Nurse Education in Practice 15 (2015) 97e102
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Linking theory to practice in introductory practice learning experiences* Diane Fotheringham*, David Lamont 1, Tamsin Macbride 2, Laura MacKenzie 3 University of the West of Scotland, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 18 November 2014
Nurse educators internationally are challenged with finding a sufficient number of suitable practice learning experiences for student nurses. This paper reports on a study which aimed to evaluate the utilisation of specialised and highly technical environments (“new” environments) as first practice learning experiences for adult nursing students in the UK. A survey was conducted on 158 first year student nurses who were allocated to either “new” or “old” (those that have been traditionally used) environments. Data analysis was conducted using ManneWhitney U test and exploratory factor analysis was performed. Results have demonstrated that all environments afford novice nurses the opportunity to observe or practice the essential skills of nursing. In addition, the “new” environments have revealed greater opportunity to observe and practice aspects of practice related to governance of care. This paper concludes that a nursing curriculum which makes clear association between the essential nature of nursing and practice based learning outcomes will help the student to appreciate contemporary nursing practice and to link nursing theory with practice. Further research is required to explain the observation that aspects of practice related to governance are more visible within highly technical areas of practice. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Theory-practice relationship Learning environment Survey research Practice placements
Background In order to meet the UK Nursing and Midwifery Council (NMC) Standards for Pre-Registration Nursing Education, the University of the West of Scotland and its associated Health Boards are committed to providing practice learning experiences for student nurses which maximise available learning opportunities and enhance learning and aid the application of theory to nursing practice (Nursing and Midwifery Council, 2010). In order to achieve this, students gain exposure to person centred care in a wide variety of environments, where patients access care appropriate to their needs and across the 24 h/7 day continuum of care. These practice learning experiences are designed to embody aspects of
* The authors acknowledge the support of Mrs Doreen Molloy, UWS, for her assistance in data collection. * Corresponding author. Tel.: þ44 (0)141 849 4204; fax: þ44 (0)141 849 4203. E-mail addresses: [email protected] (D. Fotheringham), [email protected] (D. Lamont), [email protected] (T. Macbride), [email protected] (L. MacKenzie). 1 Tel.: þ44 (0)141 201 5504; fax: þ4 (0)141 201 5575. 2 Tel.: þ44 (0)141 849 4281; fax: þ44 (0)141 849 4203. 3 Tel.: þ44 (0)141 849 4322; fax: þ44 (0)141 849 4203.
http://dx.doi.org/10.1016/j.nepr.2014.11.010 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
contemporary healthcare delivery and encompass all aspects of National Health Service (NHS) environments in Scotland including ambulatory services and community healthcare provision, as well as private, independent and voluntary organisations. However, several recent changes within the healthcare environment have acted to militate against this ambition. The NHS service reconfiguration and pay modernisation, for example, has increased staff leave entitlement and subsequent availability of mentors. Similarly, curriculum redesign and a move to a single annual intake of student nurses has caused the potential for an inundation of student nurses at specific periods in the year, thus raising the possibility of compromise in practice learning experience availability. As a result, these changes have had the effect of decreasing an already shallow capacity in some environments to critical levels. Consequently, and in common with nursing curriculum designers in many parts of the world, Faculty at the University of the West of Scotland are faced with the perennial issue of a shortage of practice learning experiences for pre-registration nursing students (National Review of Nursing Education (2002); OCNE, 2013; Smith et al., 2010; Tanner et al., 2008). In response to this and to help ameliorate this challenge, an approach to introductory practice learning experiences has been
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adopted by University of the West of Scotland and their partner service provider, NHS Greater Glasgow and Clyde which has challenged traditional local practice. This approach has involved the inclusion of acute, hospital based environments which have been, hitherto, utilised solely as a ‘specialist’ practice learning experience for second-year nursing students and, in some cases, requested as a final management practice learning experience. These “new” environments included emergency departments (ED), day surgery units, operating rooms (OR), outpatient departments, endoscopy units, critical care units (high dependency and intensive care units (ICU)) and radiology. “Old” environments may be defined as those which have been, traditionally, utilised as introductory practice learning experiences, such as general surgery wards, general medical wards and care of the elderly environments. Traditionally, these “new” environments have been rarely used for introductory practice learning experiences since they have been considered to be either particularly specialised, highly technical or areas where the boundaries between nursing and other health professionals have been disputed. Nursing practice within the ICU is considered to be extremely technical in nature, coupled with the view that this highly specialised area of practice is particularly stressful due to the proximity to loss and suffering (Mealer et al., 2007). Timmons and Tanner (2004) state that both the OR and the ED are both areas where there are disputed boundaries of practice and professionalism with other healthcare professionals within the UK and internationally, often compelling nurses within these areas to validate their professional status and self-worth. The area of nursing practice that is, perhaps, the most maligned in this regard is that which occurs within the OR. In their study, McGarvey et al. (2000) concluded that there is no good basis on which to say that the work of the nurse in theatre is, indeed, nursing and conclude that clarity in role required with a view to determining new role development. Thus, it has been concluded that novice nursing students would not be able to practice the essential skills of the nurse in these areas. The project team considered that utilising these areas for introductory and, indeed, other practice learning experiences throughout the programme of education would reflect the dynamic changes in nursing in recent years within the UK, where nurses have enhanced their roles and new services have been set up to meet the changing needs of patients (Department of Health (2006); Scottish Executive, 2006). However, it was required to evaluate the suitability of these “new” environments for novice nursing students. The Quality Assurance Agency (2012, p. 32) states that “when considering the appropriateness of physical learning resources and the learning environment provided by a delivery organisation, support provider or partner, an evaluation is made of whether these are relevant to, and adequate for, the type, level and volume of the learning to be undertaken and whether they are appropriate to secure the achievement of the relevant learning outcomes”. The practice learning outcomes concerned were closely aligned to the learning outcomes of a period of theoretical study exploring the essential nature and professional responsibilities of nursing practice, which the nursing students undertook immediately prior to this introductory practice learning experience. Therefore, the decision to incorporate these “new” environments for introductory practice learning experiences had to be based upon an assurance that the learning outcomes which the students were required to achieve during the practice learning experience could be met and that the theoretical component they had engaged in did, in fact, relate to practice. Although there is some evidence in the literature that preregistration nursing students are now placed in less traditional environments (Conneely and Hunter, 2012; Gillespie and McLaren,
2010; Harrison, 2010), there is a lack of research which evaluates this approach and it was deemed necessary to evaluate the impact of this local change to the student experience. In order to evaluate how well the “new” environments related to the theoretical underpinning and, thus, the suitability of the practice learning experience for this stage of nursing practice, the following question was posed: to what extent does the introductory practice learning experience help first year, introductory placement student nurses relate nursing theory to practice? Design This study utilised a survey method, composed of an 18 item self completion questionnaire. This questionnaire composed of one independent variable (identification of the environment), and 14 dependent variables (6-point Likert scales, where 1 ¼ strongly agree, 6 ¼ strongly disagree), designed to judge the participants' perceptions of whether they had been offered the opportunity in the environment to either practice or observe an aspect of nursing as defined by the learning outcomes of the module (Table 1). Finally, the participants were offered one free text opportunity, allowing for the identification of issues not covered in the questionnaire (O'Cathain and Thomas, 2004). Since all participants were to undertake their practice learning experience at the same time, piloting of the questionnaire was not possible and in order to ensure face and content validity, the questionnaire was reviewed by faculty members who had experience in this field (Parahoo, 2008). Sample A convenience sample of pre-registration nursing students who had completed their introductory practice learning experience in either “new” or “old” environments (n ¼ 158) were invited to participate in the study. This sample was the total population of the Adult pre-registration nursing students in this cohort. Mental Health student nurses were not invited to participate since no “new” Mental Health environments were to be utilised. Ethical considerations Ethical approval was granted by the researchers' Institution Ethics Committee and ethical scrutiny was made by NHS and local Research and Development Department of the partner Health Board. Written information regarding the nature and purpose of the survey was given to all participants and opportunity to
Table 1 Dependent Variables My first practice placement has given me the opportunity to. 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Work as part of the multidisciplinary team Observe the role of the nurse as part of the multidisciplinary team Communicate with patients Communicate with relatives Communicate with members of the multidisciplinary team Put into practice a problem solving approach to nursing care (for example, care planning for activities of daily living) Participate in the delivery of person centred care Observe and participate in the correct documentation of nursing care Develop therapeutic relationships with patients Develop working relationships with staff Find out about, and observe in practice, health and safety policies and procedures Find out about, and observe in practice, risk assessment and security policies and procedures Observe, in practice, the legal, ethical and professional issues related to nursing practice Put into practice the clinical skills that I have learned at University
D. Fotheringham et al. / Nurse Education in Practice 15 (2015) 97e102
withdraw from the survey offered. All data was treated confidentially and anonymity of all participants ensured.
99
Table 2 Ranks for independent variables. Number
Mean rank
Sum of ranks
97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130
68.72 56.03
6666.00 1849.00
68.28 57.32
6623.50 1891.50
64.31 69.00
6238.00 2277.00
66.66 62.08
6466.50 2048.50
69.82 52.79
6773.00 1742.00
64.26 69.14
6233.50 2281.50
65.93 64.24
6395.00 2120.00
69.03 55.12
6696.00 1819.00
64.06 69.73
6214.00 2301.00
68.16 57.68
6611.50 1903.50
70.63 50.41
6851.50 1663.50
70.37 51.20
6825.50 1689.50
69.01 55.18
6694.00 1821.00
64.91 67.23
6296.50 2218.50
Data analysis All variables were coded and data was inputted into Microsoft Excel and SPSS software. The non-parametric ManneWhitney U statistical test to evaluate the difference in the responses of the two groups (Maltby et al., 2010) was used. Short answers elicited from the free text opportunity produced a number of other issues not highlighted in the closed questions and were analysed using a category system to identify key themes and sub themes (Polit and Beck, 2010). Results 142 students completed the questionnaire, yielding a 91% response rate which reduced to 82% following data cleaning (n ¼ 130). Data cleaning was carried out in order to eliminate questionnaires where there was incomplete data, or the nature of the clinical area was unsure (Walters and Freeman, 2010). Descriptive statistical analysis for the independent variable showed that 91 (74.6%) participants attended “old” or traditional environments, while 33 (25.4%) attended “new” environments, which reflected the availability of the respective clinical environments in the area. Results of ManneWhitney U demonstrate that there was a high mean level of agreement from participants in both groups that each aspect of nursing theory could be applied in practice. Results also demonstrate that there was significant difference in perception in participants in the “new” group that there was more opportunity in the “new” environment to either practice or observe the aspect of nursing practice in question for five of the independent variables (Tables 2 and 3). These variables were: find out about, and observe in practice, health and safety policies and procedures observe, in practice, the legal, ethical and professional issues related to nursing practice find out about, and observe in practice, risk assessment and security policies and procedures observe and participate in the correct documentation of nursing care communicate with members of the multidisciplinary team. In order to ascertain if there was an underlying structure to the responses from the participants, an exploratory factor analysis was performed on the 14 aspects of nursing practice which were to be practiced or observed by the participants, using principle component analysis with Varimax (orthogonal) rotation. The analysis yielded four factors explaining a total of 62.145% of the variance for the entire set of variables (Table 5). This means that these results may have identified four factors of nursing practice which the participants practice and/or observe and which may be independent of one another (i.e. they are not correlated). Finally, 75 responses to the free-text opportunity were elicited and themes and sub themes were identified (Table 4) with no discernible difference in the pattern of comment between participants who had had practice learning experience in either “new” and “old” environments. “Enjoyment” of the environment, feelings of being made welcome and feelings of support from clinical mentors were the predominant comments. Of lesser importance to the participants related directly to the skills learned during theoretical preparation prior to their practice learning experience and the opportunity given to put these skills into practice, for example “theory and skills learned in university proved to be valuable”. Only
Work as part of the multidisciplinary team Observe the role of the nurse as part of the multidisciplinary team Communicate with patients
Communicate with relatives
Communicate with members of the multidisciplinary team Put into practice a problem solving approach to nursing care Participate in the delivery of person centred care Observe and participate in the correct documentation of nursing care Develop therapeutic relationships with patients Develop working relationships with staff Find out about, and observe in practice, health and safety policies and procedures Find out about, and observe in practice, risk assessment and security policies and procedures Observe, in practice, the legal, ethical and professional issues related to nursing practice Put into practice the clinical skills that I have learned at University
Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total
one participant stated that the environment aided understanding of theory as a result of participating in practice, “my placement helped my understanding of the Introduction to Nursing module”. Discussion The “Introduction to Nursing” introductory practice learning experience for the student nurses surveyed here aimed to help the novice nurse apply nursing theory to practice and to engender the essential qualities of the nurse in the student. The outcome of the findings of the survey appear to strike at the heart of the nature of nursing and the applicability of these core values and skills to nursing and nursing students, regardless of the environment. The interpretation of nursing which formed the basis of the learning in both theory and practice for the student nurses who participated in this study was based on elements of definitions of nursing established by the International Council of Nursing (ICN, 1987; ICN, 2002) and the Royal College of Nursing in the UK (RCN, 2002). The students on their introductory practice learning experience were not expected to either demonstrate or recognise decision making skills (a key element of nursing according to these definitions) but were encouraged to recognise in practice the primacy of caring, to observe and exhibit appropriate communication skills and to develop appropriate relationships with all actors. In
13
1260.00 1.989 .047
12
1128.50 2.740 .006
14
D. Fotheringham et al. / Nurse Education in Practice 15 (2015) 97e102
1543.50 .341 .733
100
Table 4 Written comments themes/sub-themes. Theme
Sub-theme
Support
Time spent with mentor Inter professional support Feeling welcomed Role model Opportunities Specific skills (e.g. manual blood pressure) Theory to practice Preparation in skills labs Learning experiences Support Opportunities (e.g. skills development) Too specialist
Clinical skills
Enjoyment
1342.50 1.570 .117
11 10 9
1461.00 .831 .406 1258.00 2.061 .039
8 7
1559.00 .257 .797
6
1480.50 .683 .495
5
1181.00 2.450 .014
4
1487.50 -.638 .524
3
1485.00 -.969 .333
2
1330.50 1.656 .098
1
1288.00 1.952 .051 ManneWhitney U Z Asymp. Sig. (2-tailed)
Table 3 ManneWhitney U test.
1102.50 2.931 .003
Clinical area
addition, the students had been required to consider the governance of care and their accountability to the delivery of care to patients and clients. However nursing is defined and whatever consensus reached, there would appear to be some doubt as to whether some areas of practice are actually practicing nursing, typified by the “new” environments. As discussed, these were formerly considered to be unsuitable for introductory practice learning experiences and the results of this study refute this assertion and demonstrate that the essential art and skills of caring are practiced in all areas concerned in this study. Bull and FitzGerald (2006, p. 7) state that, although the main focus of the OR nurse's role is technological, “ethic of care suggests what nurses do in the OR is a ‘nursing’ rather than a ‘technical’ undertaking” and Wilkin and Slevin (2004, p. 57) suggest that “caring is an essential function of ICU nursing” and central to this is the concept of care. The results of this survey would appear to concur with these analyses. The art and practice of nursing, as it has been defined in the outcomes for the practice learning experience and examined within this survey, have been universally recognised as qualities that are seen to be practiced by nurses in all the areas
Table 5 Factor loadings and communalities based on a principle components analysis with Varimax rotation with Kaiser Normalization for 14 items of nursing practice to be observed or practiced (N ¼ 130).Factor loadings < .4 are suppressed. Component 1 Work as part of the multidisciplinary team Observe the role of the nurse as part of the multidisciplinary team Communicate with patients Communicate with relatives Communicate with members of the multidisciplinary team Put into practice a problem solving approach to nursing care Participate in the delivery of person centred care Observe and participate in the correct documentation of nursing care Develop therapeutic relationships with patients Develop working relationships with staff Find out about, and observe in practice, health and safety policies and procedures Find out about, and observe in practice, risk assessment and security policies and procedures Observe, in practice, the legal, ethical and professional issues related to nursing practice Put into practice the clinical skills that I have learned at University
2
3
4
.832 .749 .816 .844 .784 .804 .483 .618
.450
.683 .643 .683 .831 .657 .575
D. Fotheringham et al. / Nurse Education in Practice 15 (2015) 97e102
and qualities that can be learned in all the areas. Thus, it would appear to be the case that caring, communicating and monitoring care and practicing essential nursing skills are common, regardless of where the student nurse is placed at this vital point in their education. Finfgeld-Connett (2008, p. 202) add that “caring is inferred to be a context-specific interpersonal process that is characterised by expert nursing practice, interpersonal sensitivity and intimate relationships. It is preceded by a recipient's need and openness to caring and the nurse's professional maturity and moral foundations. In addition, a working environment that is conducive to caring is also necessary”, and that environment has been demonstrated universally for these students. As a consequence of this study, the practice of nursing and nursing education in a wider variety of clinical areas has been tested and examined. It may be possible to deduce from these findings that wherever nurses are working and practicing that the essential skills of caring may be seen. In the selection of suitable environments, the setting of learning outcomes which focus on the development and demonstration of these nursing skills will help novice nurses to not only develop as nurses but also to appreciate the complexity of contemporary nursing, regardless of its context. Further, a curriculum which both considers the nature of nursing and makes clear links and associations between practice based and theory based learning strategies will foster a deeper understanding of the art and science of nursing. Comments offered by the participants emphasise the importance of their “enjoyment” of the placement. This “enjoyment” appeared to be dependent upon being accepted by the ward or department staff, developing their self-esteem and being shown respect by the team which they were becoming, temporarily, members. This observation concurs with evidence offered by Chesser-Smyth (2005) and Bradbury-Jones et al. (2011). It is worthy of note that only one student specifically saw the benefits within an environment of being able to link theory to practice. What has also been seen, however, somewhat unpredictably, is that the “new” environments actually offer a better opportunity to observe and practice the aspects of nursing listed above and it may be observed that the characteristics outlined in four of these variables relate to the governance of care and accountability in practice. This may reflect an aspect of staff availability such as a more advantageous staff: patient ratio, a more advantageous mentor: student ratio within “new” areas. It may reflect a more highly supervised mentor-student relationship, imposed by the highly specialised nature of the environment or reflect environments which are offering more exposure to learning experiences. It may also be the case that there is an increased awareness around issues of accountability and governance in the “new” environments or, conversely, awareness of wider accountability within a workforce which is aware of multi-professional working practices. The finding that highly specialised areas of nursing practice offer a better opportunity to observe and practice aspects of nursing related to governance has not been previously recorded in the literature and it is not clear why this relationship exists, with some possible explanations offered. The pilot, exploratory factor analysis suggests that the underlying structure to nursing which the student nurses observe or practice may be reduced to four components, one of which appears to be related governance of practice, the others relating to team work, relationship building with patients and, perhaps, problem solving. It is acknowledged that these results are based on a small, single site study with a sample size which is insufficient to draw accurate conclusions regarding either the number or nature of the components or their significance to the wider study. However, this analysis may form the basis of further research, utilising a larger, multisite sample and which may help to elucidate and confirm or refute these findings presented here.
101
Conclusion This study sought to explore whether highly specialised environments were suitable as introductory practice learning experiences for student nurses and it has been demonstrated that, for the participants of this study, the application of nursing is visible and achievable in both “old” and “new” environments. The results also act to reinforce the primacy of nursing and the core values of nursing which are seen to be practiced and recognised in all environments and conclude that both “old” and “new” environments are suitable for selection as first practice learning experiences. The selection of environments may be guided by a clear view of contemporary nursing, whatever the context. What remains unclear is why five aspects of nursing practice are, statistically, more visible in the “new” environments and some possible explanations have been offered. These results not only suggest the “new” placement areas are appropriate in meeting learning outcomes for novice students but also reveal a research agenda into the nature of nursing in specialised areas (particularly with regard to governance) and how nurse educators can best link theory to practice. Limitations No pilot study was performed and this is acknowledged as a limitation. The study was undertaken on first year, adult nursing students and a wider, more diverse population would aid generalisation of results. The sample size for principle component analysis aspect of the analysis is insufficiently large on which to base conclusions and is presented here as a pilot study. Conflict of interest None. Acknowledgement The authors would like to acknowledge the support of Mrs Doreen Molloy in data collection, Ms Rosemary Mullen, module coordinator and the students who participated in this study. References Bradbury-Jones, C., Sambrook, S., Irvine, F., 2011. Empowerment and being valued: a phenomenological study of nursing students' experiences of clinical practice. Nurse Educ. Today 31, 368e372. Bull, R., FitzGerald, M., 2006. Nursing in a technological environment: nursing care in the operating room. Int. J. Nurs. Pract. 12, 3e7. Chesser-Smyth, P.A., 2005. The lived experiences of general student nurses on their first clinical placement: a phenomenological study. Nurse Educ. Pract. 5, 320e327. Conneely, A., Hunter, D., 2012. Introducing first-year student placements in critical care. Nurs. Stand. 26, 35e40. Department of Health, 2006. Modernising Nursing Careers: Setting the Direction. DoH, London. Finfgeld-Connett, D., 2008. Meta-synthesis of caring in nursing. J. Clin. Nurs. 17, 196e204. Gillespie, M., McLaren, D., 2010. Student nurses' perceptions of non-traditional clinical placements. Br. J. Nurs. 19, 705e708. Harrison, P., 2010. Maximising effective learning for students. Gastrointest. Nurs. 8, 48e49. ICN, 1987. Position Statement. ICN, Geneva. ICN, 2002. The ICN Definition of Nursing. ICN, Geneva. Maltby, J., Williams, G., McGarry, J., Day, L., 2010. Research Methods for Nursing and Healthcare. Pearson Education, London. McGarvey, H.E., Chambers, M.G.A., Boore, J.R.P., 2000. Development and definition of the role of the operating department nurse: a review. J. Adv. Nurs. 32, 1092e1100. Mealer, M.L., April Shelton, S., Berg, B., Rothbaum, B., Moss, M., 2007. Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. Am. J. Respir. Crit. Care Med. 175 (7), 693e697.
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National Review of Nursing Education, 2002. National Review of Nursing Education 2002: Our Duty of Care. Department of Education, Canberra. NHS Education for Scotland, 2010. Health Care Support Worker Induction Standards. www.nes.scot.nhs.uk. Nursing and Midwifery Council, 2010. Standards for Pre-registration Nursing Education. NMC, London. O'Cathain, A., Thomas, K.J., 2004. “Any other comments?” Open questions on questionnaires e a bane or a bonus to research? BMC Med. Res. Methodol. 4. http://www.biomedcentral.com/1471-2288/4/25. OCNE, 2013. Oregon Consortium for Nursing Education. www.ocne.org. Parahoo, K., 2008. Questionnaires. In: Watson, R., McKenna, H., Cowman, H., Keady, J. (Eds.), Nursing Research Designs and Methods. Elsivier, Edinburgh, pp. 299e308. Polit, D.F., Beck, C.T., 2010. Essentials of Nursing Research: Appraising Evidence for Nursing Practice. Lippincott Williams and Wilkins, London. Quality Assurance Agency, 2012. UK Quality Code for Higher Education: Part B: Assuring and Enhancing Academic Quality UK Quality Code for Higher Education. Chapter B10: Managing Higher Education Provision with Others. QAA, London. http://www.qaa.ac.uk/en/Publications/Documents/quality-code-B10. pdf.
RCN, 2002. Defining Nursing. RCN, London. Scottish Executive, 2006. Delivering Care, Enabling Health: Harnessing the Nursing, Midwifery and Allied Health Professions' Contribution to Implementing Delivering for Health in Scotland. Scottish Executive, Edinburgh. Smith, P.M., Corso, L.N., Cobb, N., 2010. The perennial struggle to find clinical placement opportunities: a Canadian national survey. Nurse Educ. Today 30, 798e803. Tanner, C., Gubrud-Howe, P., Shores, L., 2008. The oregon consortium for nursing education: a response to the nursing shortage. Policy Polit. Nurs. Pract. 9, 203e209. Timmons, S., Tanner, J., 2004. A disputed occupational boundary: operating theatre nurses and operating department practitioners. Sociol. Health Illn. 26, 645e666. Walters, S., Freeman, J., 2010. Examining relationships in quantitative data. In: Gerrish, K., Lacey, A. (Eds.), The Research Process in Nursing, sixth ed. WileyBlackwell, Chichester, pp. 455e472. Wilkin, K., Slevin, E., 2004. The meaning of caring to nurses: an investigation into the nature of caring work in an intensive care unit. J. Clin. Nurs. 13, 50e59.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Linking theory to practice in introductory practice learning experiences* Diane Fotheringham*, David Lamont 1, Tamsin Macbride 2, Laura MacKenzie 3 University of the West of Scotland, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 18 November 2014
Nurse educators internationally are challenged with finding a sufficient number of suitable practice learning experiences for student nurses. This paper reports on a study which aimed to evaluate the utilisation of specialised and highly technical environments (“new” environments) as first practice learning experiences for adult nursing students in the UK. A survey was conducted on 158 first year student nurses who were allocated to either “new” or “old” (those that have been traditionally used) environments. Data analysis was conducted using ManneWhitney U test and exploratory factor analysis was performed. Results have demonstrated that all environments afford novice nurses the opportunity to observe or practice the essential skills of nursing. In addition, the “new” environments have revealed greater opportunity to observe and practice aspects of practice related to governance of care. This paper concludes that a nursing curriculum which makes clear association between the essential nature of nursing and practice based learning outcomes will help the student to appreciate contemporary nursing practice and to link nursing theory with practice. Further research is required to explain the observation that aspects of practice related to governance are more visible within highly technical areas of practice. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Theory-practice relationship Learning environment Survey research Practice placements
Background In order to meet the UK Nursing and Midwifery Council (NMC) Standards for Pre-Registration Nursing Education, the University of the West of Scotland and its associated Health Boards are committed to providing practice learning experiences for student nurses which maximise available learning opportunities and enhance learning and aid the application of theory to nursing practice (Nursing and Midwifery Council, 2010). In order to achieve this, students gain exposure to person centred care in a wide variety of environments, where patients access care appropriate to their needs and across the 24 h/7 day continuum of care. These practice learning experiences are designed to embody aspects of
* The authors acknowledge the support of Mrs Doreen Molloy, UWS, for her assistance in data collection. * Corresponding author. Tel.: þ44 (0)141 849 4204; fax: þ44 (0)141 849 4203. E-mail addresses: [email protected] (D. Fotheringham), [email protected] (D. Lamont), [email protected] (T. Macbride), [email protected] (L. MacKenzie). 1 Tel.: þ44 (0)141 201 5504; fax: þ4 (0)141 201 5575. 2 Tel.: þ44 (0)141 849 4281; fax: þ44 (0)141 849 4203. 3 Tel.: þ44 (0)141 849 4322; fax: þ44 (0)141 849 4203.
http://dx.doi.org/10.1016/j.nepr.2014.11.010 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
contemporary healthcare delivery and encompass all aspects of National Health Service (NHS) environments in Scotland including ambulatory services and community healthcare provision, as well as private, independent and voluntary organisations. However, several recent changes within the healthcare environment have acted to militate against this ambition. The NHS service reconfiguration and pay modernisation, for example, has increased staff leave entitlement and subsequent availability of mentors. Similarly, curriculum redesign and a move to a single annual intake of student nurses has caused the potential for an inundation of student nurses at specific periods in the year, thus raising the possibility of compromise in practice learning experience availability. As a result, these changes have had the effect of decreasing an already shallow capacity in some environments to critical levels. Consequently, and in common with nursing curriculum designers in many parts of the world, Faculty at the University of the West of Scotland are faced with the perennial issue of a shortage of practice learning experiences for pre-registration nursing students (National Review of Nursing Education (2002); OCNE, 2013; Smith et al., 2010; Tanner et al., 2008). In response to this and to help ameliorate this challenge, an approach to introductory practice learning experiences has been
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adopted by University of the West of Scotland and their partner service provider, NHS Greater Glasgow and Clyde which has challenged traditional local practice. This approach has involved the inclusion of acute, hospital based environments which have been, hitherto, utilised solely as a ‘specialist’ practice learning experience for second-year nursing students and, in some cases, requested as a final management practice learning experience. These “new” environments included emergency departments (ED), day surgery units, operating rooms (OR), outpatient departments, endoscopy units, critical care units (high dependency and intensive care units (ICU)) and radiology. “Old” environments may be defined as those which have been, traditionally, utilised as introductory practice learning experiences, such as general surgery wards, general medical wards and care of the elderly environments. Traditionally, these “new” environments have been rarely used for introductory practice learning experiences since they have been considered to be either particularly specialised, highly technical or areas where the boundaries between nursing and other health professionals have been disputed. Nursing practice within the ICU is considered to be extremely technical in nature, coupled with the view that this highly specialised area of practice is particularly stressful due to the proximity to loss and suffering (Mealer et al., 2007). Timmons and Tanner (2004) state that both the OR and the ED are both areas where there are disputed boundaries of practice and professionalism with other healthcare professionals within the UK and internationally, often compelling nurses within these areas to validate their professional status and self-worth. The area of nursing practice that is, perhaps, the most maligned in this regard is that which occurs within the OR. In their study, McGarvey et al. (2000) concluded that there is no good basis on which to say that the work of the nurse in theatre is, indeed, nursing and conclude that clarity in role required with a view to determining new role development. Thus, it has been concluded that novice nursing students would not be able to practice the essential skills of the nurse in these areas. The project team considered that utilising these areas for introductory and, indeed, other practice learning experiences throughout the programme of education would reflect the dynamic changes in nursing in recent years within the UK, where nurses have enhanced their roles and new services have been set up to meet the changing needs of patients (Department of Health (2006); Scottish Executive, 2006). However, it was required to evaluate the suitability of these “new” environments for novice nursing students. The Quality Assurance Agency (2012, p. 32) states that “when considering the appropriateness of physical learning resources and the learning environment provided by a delivery organisation, support provider or partner, an evaluation is made of whether these are relevant to, and adequate for, the type, level and volume of the learning to be undertaken and whether they are appropriate to secure the achievement of the relevant learning outcomes”. The practice learning outcomes concerned were closely aligned to the learning outcomes of a period of theoretical study exploring the essential nature and professional responsibilities of nursing practice, which the nursing students undertook immediately prior to this introductory practice learning experience. Therefore, the decision to incorporate these “new” environments for introductory practice learning experiences had to be based upon an assurance that the learning outcomes which the students were required to achieve during the practice learning experience could be met and that the theoretical component they had engaged in did, in fact, relate to practice. Although there is some evidence in the literature that preregistration nursing students are now placed in less traditional environments (Conneely and Hunter, 2012; Gillespie and McLaren,
2010; Harrison, 2010), there is a lack of research which evaluates this approach and it was deemed necessary to evaluate the impact of this local change to the student experience. In order to evaluate how well the “new” environments related to the theoretical underpinning and, thus, the suitability of the practice learning experience for this stage of nursing practice, the following question was posed: to what extent does the introductory practice learning experience help first year, introductory placement student nurses relate nursing theory to practice? Design This study utilised a survey method, composed of an 18 item self completion questionnaire. This questionnaire composed of one independent variable (identification of the environment), and 14 dependent variables (6-point Likert scales, where 1 ¼ strongly agree, 6 ¼ strongly disagree), designed to judge the participants' perceptions of whether they had been offered the opportunity in the environment to either practice or observe an aspect of nursing as defined by the learning outcomes of the module (Table 1). Finally, the participants were offered one free text opportunity, allowing for the identification of issues not covered in the questionnaire (O'Cathain and Thomas, 2004). Since all participants were to undertake their practice learning experience at the same time, piloting of the questionnaire was not possible and in order to ensure face and content validity, the questionnaire was reviewed by faculty members who had experience in this field (Parahoo, 2008). Sample A convenience sample of pre-registration nursing students who had completed their introductory practice learning experience in either “new” or “old” environments (n ¼ 158) were invited to participate in the study. This sample was the total population of the Adult pre-registration nursing students in this cohort. Mental Health student nurses were not invited to participate since no “new” Mental Health environments were to be utilised. Ethical considerations Ethical approval was granted by the researchers' Institution Ethics Committee and ethical scrutiny was made by NHS and local Research and Development Department of the partner Health Board. Written information regarding the nature and purpose of the survey was given to all participants and opportunity to
Table 1 Dependent Variables My first practice placement has given me the opportunity to. 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Work as part of the multidisciplinary team Observe the role of the nurse as part of the multidisciplinary team Communicate with patients Communicate with relatives Communicate with members of the multidisciplinary team Put into practice a problem solving approach to nursing care (for example, care planning for activities of daily living) Participate in the delivery of person centred care Observe and participate in the correct documentation of nursing care Develop therapeutic relationships with patients Develop working relationships with staff Find out about, and observe in practice, health and safety policies and procedures Find out about, and observe in practice, risk assessment and security policies and procedures Observe, in practice, the legal, ethical and professional issues related to nursing practice Put into practice the clinical skills that I have learned at University
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withdraw from the survey offered. All data was treated confidentially and anonymity of all participants ensured.
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Table 2 Ranks for independent variables. Number
Mean rank
Sum of ranks
97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130 97 33 130
68.72 56.03
6666.00 1849.00
68.28 57.32
6623.50 1891.50
64.31 69.00
6238.00 2277.00
66.66 62.08
6466.50 2048.50
69.82 52.79
6773.00 1742.00
64.26 69.14
6233.50 2281.50
65.93 64.24
6395.00 2120.00
69.03 55.12
6696.00 1819.00
64.06 69.73
6214.00 2301.00
68.16 57.68
6611.50 1903.50
70.63 50.41
6851.50 1663.50
70.37 51.20
6825.50 1689.50
69.01 55.18
6694.00 1821.00
64.91 67.23
6296.50 2218.50
Data analysis All variables were coded and data was inputted into Microsoft Excel and SPSS software. The non-parametric ManneWhitney U statistical test to evaluate the difference in the responses of the two groups (Maltby et al., 2010) was used. Short answers elicited from the free text opportunity produced a number of other issues not highlighted in the closed questions and were analysed using a category system to identify key themes and sub themes (Polit and Beck, 2010). Results 142 students completed the questionnaire, yielding a 91% response rate which reduced to 82% following data cleaning (n ¼ 130). Data cleaning was carried out in order to eliminate questionnaires where there was incomplete data, or the nature of the clinical area was unsure (Walters and Freeman, 2010). Descriptive statistical analysis for the independent variable showed that 91 (74.6%) participants attended “old” or traditional environments, while 33 (25.4%) attended “new” environments, which reflected the availability of the respective clinical environments in the area. Results of ManneWhitney U demonstrate that there was a high mean level of agreement from participants in both groups that each aspect of nursing theory could be applied in practice. Results also demonstrate that there was significant difference in perception in participants in the “new” group that there was more opportunity in the “new” environment to either practice or observe the aspect of nursing practice in question for five of the independent variables (Tables 2 and 3). These variables were: find out about, and observe in practice, health and safety policies and procedures observe, in practice, the legal, ethical and professional issues related to nursing practice find out about, and observe in practice, risk assessment and security policies and procedures observe and participate in the correct documentation of nursing care communicate with members of the multidisciplinary team. In order to ascertain if there was an underlying structure to the responses from the participants, an exploratory factor analysis was performed on the 14 aspects of nursing practice which were to be practiced or observed by the participants, using principle component analysis with Varimax (orthogonal) rotation. The analysis yielded four factors explaining a total of 62.145% of the variance for the entire set of variables (Table 5). This means that these results may have identified four factors of nursing practice which the participants practice and/or observe and which may be independent of one another (i.e. they are not correlated). Finally, 75 responses to the free-text opportunity were elicited and themes and sub themes were identified (Table 4) with no discernible difference in the pattern of comment between participants who had had practice learning experience in either “new” and “old” environments. “Enjoyment” of the environment, feelings of being made welcome and feelings of support from clinical mentors were the predominant comments. Of lesser importance to the participants related directly to the skills learned during theoretical preparation prior to their practice learning experience and the opportunity given to put these skills into practice, for example “theory and skills learned in university proved to be valuable”. Only
Work as part of the multidisciplinary team Observe the role of the nurse as part of the multidisciplinary team Communicate with patients
Communicate with relatives
Communicate with members of the multidisciplinary team Put into practice a problem solving approach to nursing care Participate in the delivery of person centred care Observe and participate in the correct documentation of nursing care Develop therapeutic relationships with patients Develop working relationships with staff Find out about, and observe in practice, health and safety policies and procedures Find out about, and observe in practice, risk assessment and security policies and procedures Observe, in practice, the legal, ethical and professional issues related to nursing practice Put into practice the clinical skills that I have learned at University
Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total Old New Total
one participant stated that the environment aided understanding of theory as a result of participating in practice, “my placement helped my understanding of the Introduction to Nursing module”. Discussion The “Introduction to Nursing” introductory practice learning experience for the student nurses surveyed here aimed to help the novice nurse apply nursing theory to practice and to engender the essential qualities of the nurse in the student. The outcome of the findings of the survey appear to strike at the heart of the nature of nursing and the applicability of these core values and skills to nursing and nursing students, regardless of the environment. The interpretation of nursing which formed the basis of the learning in both theory and practice for the student nurses who participated in this study was based on elements of definitions of nursing established by the International Council of Nursing (ICN, 1987; ICN, 2002) and the Royal College of Nursing in the UK (RCN, 2002). The students on their introductory practice learning experience were not expected to either demonstrate or recognise decision making skills (a key element of nursing according to these definitions) but were encouraged to recognise in practice the primacy of caring, to observe and exhibit appropriate communication skills and to develop appropriate relationships with all actors. In
13
1260.00 1.989 .047
12
1128.50 2.740 .006
14
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1543.50 .341 .733
100
Table 4 Written comments themes/sub-themes. Theme
Sub-theme
Support
Time spent with mentor Inter professional support Feeling welcomed Role model Opportunities Specific skills (e.g. manual blood pressure) Theory to practice Preparation in skills labs Learning experiences Support Opportunities (e.g. skills development) Too specialist
Clinical skills
Enjoyment
1342.50 1.570 .117
11 10 9
1461.00 .831 .406 1258.00 2.061 .039
8 7
1559.00 .257 .797
6
1480.50 .683 .495
5
1181.00 2.450 .014
4
1487.50 -.638 .524
3
1485.00 -.969 .333
2
1330.50 1.656 .098
1
1288.00 1.952 .051 ManneWhitney U Z Asymp. Sig. (2-tailed)
Table 3 ManneWhitney U test.
1102.50 2.931 .003
Clinical area
addition, the students had been required to consider the governance of care and their accountability to the delivery of care to patients and clients. However nursing is defined and whatever consensus reached, there would appear to be some doubt as to whether some areas of practice are actually practicing nursing, typified by the “new” environments. As discussed, these were formerly considered to be unsuitable for introductory practice learning experiences and the results of this study refute this assertion and demonstrate that the essential art and skills of caring are practiced in all areas concerned in this study. Bull and FitzGerald (2006, p. 7) state that, although the main focus of the OR nurse's role is technological, “ethic of care suggests what nurses do in the OR is a ‘nursing’ rather than a ‘technical’ undertaking” and Wilkin and Slevin (2004, p. 57) suggest that “caring is an essential function of ICU nursing” and central to this is the concept of care. The results of this survey would appear to concur with these analyses. The art and practice of nursing, as it has been defined in the outcomes for the practice learning experience and examined within this survey, have been universally recognised as qualities that are seen to be practiced by nurses in all the areas
Table 5 Factor loadings and communalities based on a principle components analysis with Varimax rotation with Kaiser Normalization for 14 items of nursing practice to be observed or practiced (N ¼ 130).Factor loadings < .4 are suppressed. Component 1 Work as part of the multidisciplinary team Observe the role of the nurse as part of the multidisciplinary team Communicate with patients Communicate with relatives Communicate with members of the multidisciplinary team Put into practice a problem solving approach to nursing care Participate in the delivery of person centred care Observe and participate in the correct documentation of nursing care Develop therapeutic relationships with patients Develop working relationships with staff Find out about, and observe in practice, health and safety policies and procedures Find out about, and observe in practice, risk assessment and security policies and procedures Observe, in practice, the legal, ethical and professional issues related to nursing practice Put into practice the clinical skills that I have learned at University
2
3
4
.832 .749 .816 .844 .784 .804 .483 .618
.450
.683 .643 .683 .831 .657 .575
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and qualities that can be learned in all the areas. Thus, it would appear to be the case that caring, communicating and monitoring care and practicing essential nursing skills are common, regardless of where the student nurse is placed at this vital point in their education. Finfgeld-Connett (2008, p. 202) add that “caring is inferred to be a context-specific interpersonal process that is characterised by expert nursing practice, interpersonal sensitivity and intimate relationships. It is preceded by a recipient's need and openness to caring and the nurse's professional maturity and moral foundations. In addition, a working environment that is conducive to caring is also necessary”, and that environment has been demonstrated universally for these students. As a consequence of this study, the practice of nursing and nursing education in a wider variety of clinical areas has been tested and examined. It may be possible to deduce from these findings that wherever nurses are working and practicing that the essential skills of caring may be seen. In the selection of suitable environments, the setting of learning outcomes which focus on the development and demonstration of these nursing skills will help novice nurses to not only develop as nurses but also to appreciate the complexity of contemporary nursing, regardless of its context. Further, a curriculum which both considers the nature of nursing and makes clear links and associations between practice based and theory based learning strategies will foster a deeper understanding of the art and science of nursing. Comments offered by the participants emphasise the importance of their “enjoyment” of the placement. This “enjoyment” appeared to be dependent upon being accepted by the ward or department staff, developing their self-esteem and being shown respect by the team which they were becoming, temporarily, members. This observation concurs with evidence offered by Chesser-Smyth (2005) and Bradbury-Jones et al. (2011). It is worthy of note that only one student specifically saw the benefits within an environment of being able to link theory to practice. What has also been seen, however, somewhat unpredictably, is that the “new” environments actually offer a better opportunity to observe and practice the aspects of nursing listed above and it may be observed that the characteristics outlined in four of these variables relate to the governance of care and accountability in practice. This may reflect an aspect of staff availability such as a more advantageous staff: patient ratio, a more advantageous mentor: student ratio within “new” areas. It may reflect a more highly supervised mentor-student relationship, imposed by the highly specialised nature of the environment or reflect environments which are offering more exposure to learning experiences. It may also be the case that there is an increased awareness around issues of accountability and governance in the “new” environments or, conversely, awareness of wider accountability within a workforce which is aware of multi-professional working practices. The finding that highly specialised areas of nursing practice offer a better opportunity to observe and practice aspects of nursing related to governance has not been previously recorded in the literature and it is not clear why this relationship exists, with some possible explanations offered. The pilot, exploratory factor analysis suggests that the underlying structure to nursing which the student nurses observe or practice may be reduced to four components, one of which appears to be related governance of practice, the others relating to team work, relationship building with patients and, perhaps, problem solving. It is acknowledged that these results are based on a small, single site study with a sample size which is insufficient to draw accurate conclusions regarding either the number or nature of the components or their significance to the wider study. However, this analysis may form the basis of further research, utilising a larger, multisite sample and which may help to elucidate and confirm or refute these findings presented here.
101
Conclusion This study sought to explore whether highly specialised environments were suitable as introductory practice learning experiences for student nurses and it has been demonstrated that, for the participants of this study, the application of nursing is visible and achievable in both “old” and “new” environments. The results also act to reinforce the primacy of nursing and the core values of nursing which are seen to be practiced and recognised in all environments and conclude that both “old” and “new” environments are suitable for selection as first practice learning experiences. The selection of environments may be guided by a clear view of contemporary nursing, whatever the context. What remains unclear is why five aspects of nursing practice are, statistically, more visible in the “new” environments and some possible explanations have been offered. These results not only suggest the “new” placement areas are appropriate in meeting learning outcomes for novice students but also reveal a research agenda into the nature of nursing in specialised areas (particularly with regard to governance) and how nurse educators can best link theory to practice. Limitations No pilot study was performed and this is acknowledged as a limitation. The study was undertaken on first year, adult nursing students and a wider, more diverse population would aid generalisation of results. The sample size for principle component analysis aspect of the analysis is insufficiently large on which to base conclusions and is presented here as a pilot study. Conflict of interest None. Acknowledgement The authors would like to acknowledge the support of Mrs Doreen Molloy in data collection, Ms Rosemary Mullen, module coordinator and the students who participated in this study. References Bradbury-Jones, C., Sambrook, S., Irvine, F., 2011. Empowerment and being valued: a phenomenological study of nursing students' experiences of clinical practice. Nurse Educ. Today 31, 368e372. Bull, R., FitzGerald, M., 2006. Nursing in a technological environment: nursing care in the operating room. Int. J. Nurs. Pract. 12, 3e7. Chesser-Smyth, P.A., 2005. The lived experiences of general student nurses on their first clinical placement: a phenomenological study. Nurse Educ. Pract. 5, 320e327. Conneely, A., Hunter, D., 2012. Introducing first-year student placements in critical care. Nurs. Stand. 26, 35e40. Department of Health, 2006. Modernising Nursing Careers: Setting the Direction. DoH, London. Finfgeld-Connett, D., 2008. Meta-synthesis of caring in nursing. J. Clin. Nurs. 17, 196e204. Gillespie, M., McLaren, D., 2010. Student nurses' perceptions of non-traditional clinical placements. Br. J. Nurs. 19, 705e708. Harrison, P., 2010. Maximising effective learning for students. Gastrointest. Nurs. 8, 48e49. ICN, 1987. Position Statement. ICN, Geneva. ICN, 2002. The ICN Definition of Nursing. ICN, Geneva. Maltby, J., Williams, G., McGarry, J., Day, L., 2010. Research Methods for Nursing and Healthcare. Pearson Education, London. McGarvey, H.E., Chambers, M.G.A., Boore, J.R.P., 2000. Development and definition of the role of the operating department nurse: a review. J. Adv. Nurs. 32, 1092e1100. Mealer, M.L., April Shelton, S., Berg, B., Rothbaum, B., Moss, M., 2007. Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. Am. J. Respir. Crit. Care Med. 175 (7), 693e697.
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RCN, 2002. Defining Nursing. RCN, London. Scottish Executive, 2006. Delivering Care, Enabling Health: Harnessing the Nursing, Midwifery and Allied Health Professions' Contribution to Implementing Delivering for Health in Scotland. Scottish Executive, Edinburgh. Smith, P.M., Corso, L.N., Cobb, N., 2010. The perennial struggle to find clinical placement opportunities: a Canadian national survey. Nurse Educ. Today 30, 798e803. Tanner, C., Gubrud-Howe, P., Shores, L., 2008. The oregon consortium for nursing education: a response to the nursing shortage. Policy Polit. Nurs. Pract. 9, 203e209. Timmons, S., Tanner, J., 2004. A disputed occupational boundary: operating theatre nurses and operating department practitioners. Sociol. Health Illn. 26, 645e666. Walters, S., Freeman, J., 2010. Examining relationships in quantitative data. In: Gerrish, K., Lacey, A. (Eds.), The Research Process in Nursing, sixth ed. WileyBlackwell, Chichester, pp. 455e472. Wilkin, K., Slevin, E., 2004. The meaning of caring to nurses: an investigation into the nature of caring work in an intensive care unit. J. Clin. Nurs. 13, 50e59.
