EDITORIAL doi: 10.1111/nicc.12088
Innovation in critical care nursing education: a reply The editorial by Vandijck and Hellings (2014) critically examines how we deliver pre-registration nursing curricula in a technological age. The authors challenge the term ‘innovation’ and ask nurses to reflect on what we mean by that. They also illuminate a tension that often is experienced by educators who want to facilitate a fulfilling learning experience set against the expectations of educational funders, employers, the professional body, statute and most importantly the expectations of the patients and public. The curriculum expands as practitioners draw upon different types of knowledge to meet the changing societal demands on nursing practice (NMC, 2010). Of note, very little is taken out of the curriculum, but less time might be dedicated to the delivery of the widening range of topics that are increasingly considered essential. For example, a nurse has to be information and technology literate, capable of undertaking efficient and sophisticated searches for evidence to inform their salient clinical decisions and caring actions. They have to demonstrate a suitable understanding of psychology, sociology as well as life and physical sciences that serves as a foundation to their applied clinical knowledge (NMC, 2010). They have to be critically aware of research, how to locate it, critique and apply it as appropriate. They have to be self-directed learners. Students are exposed to leadership skills (Watts and Gordon, 2012), expected to communicate effectively, care compassionately, be empathic, mindful of others’ legal rights, function with due regard to ethics and clinical governance. They are also required to be technologically competent, demonstrate dexterity in their clinical
performance, recognise deterioration and act upon it, show due respect for patients and their family and their plans for end of life care (NMC, 2010). They have to understand pharmacology, learn how to cope with new devices that deliver medication and system support. They have to learn how to involve the patient and public in shaping the care that is provided, participate in decisions that shape resource allocation and be accountable for the resources they use and money spent from the public purse. This is all part of the new partnerships in nursing education. There is a vast array of demands with priorities that change with bewildering speed as new government or health departmental policies compel us to address a new initiative, public health agenda, safety or health education need. Delivery has to take account of full and part time delivery, be flexible, facilitate widened access including making reasonable adjustment for those with disability, balance generic with specialist input and all this for a whole time equivalent, in three years. A more litigious society stimulates risk-averse behaviours among the health care providers. What practitioners can do under what circumstances becomes more sharply defined to ‘improve quality’ whilst at the same time, reduce risk of complaint or litigation. Competencies, protocols, guidelines help to determine a threshold standard of what can be done under what circumstances. Vandijck and Hellings (2014) critique this as a Tylerian model that lays emphasis on content, structure and measurable behavioural outcomes: what our sociology colleagues would critique as an instrumental model of nursing knowledge and capability that is overly bureaucratic and serves the
© 2014 British Association of Critical Care Nurses • Vol 19 No 2
new ideologies and values of managerialism (Ritzer, 2004, Klikauer, 2012). Semesters and modularity have laid further claim to the time allotted to the delivery of the academic elements that make up the pre-registration programme. Education Commissioners then seek confirmation that what they fund does demonstrate value for money and that education serves to improve patient outcomes (Health Education England, 2012). Employers, and the public, want assurance that these programmes help to shape clinicians who are fit for practice. The content of a pre-registration curriculum has always been contested with priorities, in part shaped by academics’ areas of specialism and their personal interests (Scholes, 2009). This extends to how academics champion different pedagogies to facilitate learning. The latest drive being to connect with learners through new technologies and devices, so that learning can be interactive, and ultimately be interesting and creative. Sometimes, the quest to be innovative can obscure what needs to be learnt. The medium can take priority and more time can be spent on debating the merits of a device or interactive IT application than perhaps what learning technologies can do to facilitate student engagement and depth of sustained learning. Ever was this so with ‘new ways’ of delivering content once heralded as innovative are now being considered routine and possibly even mundane. For example, interprofessional learning, problem based learning, action learning sets, facilitated reflection and video learning. Moulage, electronic portfolios, and simulation are now repackaged into interactive, virtual environments accessed through digital devices to make them trendy 61
Editorial
and seem much more exciting (Bonnel and Smith, 2010). Project enthusiasts might advocate the use of these devices and approaches without any empirical evidence to illustrate the longer term impact of that mode of delivery on learning and practice. When we add to this mix different student learning styles, preferences and approaches to inquiry, often but not exclusively dictated by discipline and experience, a whole raft of complexity is added. One solution is to simply provide a laptop or tablet and leave the student to discover what they need through the Internet. However, a profession has threshold standards and we have to shape the direction of learning to achieve the necessary requirements and that is often articulated as learning outcomes or competencies. Vandijck and Hellings (2014) suggest that innovation is not so much about what we teach but how we facilitate learning. I would argue it is both. How these new media are implemented, who invests in them, how they are managed, updated, and more importantly applied is vital. Higher education institutions and the partners in practice and industry have to make significant investment in new media for teaching and learning to create a virtual learning environment, invest in online learning, digital devices, or simulation suites. Gaining consensus as to which platforms and products to purchase is far from straight-forward and negotiations can cause considerable delay. Strategic decisions have to be made about where and how money is allocated. The pace of technological advancement can mean that resources can be quickly outmoded with investment showing little return. Training has to be provided to support academics and students with the technology, as well as to update and maintain the
62
equipment. The scale of investment that ensures equal access to devices across a student cohort and across a higher education provider is eye-watering. It is not as simple as advocating for alternative approaches to programme delivery, evaluating them and adapting when necessary. The investment has to yield results in the short and longer terms and that is the Achilles’ heel to Vandijck and Hellings’ argument. The pace of technological advancement is so speedy that by the time we have empirical evidence of the impact on learning, the technology has moved on to the next new trend in teaching. Teaching technologies have progressed along with what we teach to whom and when. We have moved considerably since the dreaded over-head projector, but are we fully prepared to deliver teaching in second life, 3D virtual worlds? Students and academics are faced with submissions through electronic dashboards, materials from drop boxes, share point and various email accounts, as well as the text and telephone. Is this innovation or an exponential increase in the volume of materials, speed of their traffic that serve only to increase the expectations made of us? All this creates frenetic busy-ness that can divert us from reflection and critical thinking. I am mindful of the biggest complaint made by postgraduate students at our University, which is the absence of a dedicated desk space surrounded by silence so they might concentrate on their research and reading. Oh for the days of a librarian in charge of real books and paper journals who lifted her finger to her lips and uttered the immortal sound: sssshhhhh! What knowledge will best serve the patients and the public, and make them safe in our care. How might
that best be facilitated, regulated and assured? It might not be on trend, but it should be as Vandijck and Hellings (2014) conclude; one that prepares practitioners who are knowledgeable, skillful and compassionate and capable of responding to the challenges of a rapidly changing clinical environment that happens to be situated in a digital age. Julie Scholes Professor of Nursing and Co-Editor, Nursing in Critical Care
REFERENCES Bonnel W, Smith K. (2010). Teaching Technologies in Nursing and the Health Professionals: Beyond Simulation and Online Learning. New York: Springer Publishing. Department of Health (DH). (2013). Education outcomes framework; https://www. gov.uk/government/uploads/system/up loads/attachment_data/file/175546/Educ ation_outcomes_framework.pdf and https://hee.nhs.uk/work-programmes/ education-outcomes/ (accessed 16/1/14). Klikauer T. (2012). Managerialism: A Critique of an Ideology. Basingstoke: Palgrave McMillan, Houndsmils. Nursing and Midwifery Council (NMC). 2010. Standards for pre-registration nursing curriculum; http://standards.nmc-uk.org/ PublishedDocuments/Standards%20for% 20pre-registration%20nursing%20educat ion%2016082010.pdf (accessed 16/1/14). Ritzer G. (2004). The McDonaldisation of Society. Thousand Oaks: Pine Forge Press, Sage Publication. Scholes J. (2009). Developing Expertise in Nursing. Oxford: Blackwell Publishing. Vandijck D, Hellings J. (2014). Innovation in critical care nursing education. Nursing in Critical Care; 19: 59–60. Watts C, Gordon J (2012) Leadership and preregistration nurse education; http://www. williscommission.org.uk/__data/assets/ pdf_file/0009/480087/Leadership_and_ pre-registration_nurse_education.pdf (accessed 16/1/14).
© 2014 British Association of Critical Care Nurses
Innovation in critical care nursing education: a reply The editorial by Vandijck and Hellings (2014) critically examines how we deliver pre-registration nursing curricula in a technological age. The authors challenge the term ‘innovation’ and ask nurses to reflect on what we mean by that. They also illuminate a tension that often is experienced by educators who want to facilitate a fulfilling learning experience set against the expectations of educational funders, employers, the professional body, statute and most importantly the expectations of the patients and public. The curriculum expands as practitioners draw upon different types of knowledge to meet the changing societal demands on nursing practice (NMC, 2010). Of note, very little is taken out of the curriculum, but less time might be dedicated to the delivery of the widening range of topics that are increasingly considered essential. For example, a nurse has to be information and technology literate, capable of undertaking efficient and sophisticated searches for evidence to inform their salient clinical decisions and caring actions. They have to demonstrate a suitable understanding of psychology, sociology as well as life and physical sciences that serves as a foundation to their applied clinical knowledge (NMC, 2010). They have to be critically aware of research, how to locate it, critique and apply it as appropriate. They have to be self-directed learners. Students are exposed to leadership skills (Watts and Gordon, 2012), expected to communicate effectively, care compassionately, be empathic, mindful of others’ legal rights, function with due regard to ethics and clinical governance. They are also required to be technologically competent, demonstrate dexterity in their clinical
performance, recognise deterioration and act upon it, show due respect for patients and their family and their plans for end of life care (NMC, 2010). They have to understand pharmacology, learn how to cope with new devices that deliver medication and system support. They have to learn how to involve the patient and public in shaping the care that is provided, participate in decisions that shape resource allocation and be accountable for the resources they use and money spent from the public purse. This is all part of the new partnerships in nursing education. There is a vast array of demands with priorities that change with bewildering speed as new government or health departmental policies compel us to address a new initiative, public health agenda, safety or health education need. Delivery has to take account of full and part time delivery, be flexible, facilitate widened access including making reasonable adjustment for those with disability, balance generic with specialist input and all this for a whole time equivalent, in three years. A more litigious society stimulates risk-averse behaviours among the health care providers. What practitioners can do under what circumstances becomes more sharply defined to ‘improve quality’ whilst at the same time, reduce risk of complaint or litigation. Competencies, protocols, guidelines help to determine a threshold standard of what can be done under what circumstances. Vandijck and Hellings (2014) critique this as a Tylerian model that lays emphasis on content, structure and measurable behavioural outcomes: what our sociology colleagues would critique as an instrumental model of nursing knowledge and capability that is overly bureaucratic and serves the
© 2014 British Association of Critical Care Nurses • Vol 19 No 2
new ideologies and values of managerialism (Ritzer, 2004, Klikauer, 2012). Semesters and modularity have laid further claim to the time allotted to the delivery of the academic elements that make up the pre-registration programme. Education Commissioners then seek confirmation that what they fund does demonstrate value for money and that education serves to improve patient outcomes (Health Education England, 2012). Employers, and the public, want assurance that these programmes help to shape clinicians who are fit for practice. The content of a pre-registration curriculum has always been contested with priorities, in part shaped by academics’ areas of specialism and their personal interests (Scholes, 2009). This extends to how academics champion different pedagogies to facilitate learning. The latest drive being to connect with learners through new technologies and devices, so that learning can be interactive, and ultimately be interesting and creative. Sometimes, the quest to be innovative can obscure what needs to be learnt. The medium can take priority and more time can be spent on debating the merits of a device or interactive IT application than perhaps what learning technologies can do to facilitate student engagement and depth of sustained learning. Ever was this so with ‘new ways’ of delivering content once heralded as innovative are now being considered routine and possibly even mundane. For example, interprofessional learning, problem based learning, action learning sets, facilitated reflection and video learning. Moulage, electronic portfolios, and simulation are now repackaged into interactive, virtual environments accessed through digital devices to make them trendy 61
Editorial
and seem much more exciting (Bonnel and Smith, 2010). Project enthusiasts might advocate the use of these devices and approaches without any empirical evidence to illustrate the longer term impact of that mode of delivery on learning and practice. When we add to this mix different student learning styles, preferences and approaches to inquiry, often but not exclusively dictated by discipline and experience, a whole raft of complexity is added. One solution is to simply provide a laptop or tablet and leave the student to discover what they need through the Internet. However, a profession has threshold standards and we have to shape the direction of learning to achieve the necessary requirements and that is often articulated as learning outcomes or competencies. Vandijck and Hellings (2014) suggest that innovation is not so much about what we teach but how we facilitate learning. I would argue it is both. How these new media are implemented, who invests in them, how they are managed, updated, and more importantly applied is vital. Higher education institutions and the partners in practice and industry have to make significant investment in new media for teaching and learning to create a virtual learning environment, invest in online learning, digital devices, or simulation suites. Gaining consensus as to which platforms and products to purchase is far from straight-forward and negotiations can cause considerable delay. Strategic decisions have to be made about where and how money is allocated. The pace of technological advancement can mean that resources can be quickly outmoded with investment showing little return. Training has to be provided to support academics and students with the technology, as well as to update and maintain the
62
equipment. The scale of investment that ensures equal access to devices across a student cohort and across a higher education provider is eye-watering. It is not as simple as advocating for alternative approaches to programme delivery, evaluating them and adapting when necessary. The investment has to yield results in the short and longer terms and that is the Achilles’ heel to Vandijck and Hellings’ argument. The pace of technological advancement is so speedy that by the time we have empirical evidence of the impact on learning, the technology has moved on to the next new trend in teaching. Teaching technologies have progressed along with what we teach to whom and when. We have moved considerably since the dreaded over-head projector, but are we fully prepared to deliver teaching in second life, 3D virtual worlds? Students and academics are faced with submissions through electronic dashboards, materials from drop boxes, share point and various email accounts, as well as the text and telephone. Is this innovation or an exponential increase in the volume of materials, speed of their traffic that serve only to increase the expectations made of us? All this creates frenetic busy-ness that can divert us from reflection and critical thinking. I am mindful of the biggest complaint made by postgraduate students at our University, which is the absence of a dedicated desk space surrounded by silence so they might concentrate on their research and reading. Oh for the days of a librarian in charge of real books and paper journals who lifted her finger to her lips and uttered the immortal sound: sssshhhhh! What knowledge will best serve the patients and the public, and make them safe in our care. How might
that best be facilitated, regulated and assured? It might not be on trend, but it should be as Vandijck and Hellings (2014) conclude; one that prepares practitioners who are knowledgeable, skillful and compassionate and capable of responding to the challenges of a rapidly changing clinical environment that happens to be situated in a digital age. Julie Scholes Professor of Nursing and Co-Editor, Nursing in Critical Care
REFERENCES Bonnel W, Smith K. (2010). Teaching Technologies in Nursing and the Health Professionals: Beyond Simulation and Online Learning. New York: Springer Publishing. Department of Health (DH). (2013). Education outcomes framework; https://www. gov.uk/government/uploads/system/up loads/attachment_data/file/175546/Educ ation_outcomes_framework.pdf and https://hee.nhs.uk/work-programmes/ education-outcomes/ (accessed 16/1/14). Klikauer T. (2012). Managerialism: A Critique of an Ideology. Basingstoke: Palgrave McMillan, Houndsmils. Nursing and Midwifery Council (NMC). 2010. Standards for pre-registration nursing curriculum; http://standards.nmc-uk.org/ PublishedDocuments/Standards%20for% 20pre-registration%20nursing%20educat ion%2016082010.pdf (accessed 16/1/14). Ritzer G. (2004). The McDonaldisation of Society. Thousand Oaks: Pine Forge Press, Sage Publication. Scholes J. (2009). Developing Expertise in Nursing. Oxford: Blackwell Publishing. Vandijck D, Hellings J. (2014). Innovation in critical care nursing education. Nursing in Critical Care; 19: 59–60. Watts C, Gordon J (2012) Leadership and preregistration nurse education; http://www. williscommission.org.uk/__data/assets/ pdf_file/0009/480087/Leadership_and_ pre-registration_nurse_education.pdf (accessed 16/1/14).
© 2014 British Association of Critical Care Nurses
