from high levels of mentor support. The mentor’s role in supporting students, particularly as it pertains to RNs, is addressed in the literature and in nursing competency standards (Andrews et al. 2010; Levett-Jones et al. 2009; Nursing and Midwifery Board of Australia 2006). However, there is little in the literature that addresses the role that care workers and ENs play in mentoring nursing students in RACFs, an environment where these staff predominate (King et al. 2012; The National Care Forum 2013). Significantly, based upon the student feedback, the action research approach utilized in this study appears to have improved the mentorship ability of a range of staff. The supported placement provided students with teaching and learning benefits around both improved understanding of the importance of a holistic focus to care, which is recognized as a crucial component to quality dementia care (White-Chu et al. 2009), and satisfaction with their learning activities. For example, the findings suggest that in intervention facilities, the structured programme provided students with a range of experiences that facilitated learning and teaching, and meant
34
E. Lea et al.
that students did not find themselves engaged in the limited repertoire of routine activities and tasks that often characterize aged care placements (Brown et al. 2008; Henderson et al. 2008). In particular, the TACFP had successful outcomes related to knowledge of dementia. Students initially (pre-placement) had deficiencies in their understanding of dementia, which has also been reported elsewhere (Kwok et al. 2011; Robinson & Cubit 2007; Scerri & Scerri 2013), and may be linked to limited or variable aged care and dementia-specific content in higher education undergraduate healthcare courses internationally (All-Party Parliamentary Group 2012; Duggan et al. 2013; Tullo & Gordon 2013). The supported placement the intervention students received in this study was able to improve these dementia knowledge deficiencies, more so than for the control students. Together, these outcomes highlight the potential for second year nursing students to learn and develop from a quality aged care placement, which is particularly important given the link between a positive aged care placement and student attitudes to aged care, as well as their desire to work in the sector (Brown et al. 2008). This not only has likely longterm benefits for the aged care sector in terms of improved recruitment and retention but also for the quality of the future healthcare workforce. The healthcare workforce needs to be prepared to deal with the ageing population and the escalation of chronic diseases, including dementia, which characterize the 21st century health needs (World Health Organization 2012). Limitations and further research
A limitation of the research is the study size and the implications this has for generalization. However, due to the resourceintensive nature of this project, it was not possible to increase the sample size at this project stage. Subsequent stages of the project will consolidate the programme across additional second year nursing student placements.
Conclusion and Implications for Nursing and Health Policy This research shows that an enriched, supported professional experience placement in aged care, which employs an action research framework to build capability among mentors to support students and an opportunity for students to debrief and critically reflect, provides second year nursing students with an improved placement experience over ‘standard’ aged care placements. Such placements enable nursing students to feel welcome, experience satisfaction with learning activities, and improve their attitudes to and understanding of aged care, effectively enhancing students’ exposure to education in areas such as dementia and facilitating their learning about holistic care practices. Employing a strategic approach to facilitation of
© 2014 International Council of Nurses
teaching and learning via mentor support to provide a quality placement in residential aged care will potentially prepare students more completely for their future role as nurses. This applies not only to those who will work in the aged care sector but also in the acute or community sectors, where nurses will be required to manage the complex chronic healthcare needs associated with an ageing population.
Acknowledgements The authors thank the aged care facility and university staff and students involved with the project.
Author contributions EL, AM, SA, FM and AR contributed to study conception/ design; EL, MB, SA, CE and AR contributed to data collection/ analysis; EL and AR drafted the manuscript, whereas all other authors critically revised it for important intellectual content; CE provided statistical expertise; all authors approved the final version.
References Abbey, J., et al. (2006) Clinical placements in residential aged care facilities: the impact on nursing students’ perception of aged care and the effect on career plans. Australian Journal of Advanced Nursing, 23 (4), 14–19. All-Party Parliamentary Group (2012) Unlocking Diagnosis: All-Party Parliamentary Group Report 2012. British Government, London. Andrews, M., et al. (2010) Implementation and sustainability of the nursing and midwifery standards for mentoring in the UK. Nurse Education in Practice, 10, 251–255. Andrews, S., McInerney, F. & Robinson, A. (2009) Realizing a palliative approach in dementia care: strategies to facilitate aged care staff engagement in evidence-based practice. International Psychogeriatrics, 21 (1), S64–S68. Andrews, S., et al. (2012) Reducing staff isolation and developing evidenceinformed practice in the aged care environment through an action research approach to falls prevention. Advances in Nursing Science, 35 (1), 3–13. Australian Bureau of Statistics (2013) Population Projections Australia, 2012 (Base) to 2101 (Cat. No. 3222.0). ABS, Canberra. Australian Institute of Health and Welfare (2012) Residential Aged Care in Australia 2010–2011: A Statistical Overview. Aged Care Statistics Series No. 36. AIHW, Canberra. Brown, J., et al. (2008) Transforming students’ views of gerontological nursing: realising the potential of ‘enriched’ environments of learning and care: a multi-method longitudinal study. International Journal of Nursing Studies, 45 (8), 1214–1232. Caffrey, C., et al. (2012) Residents Living in Residential Care Facilities: United States, 2010. National Center for Health United States, Hyattsville, MD. Chan, D. (2001) Development of an innovative tool to assess hospital learning environments. Nurse Education Today, 21 (8), 624–631.
Improving student nurses’ aged care understandings
Duggan, S., Mitchell, E.A. & Moore, K.D. (2013) ‘With a bit of tweaking. . .we could be great’. An exploratory study of the perceptions of students on working with older people in a preregistration BSc (Hons) Nursing course. International Journal of Older People Nursing, 8, 207– 215. Elliott, K.J., et al. (2012) Building capacity and resilience in the dementia care workforce: a systematic review of interventions targeting worker and organizational outcomes. International Psychogeriatrics, 24 (6), 882– 894. Forder, J. & Fernandez, J.-L. (2011) Length of Stay in Care Homes. Bupa Care Services, PSSRU, Canterbury. Grealish, L., et al. (2013) Promoting student learning and increasing organizational capacity to host students in residential aged care: a mixed method research study. Nurse Education Today, 33, 714–719. Hansen, E.C. (2006) Successful Qualitative Health Research – A Practical Introduction. Allen and Unwin, Sydney, NSW. Henderson, J., et al. (2008) Older people have lived their lives: first year nursing students’ attitudes towards older people. Contemporary Nurse, 30 (1), 32–45. Holroyd, A., et al. (2009) Attitudes toward aging: implications for a caring profession. Journal of Nursing Education, 48 (7), 374–380. Kemmis, S. & McTaggart, R. (1986) The Action Research Planner. Deakin University Press, Geelong, Vic. King, B.J., Roberts, T.J. & Bowers, B.J. (2013) Nursing student attitudes towards and preference for working with older adults. Gerontology and Geriatrics Education, 34 (3), 272–291. King, D., et al. (2012) The Aged Care Workforce, 2012. Australian Government Department of Health and Ageing, Canberra. Kwok, T., Lam, K., Yip, A. & Ho, F. (2011) Knowledge of dementia among undergraduates in the health and social care professions in Hong Kong. Social Work in Mental Health, 9 (4), 287–301. Lea, E., et al. (2012) Beyond the ‘tick and flick’: facilitating best practice falls prevention through an action research approach. Journal of Clinical Nursing, 21 (13–14), 1896–1905. Levett-Jones, T., Lathlean, J., Higgins, I. & McMillan, M. (2009) Staffstudent relationships and their impact on nursing students’ belongingness and learning. Journal of Advanced Nursing, 65 (2), 316– 324. McVey, P., McKenzie, H. & White, K. (2014) A community-of-care: the integration of a palliative approach within residential aged care facilities in Australia. Health and Social Care in the Community, 22 (2), 197–209. National Health and Medical Research Council, Australian Research Council & Australian Vice-Chancellors’ Committee (2007) National Statement on Ethical Conduct in Human Research. NHMRC, ARC, AVCC, Canberra.
© 2014 International Council of Nurses
35
Neville, C., Dickie, R. & Goetz, S. (2014) What’s stopping a career in gerontological nursing? Literature review. Journal of Gerontological Nursing, 40 (1), 18–27. Nursing and Midwifery Board of Australia (2006) National Competency Standards for the Registered Nurse. Nursing and Midwifery Board of Australia, Melbourne. Available at: http://www.nursingmidwiferyboard .gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx) (accessed 5 June 2014). Robinson, A. & Cubit, K. (2005) Student nurses’ experiences of the body in aged care. Contemporary Nurse, 19 (1–2), 41–51. Robinson, A. & Cubit, K. (2007) Caring for older people with dementia in residential care: nursing students’ experiences. Journal of Advanced Nursing, 59 (3), 255–263. Robinson, A., Andrews-Hall, S. & Fassett, M. (2007) Living on the edge: issues that undermine the capacity of residential aged care providers to support student nurses on clinical placement. Australian Health Review, 31 (3), 368–378. Robinson, A., et al. (2008a) Modelling Connections in Aged Care: Development of an Evidence-Based/Best Practice Model to Facilitate Quality Clinical Placements in Aged Care. Report on Stages 1–3 (Amended). School of Nursing and Midwifery, University of Tasmania, Hobart. Robinson, A., et al. (2008b) Attracting students to aged care: the impact of a supportive orientation. Nurse Education Today, 28 (3), 354–362. Robinson, A., et al. (2013) Teaching Aged Care Facilities: Implementing Interprofessional Prevocational Education and Practice in Residential Aged Care. Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania. Scerri, A. & Scerri, C. (2013) Nursing students’ knowledge and attitudes towards dementia – a questionnaire study. Nurse Education Today, 33 (9), 962–968. Stevens, J. (2011) Student nurses’ career preferences for working with older people: a replicated longitudinal survey. International Journal of Nursing Studies, 48 (8), 944–951. The National Care Forum (2013) Personnel Statistics Report: Survey of NCF Member Organisations. NCF, Coventry. Toye, C., et al. (2014) Dementia knowledge assessment tool version two: development of a tool to inform preparation for care planning and delivery in families and care staff. Dementia: The International Journal of Social Research and Practice, 13 (2), 248–256. Tullo, E. & Gordon, A. (2013) Teaching and learning about dementia in UK medical schools: a national survey. BMC Geriatrics, 13, 29. White-Chu, E.F., et al. (2009) Beyond the medical model: the culture change revolution in long-term care. Journal of the American Medical Directors Association, 10, 370–378. World Health Organization (2012) Dementia: A Public Health Priority. World Health Organization, Geneva.
Copyright of International Nursing Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
