Dimensions on Nursing Teaching and Learning: Supporting Nursing Students in Learning Nursing 3030397661, 9783030397661

Table of contents :
Acknowledgements
Contents
About the Editor
About the Authors
Abbreviations
1: Pedagogy for Nursing: Challenging Traditional Theories
1.1 Introduction: The Challenge of Learning to Be a Nurse
1.2 Pedagogy or Andragogy?
1.3 Diversity of Nursing Students: Changing Demographics
1.4 Resonances with the CPD Student Nurse Experience of Higher Education
1.5 Transitions Project
1.6 Findings: A Snapshot
1.6.1 Demographics: The Mature Student with Prior Experience
1.6.2 Support
1.6.3 Study Experience
1.7 Revisiting Adult Learning Theory: Applications to Nursing Curriculum Development
1.8 Proposed Application with Nurse Education: Supporting Independence and Transition
1.9 Conclusion
References
2: Learning in Partnership
2.1 Partnership Working as an Imperative
2.2 Developing Programmes of Learning
2.3 Partnership Working: Supporting Learning
2.4 Supporting Practice: Meeting the Challenge
2.5 Partnership Working to Support Learning: Different Ways of Working
2.6 Partnership Working to Develop and Enhance Clinical Practice
2.7 Conclusion and Recommendations for the Future
2.8 Recommendations
References
3: Clinical Learning Environments
3.1 Clinical Environments for Learning Nursing
3.2 Background to HEALint (Supporting Internationalisation of Traineeships in the  Healthcare Sector)
3.3 What Is an Effective Clinical Learning Environment?
3.3.1 Attributes of Clinical Learning Environment
3.3.2 HEALint Benchmarks
3.3.3 Instruments for Measuring CLE
3.4 Development of the Audit Instrument
3.5 Conclusion
References
4: Supervising, Supporting Learning and Coaching
4.1 Introduction: Changes to Professional Education
4.2 The Practice Learning Context
4.3 Background to STEP
4.4 STEP Themes
4.4.1 Orientation and Comprehensive Orientation
4.4.2 Helpful Others
4.4.3 Student Peer Support and Learning
4.4.4 Partnership Working
4.4.5 Expansive Learning
4.5 Expanding Placement Opportunities
4.6 Conclusion
References
5: Inclusive Learning, Diversity and Nurse Education
5.1 Introduction: Diversity and Widening Participation
5.2 Challenges of Diversity and Inclusive Pedagogy
5.3 Transition
5.4 Sense of Belonging and Developing Identity
5.5 Reality of Learning to Be a Professional
5.6 Inclusive Curriculum and Inclusive Learning in Nurse Education
5.7 What Does an Inclusive Curriculum Look Like?
5.8 Conclusion
References
6: Innovative Approaches to Nurse Teaching and Learning
6.1 Introduction: Authentic Learning
6.2 What Is Simulation?
6.3 What Makes an Innovative Simulation?
6.4 Virtual Reality and Augmented Reality
6.5 A Learning Framework for Virtual and Simulation
6.6 Innovative Simulation Pedagogy for Academic Development (ISPAD): Background
6.6.1 SimNursKit 1: Year One
6.6.2 Development of the SimNursKit 1 Simulated Scenario
6.6.3 Implementation and Evaluation of SimNursKit 1
6.6.4 SimNursKit 2: Year 2
6.6.5 SimNursKit 3: Year 3
6.7 Benefits of Different Simulation Approaches
6.8 Conclusion
References

Citation preview

Dimensions on Nursing Teaching and Learning Supporting Nursing Students in Learning Nursing Sheila Cunningham Editor

123

Dimensions on Nursing Teaching and Learning

Sheila Cunningham Editor

Dimensions on Nursing Teaching and Learning Supporting Nursing Students in Learning Nursing

Editor Sheila Cunningham School of Health and Education Middlesex University London UK

ISBN 978-3-030-39766-1    ISBN 978-3-030-39767-8 (eBook) https://doi.org/10.1007/978-3-030-39767-8 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Acknowledgements

Contributions from the following projects and teams are recognised as being important to the chapters within this book: Project Team for HEALInt https://healint.eu/ Project Team for ISPAD https://www.um.edu.mt/healthsciences/nursing/ispad/home Project Team for STEP http://www.stepapproach-learning.org/ In addition, we acknowledge the nursing and midwifery teaching colleagues and clinical staff within the various clinical areas which support students and of course to all the students for whom we strive to support becoming the professionals of the future. Sheila Cunningham, Editor.

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Contents

1 Pedagogy for Nursing: Challenging Traditional Theories ������������������������  1 Venetia Brown and Sheila Cunningham 2 Learning in Partnership�������������������������������������������������������������������������������� 21 Sinead Mehigan 3 Clinical Learning Environments������������������������������������������������������������������ 33 Sheila Cunningham 4 Supervising, Supporting Learning and Coaching�������������������������������������� 49 Kathy Wilson, Nora Cooper, and Pam Hodge 5 Inclusive Learning, Diversity and Nurse Education���������������������������������� 65 Sheila Cunningham and Nicky Lambert 6 Innovative Approaches to Nurse Teaching and Learning�������������������������� 83 Mariama Seray-Wurie, Clare Hawker, and Sarah Chitongo

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About the Editor

Sheila Cunningham  is an Associate Professor with a role in developing teaching. Her doctoral studies revolved around inclusivity and diversity in learning and teaching for professional programmes. She is also involved in curriculum development and has a particular interest in student learning especially biosciences. She has a role with coordinating and managing Erasmus and international exchanges for nursing students. She is a Principal Fellow of the Higher Education Academy (now Advance HE) and currently is Chair of the University Teaching Fellows Group.

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About the Authors

Venetia Brown  has more than 20 years of experience in nurse education (having started her teaching career as a Lecturer in women’s health). Her core philosophy is equal opportunity, access, participation and attainment in education at all levels and particularly within HE. Her doctoral thesis reflects this philosophy. Her study on the experience of HE for healthcare CPD student demonstrated the need for HE to ensure their processes, policies and procedures as well as pedagogical practices are flexible enough to meet the needs of non-traditional students. Her current interest is working with key stakeholders to reduce the attainment gap for BAME students in HE. Sarah  Chitongo  is a Nurse and Midwife with 18 years of experience in all the areas of Midwifery. She is also an experienced Senior Manager who left the National Health Service (NHS) as a Midwifery Manager. Sarah is also a Specialist Advisor to the American Pregnancy Association and provides regular consultancy to voluntary maternity organisations in the UK and Reviewer of Ethnicity and Health Journals. She is also a Clinical Skills Manager in the School of Health and Education at Middlesex University and her role involves shaping and implementation of long-­ term strategic plans within the Nursing and Midwifery Clinical Skills Department, ensuring that these fit within broader functional, academic and university strategies and has interest in the experiential teaching pedagogy. She is also the pioneer of bringing Augmented Reality in Midwifery Education and its implementation and adaption into the curriculum. Sarah is also a project lead in several national health projects in addressing health inequalities. Nora Cooper  has been a Registered Nurse for over 30 years and has been in Nurse Education for over 20 years and has held a variety of teaching roles and has taught undergraduate and postgraduate students. Her main area of interest at this point is supporting qualified nursing staff who support learners in the clinical area to navigate the new roles of Practice Assessor and Practice Supervisor that came into place in September 2019.

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About the Authors

Clare  Hawker  is an experienced Lecturer in Adult Nursing and Director of Simulation and Technology in the School of Health Sciences at Cardiff University. Her role as Director of Simulation and Technology is to lead and oversee the development and implementation of technology and simulation as they apply to learning, teaching and research within the school, considering new technological developments in the areas of information technology, simulation and learning technology. Developing innovative approaches to learning and teaching has always been an area of interest leading to a number of projects including the Erasmus Funded Innovative Simulation for Pedagogy Academic Development (iSPAD) project. Clare is an active member of the Wales Centre for Evidence Based Care and has conducted a systematic review exploring the effectiveness of strategies and interventions that aim to assist the transition from student to newly qualified nurse. Clare’s PhD thesis was a mixed methods study exploring preregistration nursing students’ education and training in aseptic technique in the UK. The integration of augmented and virtual reality in teaching is an area of current research interest. Pam Hodge  is a Registered Mental Health Nurse and Lecturer in Practice Learning at Middlesex University. Pam’s role at the university relates to all the areas of practice learning, including identifying and preparation with new practice placement areas for student nurses and trainee nursing associates. Pam’s work focuses on enhancing the learning opportunities for the nursing learners outside of the acute sector, in primary care, care homes and other non-traditional placements, across the North London area. As an Academic Link Lecturer with a wide variety of practice areas, a large part of the role involves developing new relationships with practice partners and collaborative working, elements of the role she especially enjoys. The role includes being part of a number of research projects related to primary care experiences for nurses, health and social care support workers and practice learning. Her MA research focused on the practice learning valued by care home nurses and she is expanding this work with colleagues. As part of the Strengthening Team-based Education in Practice (STEP) project, Pam contributed to a chapter in ‘Facilitating Learning in Practice’ (Morley, Wilson and Holbery, 2019) focusing on the value to students and healthcare assistants in working together to support the learning journey. Nicky  Lambert  is an Associate Professor (Practice) at Middlesex University, where she is Director of Teaching and Learning for Mental Health and Social Work. She is registered as a Specialist Practitioner (NMC) and is a Senior Teaching Fellow (SFHEA). She is also a co-director of the Centre for Coproduction in Mental Health and Social Care. Nicky has worked across a range of mental health services both in the UK and internationally supporting staff and practice development in acute and mental health trusts, councils, businesses and charities. She is active in supporting mental health and well-being with the RCN and Unite. She is an editorial board member for Mental Health Nursing, a member of MHNAUK and on the education and communication committees. Nicky engages with local trusts and with the

About the Authors

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RCPsych to support sexual safety in mental health services. She is also a trustee for West Hampstead Women's Centre and has a professional Twitter feed: @niadla. She has teaching and research interests in women's health, physical and mental health, co-production, social media and health education. Sinead  Mehigan  is the Head of the Adult, Child and Midwifery Department at Middlesex University and Senior Responsible Officer for the CapitalNurse Routes into Nursing workstream. She was also a programme leader for a year. Sinead’s Department runs pre- and postregistration programmes for adult, child and veterinary nurses, midwives and nursing associates. Her clinical background is in perioperative nursing. Over her career, Sinead has held positions in clinical practice, clinical commissioning and as an academic. Her academic interests include partnership working, leadership, anaesthetic and perioperative nursing, preceptorship, workforce development, nursing retention and supporting learners in practice. Her approaches to learning and teaching are based on using active blended learning approaches to help develop students’ abilities to use clinical reasoning skills in their practice settings. Mariama Seray-Wurie  became a Registered Adult Nurse in 1989 and has been a Lecturer at the University of West London and a Senior Lecturer in adult nursing at Middlesex University since 2005. Her clinical background was in infectious diseases and haematology and she graduated with an MA in Learning and Teaching in Healthcare in 2005 and is a registered teacher with the NMC. Mariama’s teaching focus is mainly with preregistration nursing curriculum development and programme management as the Director of Programmes for adult nursing at Middlesex University, acute nursing care, clinical skills and simulated practice learning. She has presented at national and international conferences on student experiences. This is the link that identifies all the partners for the iSPAD project https://www. um.edu.mt/healthsciences/nursing/ispad/home. Kathy Wilson  is responsible for monitoring and enhancing practice learning for nursing and midwifery students, in line with professional and regulatory body requirements. In the past four years, Kathy has worked on a number of Health Education England funded projects related to mentorship, placement and practice assessment and is currently chair of the Pan London Practice Learning Group (PLPLG). The current HEE funded project that Kathy is leading on is the STEP project, i.e., ‘Strenghtening Team-based Education in Practice’ which is a large collaborative research-based project focusing on enhancing the student experience to develop a more positive culture of learning in practice. A recent publication titled ‘Facilitating Learning in Practice’ (Morley, Wilson and Holbery, 2019) outlines the five themes of the STEP  approach and provides recommendations for enhancing learning in practice, in line with the NMC standards for education published in 2018.

Abbreviations

AR BAME CLE CPD FE HE NMC TEL VR WP

Augmented reality Black, Asian and minority ethnic groups Clinical learning environment Continuous professional development Further education Higher education Nursing and Midwifery Council Technology enhanced learning Virtual reality Widening participation

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Pedagogy for Nursing: Challenging Traditional Theories Venetia Brown and Sheila Cunningham

1.1

Introduction: The Challenge of Learning to Be a Nurse

Health care in the twenty-first century demands nurses to be prepared to meet the needs of diverse patients, act as leaders, deliver safe, high quality patient care, work in a continuously challenging, unpredictable and pressured environment and respond to global health challenges (CoD 2016). To prepare nurses for this is no small endeavour for nurse educators. The challenge for nurse teachers then is to prepare nurses for this and the “unknown” and future pressures. In the United Kingdom (UK) the Nursing and Midwifery Council (NMC 2018) indicate in their future nurse proficiencies that nurses ought to be skilled practitioners, leaders and possess high level decision-making and cognitive skills. Yet do not identify a suitable pedagogical preparation to address this. In the USA, Benner (2012) advocates a radical transformation in thinking about learning and teaching in nursing moving from more technical-rationale approaches and broadening the attributes of nurses to include many of the aspects the UK (NMC) hold and advocate for additional preparation for nurses of the present and future. As nursing is mostly located within higher education institutions, the rapid evolution of nursing education has resulted in underpinning pedagogical principles that appear to be falling behind in place of technical rational “content” and skill requirements (Hughes and Quinn 2013; Horsfall et al. 2012; Mackintosh-Franklin 2016). This may be a feature of the traditional non-HE background of nursing education (Ironside 2006), the curriculum drivers for outcomes of competencies (Hughes and Quinn 2013), of massification (Carey 2012) or of limited focus on pedagogy generally (Horsfall et al. 2012). Transition to university education can be difficult for nursing students (Price 2002). More significantly then arises the need to support nurses students through V. Brown (*) · S. Cunningham Department of Adult, Child and Midwifery, School of Health and Education, Middlesex University, London, UK e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2020 S. Cunningham (ed.), Dimensions on Nursing Teaching and Learning, https://doi.org/10.1007/978-3-030-39767-8_1

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this. Jinks (1997) argues in early work that how pre-registration nursing students are cared for by nurse teachers is then replicated by students when delivering patient care. This places a heavy responsibility on nurse educators to role model, support professional attributes in students and support their transition professionally. The “massification” of higher education (Guri-Rosenblit et  al. 2007) over the last two decades provided educational opportunities to a wider group of diverse people and a consequent increase in “non-traditional” students entering higher education and healthcare professions. Wong (2018) suggested “non-traditional” refers to students entering higher education who have population characteristics not normally associated with entrants to higher education, for example, lower social classes, under-­ represented ethnic or age groups all historically under-represented. This diversity population is referred to as “widening participation” and in healthcare involves more than increasing the numbers of traditionally under-represented groups. It is also about ensuring that they remain within programmes, achieve, succeed and progress (Parry 2003). As such support for nursing students is an important issue especially for those institutions where there are significant numbers of students from non-­ traditional backgrounds (Ooms et  al. 2012). There is no one specific pedagogical approach espoused for nursing and literature points to a variety of approaches all of which fit differing purposes and needs. In the UK, the Nursing and Midwifery Council (NMC) offer no specific pedagogical guidance yet have an expectation of what a nurse is, thinks and does. Furthermore, the European nursing benchmark document: Tuning (Gobbi 2011; Tuning n.d.) project also leaves this as open and discretionary. It does indicate competencies however not teaching or pedagogical approaches to achieve these and rather outlines generic skills and how these may be demonstrated. In 2005, a position paper by the National League for Nursing (USA) challenged nurse educators to develop research-based pedagogies and Benner proposed a transformative pedagogy approach (Benner 2012). Thus from this and wider literature, it appears that nursing lacks a predominant or explicit pedagogy. It is time to revisit what this means and draw on perspectives of pedagogic or andragogic philosophy to determine the merits of each and whether we as nurse teachers have held a narrow view of the practices within each of these and thus contributing to challenges in transition for our nursing students. This begs the question: how do nurse teachers approach teaching and learning nursing while addressing the needs of these diverse students.

1.2

Pedagogy or Andragogy?

Ironside (2001, 2006) and Horsfall et al. (2012) argue that much of the literature on nursing education has a limited evidence base resulting in a lack of critical debate on pedagogy. Even more currently, there appears to be a lack of broad understanding of nurse education with moves by influential educationalists to raise the issue of what the evidence base for nursing and thus nursing education is (Benner 2012). One could argue this also include possessing a understanding of one’s own teaching philosophy to guide the learning (of evidence or knowledge base) where a nurse

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teacher draws on their own frame of reference and values and beliefs of learning and teaching and their own role within that. This then acts a benchmark for evaluating their teaching and impact on students. Faye et al. (2015) highlight this provides the basis for reflection and examination for practice and impact of teaching approaches which gives rise to appropriate approaches to teaching, learning, orientation and practices around this. As a term “pedagogy” is derived from and associated with the teaching of children and the young. When used in its broadest sense it includes “what is taught, how it is taught, how it is learned and more broadly the nature of knowledge and learning … knowledge is produced, negotiated, transformed and realised” (Ironside 2001, p. 73). On the other hand, the term “andragogy”, which has historical roots in European environments, refers to the teaching of “adults” evident in the root “andros”. This is underpinned by notions of education from Plato whereby adults were subject to instruction (teaching) for character building or forming and the development of “self-knowledge” and appears within both general and vocational education (Loeng 2018). It gained much popularity in 1970s in western literature by proponents such as Knowles (1975) who narrowed and defined it as a set of assumptions about adult learners. Knowles (1975) further proposed recommendations concerning planning, directing and evaluating adults’ learning by identifying a series of assumptions (four) about adults and learning. He did later, add a fifth assumption in 1983 (Knowles et al. 2015). He suggested the key to this approach to learning is underpinned by adult intrinsic motivations, desire and sense making activities and is an early example of learning as driven by the learner in a co-produced or co-­directed way. It is a crude distinction to separate the notions as it implies a tangential change to learning approaches with increasing age, maturity and “volunteerism” of the individual. It is argued this theory is a simplification postulating child learning is dependent and adult learning self-directed (Jarvis 2004) thus perpetuating, potentially, a deficit model of learning. Early writers on andragogy interestingly viewed the goals of andragogy as a continuation of pedagogy (Loeng 2018) with a presumed shift in power, need and agency. In the face of challenges, Knowles et al. (2015) do contend that they are not distinct and may be applicable in the other situations, i.e., pedagogical tenets for adults. There is a long tradition of humanist thinking within nursing practice led by theorists such as Peplau and Henderson and alongside other leaders such as Benner, Leninger, Parse and Watson (Current Nurses 2011; Sitzman and Eichelberger 2017) and as such aligning to a humanist view of adult learning (andragogy) seems natural. However, it is argued that this ought not to be automatic without questioning (Jarvis 2004). More recently, the term “pedagogy” appears more than andragogy in nurse education literature. In her narrative synthesis of publicly available curriculum documents for nurse programmes in the UK, Mackintosh-Franklin (2016) found a discrepancy in how learning and teaching approaches are articulated. The term pedagogy was used approximately 50% of the time, with andragogy not at all and the nearest synonym being “adult learning principles”; however, the exact nature of what these meant for practice was unclear. She does acknowledge the

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limitations of this in that these documents may not give the complete picture of pre-­ registration nurse education or educator approaches. It is argued that in any event the place of pedagogy has been less prominent in pre-registration nurse courses as nurse educators focus predominantly on their role as subject specialists (Mackintosh-Franklin 2016). This results in “passing on” of knowledge and content driven approach and dense programmes of nursing. Horsfall et al. (2012) and Welch (2011) continue to identify nurse educators’ concentration on skill, knowledge acquisition and measurable outcomes, thus perpetuating traditional behaviourist approaches. This could be argued to be intensified by increasing student numbers and capacity efficiencies (Carr 2008). Hughes and Quinn (2013) argue nurse education programmes could be seen as largely instrumental or “skill led”. Defining clear competencies for the newly graduated registered nurse is a significant opportunity to articulate the value and contribution of the profession; however, it could be reduced to a skill list. The Council of Deans (2016) concurs with this view asserting competency-based model limitations and the risk of creating a “box-ticking” educational culture. This in turn stifles innovation and creativity. The challenge for the nurse teacher remains as ensuring high level technical skills, lifelong and life wide learning skills, inter and intraprofessionally competence while also drawing on and benefitting from the diversity and experiences of the emergent practitioner. Thus far, it could be argued that a more technical and “knowledge deposit” teaching approach akin to Freire’s (1995) notions of restriction and power imbalances. While not quite “oppressive”, it does point to teacher oriented approaches. As Ironside (2001) argues it is orderly and purposeful for accumulation of information but leads to superficial learning and is in need of revisiting. The student-centred approach resonates with the andragogic or humanistic approach to education. Allen (2010) argues this paradigm shift places learners at the centre of their educational journey moving them from passive recipients through to the development of autonomous and lifelong learning skills. Other supporters of learner centred approaches suggest it is effective in engaging students, supports intrinsic desire to learn lifelong (Chambers et al. 2013) and promotes deeper learning (Hockings 2009) and retention overall. Literature highlights many issues that affect nursing students’ first year transition and experiences. These include focus and engagement, workload (namely assessments), perceived and actual support, learning while in placement, expectations, conflicting commitments, approaches to teaching and learning, levels of attrition and relationships with lecturers (Gale et al. 2015). However, studies are varied with comparatively few of the overall first year experience of health care students. In an Australian study of 112 nursing students from non-traditional backgrounds, Birks et al. (2013) found that key issues in assisting in transition were adapting to the role of being a nursing student at university and awareness of and access to support services. More recently, Frazer et al. (2014) explored first year experiences of nursing and midwifery students in Ireland; however, this only focused on their clinical learning experiences and no other component. Porteous and Machin (2018) in a small UK phenomenological study of ten first year nursing students experiences of transition concluded that transition was punctuated with periods of uncertainty and

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support seeking behaviours; however, key to successful transition was the development of self-efficacy. Furthermore, key support including that of personal tutors was influential. This study was small and included nurses from all fields of practice but remains non-generalizable. As a limitation, it omitted to indicate how diverse the student group was and appeared polarized to successful students (albeit it was a longitudinal study) whereas the larger student body and mal-coping was not addressed and could be more enlightening. Preparation for university emerges in two studies. James et al. (2010) found that the students felt well-prepared at school for university but Lumsden et al. (2010) found that students who self-reported educational histories of passive engagement, receiving a “content laden” approach and limited use of the library were ill-prepared for the expectations of them when they arrived at university. This brings into focus if nurse teachers are aware of their students characteristics and their experiences of teaching and learning prior to university embarking on a professional programme. Increasingly, it can only be concluded the evidence base with which to inform pedagogical approaches is patchy.

1.3

Diversity of Nursing Students: Changing Demographics

There is an argument that the changing demographics of nursing students does not reflect the university undergraduate body in general (Brown 2015). This could be argued to have resonance with traditionally viewed professional students on continual professional development programmes (CPD); however, it is interesting to note this is a variability which points to issues of local needs to address nursing education needs and pedagogical practice. Knowing the local picture offers different insights into how to approach teaching and learning for this type of learner. In relation to the national picture, the Office for Students (OfS 2019) indicates that in general for the HE student population the groups which are under-­represented in higher education are mature, i.e., aged 21 and over, students from areas of lower HE participation, lower household income and/or lower socioeconomic status groups, Black, Asian and minority ethnic (BAME) students and care leavers (UUK 2018b). The opposite is often visible within nursing student groups but there are sector changes. In relation to pre-registration nursing UCAS data for 2017, there appears a picture of mature students which is on the decline but still prevalent. This appears to feature at 7% for those aged 21 years and over and 9.8% for those over 26 years. Part of the decline is attributed by UCAS to the changes in the funding of nursing courses which in the UK was briefly aligned to other university courses and funded by students through loans. Locally, there are variations—for example, at the authors’ institution 2018/19 data nursing and midwifery appear in opposition to this trend with 86% mature students compared with 51% reported in general nationally (OfS 2018a). Locally then of the 86% mature students, 76% were studying for a first degree. In relation to attainment OfS data indicates 67% of mature students obtained a first class degree compared to 79% of under 21s. In addition, the same local picture 2018/19 data indicates a high proportion of students from Black and minority ethnic (BAME)

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groups with 73% represented in nursing and midwifery. However interestingly the same national pattern emerges in relation to attainment, namely the OfS data indicated 22% difference in attainment of 1st/2.1 (OfS 2018b).

1.4

 esonances with the CPD Student Nurse Experience R of Higher Education

In attempting to construct demographic profile of the healthcare CPD student, Brown (2015) found, in terms of age, the largest number of CPD students fell into the 30–39 age range (56%) and this was consistent across all student groups that participated in the study (Fig. 1.1). In comparison, national statistics for 2010/11 indicate that approximately 53% of undergraduate students fell in the under-20 age range. It cannot be accepted that the age related demographic was representative of the CPD student body at large but it could be argued that accessing CPD studies is often dependent on having a minimum number of years of experience in a related clinical setting. In addition, waiting for funding and release time from employers may also add years (of experience), possibly increasing the age at which CPD studies are undertaken. Brown’s (2015) study further looked at years since qualification and CPD funding source from which it was then possible to draw up an initial healthcare CPD student demographic profile. From this it was derived that the healthcare CPD student profile was in general more mature (between ages 30 and 40 years), qualified for between 0 and 10 years and funded by employers for stand-alone modules but may fund own CPD studies for longer programmes. Summary in Fig. 1.2. In her study, Brown (2015) found a contrast between participants their pre- and post-registration study experiences. This included loss of cohort identity, and the associated loss of group support and sense of belonging, a key feature of discussions. 80 70

Percentage

60 50

Social work

40

MSc Mentorship

30

Combined UG

20 10 0 20-29

30-39

40-49 Ages

Fig. 1.1  Ages of CPD students by study group (%)

50 -59

60+

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Age: generally older—30s and 40s Time qualified: 0–10 years Is usually combining CPD study, full-time work with home and family responsibilities Funding: by employers for stand-alone modules, but may be funding their own CPD studies for longer programmes. May have limited time to focus on CPD studies May only be accessing the University once a week for a half or full day Has limited time to use the learning resource services when at University

Does not necessarily see themselves as typical university student i.e. full-time, undergraduate, three-year, requiring access to the full range of student services.

Fig. 1.2  Characteristics of CPD students

There was a strong sense of not being able to call on members of a cohort to discuss studies, share ideas and perspectives on study tasks. The “in and out”-ness of the CPD study experience was acknowledged as convenient in terms of fitting in studies at a time and place that suited the students’ work and personal lives, but this seemed to be a trade-off in terms of the desire to belong to and the benefits accruing from being part of a permanent cohort or study group. The experiences described by the participants suggested that they had had to make a transition in the study experience from pre-registration nursing student in HE to healthcare CPD student in HE. Brown (2015) concluded at the time this was unique to the healthcare CPD student; however, during review of the demographic profile of the most recent intake of pre-registration students within the same institution it emerges there are features in common most notably: age. While one cannot be certain that there are other demographic factors which pre-registration student have in common with CPD students, anecdotal experience and interactions with student nurses suggest that in addition to age, what they also have in common with the healthcare CPD student is: combining study with family responsibilities and possibly with work (particularly if one views placement experience as work). It is not unreasonable to suggest that because of these multiple demands: study; family; work—pre-registration student nurses in question may also be time poor and as such have limited time to focus on their studies. This is reflected in the participant quotes:

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V. Brown and S. Cunningham ‘Working in a full-time job and mum. Leave coursework at the very last minute - puts a lot of pressure on me’. ‘How full-time nurses juggle work and study isn’t really taken into account. Could be more flexible to changing needs of full-time study i.e. getting extensions on academic work deadlines’.

This is reflected in varied other countries notably the USA. US studies indicate that the “non-traditional” student shares similar experiences. The non-traditional student in the USA (NCES 2018) is characterized by one or more of the following: • • • • • • •

Being independent for financial aid purposes Having one or more dependents Being a single caregiver Not having a traditional high school diploma Delaying postsecondary enrolment Attending school part time Being employed full time

In their qualitative study on the experiences of non-traditional students in higher education, Bohl et al. (2017) identified five themes which reflected the student experience: motivations to return, academic challenges, generation gap, support systems and the benefits of being a non-traditional student. Of particular interest and importance is the academic challenge theme. Bohl et al. talk about the length of time since the students last studied and the impact that this had on them “getting into an academic routine” on their return to study (Bohl et al. 2017 p. 169). In their study of adult learners, Rabourn et al. (2018) students echo the findings of Bohl et al. (2017) in that they also identified work and family responsibilities as a barrier. They also found that lack of either time and/or money impacted on their ability to engage. Time is a significant finding which was also reflected in Brown (2015) where students discussed the difficulty in finding the time to study and to apply oneself to study because of full-time work, childcare or other domestic commitments. Participants described the importance of needing to plan in advance and to set time aside to study in their busy lives: P1: It’s different from pre-reg because when you are there you are there full-time student, so don’t have to think ‘oh I have to work tomorrow so I have to get through this load of work’. And again combined with your housework and then you say ‘oh tomorrow I have to go to work so have only this many hours to finish this so you know, you always have to set yourself time and give yourself deadline to get through it otherwise it’s impossible.

The study participants also described going “off plan” because of other commitments. P3: I have a 4-year-old son and I might go home to today and I’m not working tomorrow and I’m thinking tomorrow’s the day to do, and then something may happen, maybe he’s ill, if he’s not gone to nursery, as soon as he’s gone to nursery I need to do some and then look it’s 3.00 and it’s time to pick him up from nursery. I didn’t even get to do what I wanted to do and planned so it’s more family commitment as well.

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It appears then that the combination of study at home and the impact of other commitments is likely not unique to CPD students but extends to pre-registration, full-time nursing students. Multiple commitments and time are key factors in how well students are able to engage with academic work which begs the question of the connection with age as a factor affecting one’s ability to engage with such programmes of study. It is recognized there is an attainment gap in attainment between age groups and ethnicity (OfS 2018a, b). Locally attainment gaps are a cause for concern. This may be attributed to a number of factors such as structural systems of discrimination and/or indirect discrimination and/or unconscious bias, coupled with lack of insight or understanding into variations in the teaching and learning experiences of this group which might impact on learning and attainment (UUK and NUS 2019). It is imperative to understand the factors which may influence and impact on this nationally but also locally and it is with this in mind the study of first year experiences of learning and teaching, transition and perception of professional learning was undertaken at this north London university.

1.5

Transitions Project

The issue of approaching learning and teaching arose within this institution in response to student resistance and challenging independent learning. There appeared to be issues within other disciplinary professional programmes across the faculty too which caused the staff with key responsibilities for teaching and learning to question the student experiences and perceptions of learning and teaching. Issues of concern were varied including: timekeeping and management, communication, engagement with learning activities, identity and sense of belonging, position and agency within learning. This was not an issue of attrition or of achievement; however, it was felt this may be a consequence which is best addressed early on and interventions (if needed) tailored to the professional group, in this instance nursing and healthcare students. The question then arose as to what the key issues were, what were the antecedents and how to address them for successful learning and teaching (Fig.  1.3). This project involved a number of dimensions and elements; however, for the nursing and midwifery students, the means of exploration were focus groups to address their perceptions of learning and teaching and how these linked to their prior experiences. In the first phase of the project, we collected data from seven focus groups comprising a total of 37 participants. The breakdown was as follows: • • • •

Adult nurses n = 7 Mental health nurses n = 14 Midwives n = 8 Transition1 n = 8

1  Qualified overseas/working in UK as healthcare support workers undertaking a transition module prior to entry to year 3 of the BSc Nursing programme.

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Key Research project questions. What teaching and learning strategies are used in students’ previous educational institutions (level 3 /6th form/further education)? How well prepared do students feel to engage in learning in nursing and midwifery degree programmes in HE? How well do students transition from their level 3 (6th form/ further education) experiences to higher education? What do we do in year 1 to encourage student autonomy and responsibility for learning and to support transition?

Fig. 1.3  Transitions Project Table 1.1  First year students experiences of learning and teaching

1.6

Themes from focus group transcripts •  Dimensions of support •  Relationship with academic staff •  Placement expectations •  Needs of students entering university •  Student expectations •  Sense of belonging

Findings: A Snapshot

These emerged as reflecting the particularities of the student demographics, the perception and use of support and the study experience all underpinned by motivation, provenance of the student and aspirations for their career (Table 1.1). Each had its own issues and while they are not necessarily generalizable they point to issues of consideration when planning or adopting a pedagogic approach.

1.6.1 Demographics: The Mature Student with Prior Experience Responses varied but these quotes illustrate the extracted themes: ‘I’ve been working as a carer for about five or six years with people with Alzheimer’s.’ ‘I didn’t think I was good enough to get on the course because of my grades when I was younger but it made me more interested in the course, yes, so I think I did pretty well because I tried so hard’ (p. 6) ‘So this time last year I was working as a maternity support worker, something I’ve done for ten years…I sort of always knew I wanted to do midwifery and I applied late, so I kind of left to the last minute and applied’ (p. 63) ‘I was a security officer, to be precise here in the University…I took it upon myself to do research…I took the exams, did everything and I passed and here I am’ (p. 22)

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1.6.2 Support This reflects the findings of the US study where influence and perceptions of staff and institution were discussed by the study participants. The PPDTs [personal tutors] are so wonderful…‘Like one of my sessions, I failed one of the courses, so I was like, okay, I think I’ll have to withdraw because this is just not what I want. … She said, I believe in you, I know you can make it, so you’re not going to withdraw’. (p. 7) Academic staff - ‘Well you had to like chase other people about, like you know, everyone was helpful in the end but primarily it was like, well it’s not my job, … they sort of like passed you along …’ (p. 5) ‘I find it very homely. I feel like I’m home, seeing as our tutor is a Philippine also and teaching us. I feel like I’m home. At least she knows the struggle between now and how we were before’. (p. 56) ‘We are serious and we need I think encouragement and support. Despite that we are paying for ourselves, you understand’. (p. 23)

1.6.3 Study Experience This sheds light on the previous teaching and learning experiences of the non-­ traditional/mature student nurse. ‘the English that we studied from back home is very different here, like academic writing wise is very different, because in the Philippines when we write essays we write it however we want it, like from our heads straight down to the paper and we don’t really think about that with plagiarism, we don’t think about referencing this and that. (p. 53) ‘…Thinking it would carry on as I had had it in college. But coming here, the very first class schedule, Vascular, left me wondering how am I going to cope? And I found I wasn’t the only one’. (p. 35) ‘In Brazil we had less essays as well, but the way we write is different, so I kind of find myself in the same situation, because I’m really struggling with my essays’. (p. 50) ‘These people are adults, learn them, address to them, talk to them like adults and carry them along’. (p. 26) ‘I wish they could give assessment after every topic, every lecture, that would help us, you know, to test us how much and make us to read’ (p. 37) The study findings offer insights into the expectations and diverse needs of students commencing professional practice programmes in an HE context and how to support student transition. There was evidence that as part of developing self-­ efficacy, learner autonomy, greater levels of resilience and coping strategies also improved over time. The development of student resilience is key within nurse education (Thomas and Hunter Revell, 2015). The context is also important since this reflects the curriculum (and hence pedagogy) from the last nursing

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pre-registration iteration (in 2011) in the UK and thus may reflect some of this. It is also important to gain this insight in light of what we know about the challenges facing mature/BAME student attainment and act on local issues with a wider frame and local needs in mind. It is clear that current pedagogies are insufficient and a rethink is necessary. This points to issues of how one approaches pedagogy and whether there is one existing that will meet the needs of nurse educators and diverse student groups. Pedagogy ought also be sensitive enough to be modifiable or flexible to address differing needs as groups increase further in diversity. The findings also point to varied transition journeys all with unique challenges. There is the potential for a disconnect with nurse teachers conceptions of what constitutes a student learning journey, assumptions about learning nursing and student actual transition which points to how they position themselves, their pedagogy and constituent practice. Current pedagogies for nursing and educational approaches have been heavily criticized for the lack of evidence upon which to base them (Benner 2015). Approaches such as problem-based learning and reflective practice received much attention and yet are also subject to a limited evidence base for nursing. While a key tenet of nurse education for patient care is “evidence based practice”, educational practice lags behind in such underpinning evidence. Furthermore, nurse educational studies tend to be small scale, short term and single sited and thus limited. Brown et  al. (2008) argue that nurse educationalists need to increase their “pedagogical literacy” (p. 283), and in a position paper from the National League for Nursing (2005) in the USA nurse educators have even challenged to develop research-based pedagogies for current education and practice. Part of this issue is the lack of critical debate or willingness to engage in this by nurse educators (Horsfall et al. 2012). This then is said to have led to a resultant devaluing of terms such as empowerment, critical pedagogy and student-centred approaches (ibid). Kantor (2009) maintains that the current rapidity with health needs and care changes within clinical practice ought be mirrored with changes in nurse education. Only then would this ensure the best preparation for future qualified nurses in the clinical environment and emergent challenges they will face. Crookes (2015) claim students are only willing to engage with topics if they can see the implications or application; thus, nurse teachers must seek ways to achieve the engaging and meaningful experiences to enable this. The National League for Nursing (NLN) advocates moving away from a nurse curriculum which is “behaviourist, content focussed undergraduate curriculum to one that is participative, active and experiential” (cited in Benner 2012). Crookes (2015) research indicated techniques as opposed to pedagogies including technology and online techniques, simulation, gaming, art teaching, narrative teaching, problembased or scenario-based techniques and reflection techniques to achieve active participation. Chambers et al. (2013) advocate discovery learning underpinned by constructivism yet opens up the view of enquiry based on heuristic learning positioning the students as active agents in their learning. Knowles (1975) and Knowles et  al. (2015) constructs of adult education relevancy orientated approaches remains salient and perhaps would benefit from explicit connections.

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 evisiting Adult Learning Theory: Applications R to Nursing Curriculum Development

There is a belief in many areas that teachers (of nurses or anyone) require a carefully formulated teaching philosophy for teaching and learning. The question is why this might be useful and in the main appears to point to how a teacher draws on their values and beliefs of learning and teaching and their position and role within this to focus and guide the educator and act as a benchmark for evaluating their teaching. Revisiting Knowles et al. (2015) view on adult learning can provide a platform for this and offer approaches to promoting student autonomy, independence and aid transition. In Knowles’ et al. (2015) updated version of his theory of adult learning, key features of the model that are revisited elements are revised. Knowles’ learning theory is based on the following six assumptions about individuals as learners: • • • • • •

The need to know The learners self-concept The role of experience Readiness to learn Orientation to learning Motivation

These assumptions share common threads within pedagogic and the andragogic approaches to learning. Key differences in perspective between the two are summarized in Fig. 1.4 below. Knowles et  al. (2015) acknowledge a tendency to view pedagogy as bad and andragogy as good and offered a revision and clarification. A learner and their approach to learning can be located wholly within one or other model. The premise is that any individual whether adult or child may have teaching and learning Assumption The need to know

Pedagogical What

The learners self-concept

Dependent (on teacher)

The role of experience

Teacher focused experience

Readiness to learn Orientation to learning Motivation

Andragogical Why Responsible for own decision

Based on life experience (different in volume and quality) What teachers says should be To learn the things the learner learned needs to know Subject centred Life/task centered External (e.g. grades)

Internal (e.g.quality of life/ self-esteem)

Fig. 1.4  Assumptions compared from pedagogic and andragogic approaches. Adapted from Knowles et al. (2015)

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Andragogy

Pedagogy

Assumptions The need to know The learner’s self-concept The role of experience Readiness to learn Orientation to learning Motivation

Fig. 1.5  Diagrammatic representation of the pedagogy–andragogy continuum

experiences which may not wholly align to either model for all six assumptions. An adult may therefore not have had teaching and learning experiences fully in line with an andragogic approach. Their most recent experience may reflect a more pedagogic approach to teaching and to learning (for some assumptions) drawn from and influenced by the pedagogic principles adopted by past teachers. In short, a learner’s experience may vary for each assumption and of course change over time. The updated version of this model and assumptions provides a useful platform by which to examine the experiences of our students and how this impacts on their transition journeys within higher education. It may be argued then that there has not been the focus on pre-registration students’ prior learning experience nor any attempt to establish where, for each of the assumption, the student locates themselves on the pedagogy–andragogy continuum (Fig. 1.5). An exercise of this sort would provide greater insight into the student’s readiness to engage with studies at higher education. As the findings from the study indicate, for many it is the first time they will have studied at level 4 (or first year degree level) and their first experience of higher education. If the pre-registration nursing curriculum is designed in line with the andragogic model and students’ prior teaching and learning experiences do not wholly align with the teaching and learning strategies which reflect an andragogic approach, they will need support to move along the continuum to engage effectively with andragogic approaches.

1.8

 roposed Application with Nurse Education: P Supporting Independence and Transition

A holistic approach to curriculum design which recognizes and actively addresses the factors which impact on the teaching and learning experience of learners is required. A suggested model includes demographic and diversity monitoring acknowledging

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that there may be individuals within each learning group whose may be under-represented demographically. Whether that demographic is ethnicity, age, disability or other protected characteristic, it is important for academic staff to be aware of the impact that this may have had on their prior teaching and learning experiences. The model requires academics to actively engage with learners to gain an understanding of their teaching and learning experience from three perspectives: their (changing) position on the pedagogic–andragogic continuum (for all six assumptions); their prior teaching and learning experience (including preparation for transition to university) and their current learning context (family, work, location, etc.). These contemporary challenges reposition the learner as active participants with integral processes of interpersonal interactions which incorporate values, ethics and emotions within these processes. The outcomes are replaced with the processes which are especially valuable within nurse education since the skills and roles of nurses become increasingly more complex and require a range of processes and skills evolving in a lifelong learning approach (Ironside 2006; Horsfall et al. 2012). It is worth addressing proposals by Benner (2012) who advocates a radical transformation in thinking about learning and teaching in nursing. Drawing on an andragogical approach to realize this, it focuses on the attributes of the learner and the professional destination they aspire to. More specifically, a focus on approaches to support learners to: 1 . Integrate knowledge acquisition with knowledge use and deeper learning 2. Shift emphasis from critical thinking to multiple ways of thinking 3. Socialize and form active student participation in that nurse formation 4. Situate thinking about knowledge that is productive 5. Develop strategies which create clinical imagination, ethical comportment and patient focused care It is argued that nurse educators need to engage more in the scholarship of learning and teaching, which involves studying the effect of curricula and the learning experiences created with students (Boyer 1990 cited in Kern et al. 2015) and then disseminating this to the broader nursing community. Use of this model will provide the teaching and learning team and specifically the personal or pastoral teacher support with baseline information upon which, in collaboration with the learner, they will be able to identify areas of learning strength and negotiate areas to development. The intention is that this underpins and nurturing dialogue and it revisited on a regular basis in order to identify progress and ongoing learning development needs as the learner progresses through each level of learning. This model constitutes one of four quadrants of a primary model (Fig.  1.6) designed to facilitate active teacher/learner engagement to monitor on-going learner development and progress, learning need, and progress along the P-A continuum. In adopting and operationalizing this model, there are a series of stages (Fig. 1.7). It is proposed that they:

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Fig. 1.6 Holistic assessment of initial learner/learning status

Monitor demographics/diversity

Locate on P-A continuum

Establish learning context

Establish prior learning experience Stage 1

Generic preparation and support for transition to univeristy

Co-reflection and planning based on outcome of learner/learning status

Stage 2

Teaching and learning stategiespersonalised learning designed to enable progression on the P-A continuum

Fig. 1.7  Active learner/tutor engagement model

Regular, active teacher engagement with learners including monitoring of progression on P-A contiuum and the influence of changing learning contexts

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1. Start with generic preparation for transition to higher education. This might take the form of online materials made available to students as soon they have accepted the offer of a place study at university and might include reflective exercises which focus on the skills required for successful study at university. 2. The next phase of the model is the holistic assessment of initial learner/learning status as discussed above. 3. The focus of the next phase is regular, active teacher engagement with the learner and co-monitoring of learner progression on the P-A continuum. Changes in learning contexts should also be considered. Phases 2 and 3 are both underpinned by teaching and learning strategies which focus on personalized learning designed to enable learner progression on the P-A continuum. Personalized learning strategies can be discussed, negotiated and agreed between the learner and the teacher. Patrick et  al. (2013) argue that personalized learning (PL) ‘contrasts with the conventional “one-size-fits-all” education where students receive identical types of instruction, assignments and assessments without considering their individual differences and needs.’ Key concepts of PL according to Li and Wong (2019) are individualization, student-centredness, student agency, learner profiles and a flexible learning environment. PL is a natural fit as a learning strategy given the variation in the positioning of learners on the P-A continuum, their prior learning experiences and current learning contexts.

1.9

Conclusion

The changing demographic profile of student nurses and the variety of teaching and learning experiences which they may have experienced prior to accessing higher education is underexplored. This chapter debated and compared the demographics and experiences of pre-registration student nurses and nurses accessing HE for CPD purposes and argued that the demographic profile of student nurses is changing to such that it more closely mirrors that of the traditional CPD student. It is argued that the CPD student and the pre-registration student in many parts of the UK (and more globally) can be characterized as non-traditional students. The characteristics of the non-traditional student in general such as the USA compare similarly with the CPD and pre-registration student in the UK which makes this an interesting global issue. Key characteristics of the non-traditional student align with those identified by the UK body Office for Students (OfS)—in terms of possessing characteristics which in the main mean they are under-represented within higher education. These include age and ethnicity among various other characteristics though this is clearly not uniform across differing contexts and nations. This creates issues for nurse teachers or educator and this chapter focused on one specific project which was undertaken related to this in one UK university which aimed to explore the experience of transition to higher education of pre-registration first year student nurses. The qualitative findings of this study pointed to student nurses having been exposed to a variety of

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learning experiences which can be theorized to be located on a pedagogy–andragogy continuum linked to assumptions in Knowles’ theory of adult learning. In drawing on this data and revisiting Knowles’ work, an argument can be made that the assumptions on which the separate theories of pedagogy and andragogy are based need further consideration as connected and connect the development of the learning context for any particular student. The development of self-efficacy within the first year experience of student nurses is an important aspect to the learning process and meeting the needs of the students. A two-stage model is proposed for nurse education to take into account the changing demographic profile of student nurses and their varied teaching and learning experiences prior to accessing university and how best to support students transitioning and make sense of learning for professional (or any higher education) programmer.

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Office for Students (Ofs) (2018a) Mature and part-time students. https://www.officeforstudents. org.uk/media/3da8f27a-333f-49e7-acb3-841feda54135/topic-briefing_mature-students.pdf. Accessed 01 Oct 2019 Office for Students (Ofs) (2018b) Ethnicity. https://www.officeforstudents.org.uk/adviceand-guidance/promoting-equal-opportunities/evaluation-and-effective-practice/ ethnicity/ Office for Students (Ofs) (2019) Access and participation plan guidance. Ofs 2019.05. https:// www.officeforstudents.org.uk/media/0bcce522-df4b-4517-a4fd-101c2468444a/regulatorynotice-1-access-and-participation-plan-guidance.pdf. Accessed 28 Sept 2019 Ooms A, Fergy S, Marks-Marana D, Burke L, Sheehy K (2012) Providing learning support to nursing students: a study of two universities. Nurse Educ Pract 13:89–95 Parry G (2003) A short history of failure. In: Peelo M, Wareham T (eds) Failing students in higher education. Open University Press/SRHE, Buckingham, pp 15–28 Patrick S, Kennedy K, Powell A (2013) Mean what you say: defining and integrating personalized, blended and competency education. International Association for Online K12 Learning (INACOL). https://www.inacol.org/wp-content/uploads/2015/02/mean-what-you-say-1.pdf. Accessed 28 Sept 2019 Porteous D, Machin A (2018) The lived experience of first year undergraduate student nurses: a hermeneutic phenomenological study. Nurse Educ Today 60:56–61. https://doi.org/10.1016/j. nedt.2017.09.017 Price B (2002) Gaining the most from your tutor. Nurs Stand 16(25):40–44 Rabourn K, BrckLorenz A, Shoup R (2018) Reimagining student engagement: how nontraditional adult learners engage in traditional postsecondary environments. J Contin High Educ 66(1):22–33 Sitzman K, Eichelberger LW (2017) Understanding the work of nurse theorists: a creative beginning, 3rd edn. Jones Bartlett, Burlington Thomas LJ, Hunter Revell S (2015) Resilience in nursing students: an integrative review. Nurse Educ Today 36:457–462 Tuning (n.d.) Approaches to teaching, learning and assessment in competences based degree programmes. http://www.unideusto.org/tuningeu/teaching-learning-a-assessment.html. Accessed 01 Sept 2019 Universities UK (UUK) (2018b) Patterns and trends in UK higher education. https://www.universitiesuk.ac.uk/facts-and-stats/data-and-analysis/Documents/patterns-and-trends-in-uk-highereducation-2018.pdf. Accessed 01 Oct 2019 Universities UK (UUK), National Union of Students (NUS) (2019) Black, Asian and minority ethnic student attainment at UK universities. #closingthegap. https://www.universitiesuk. ac.uk/policy-and-analysis/reports/Documents/2019/bame-student-attainment-uk-universitiesclosing-the-gap.pdf. Accessed 29 Sept 2019 Welch S (2011) Nursing caps to feminist pedagogy: transformation of nurse education. Teach Learn Nurs 6:102–108 Wong B (2018) By chance or by plan?: the academic success of nontraditional students in higher education. AERA Open 4(2):2332858418782195. https://doi.org/10.1177/2332858418782195

2

Learning in Partnership Sinead Mehigan

2.1

Partnership Working as an Imperative

The professions, along with other public service professions, such as teaching and medicine, need to ensure that staff preparing to register develop competence, so that public safety is maintained. As practice disciplines, nursing and midwifery students prepare for their roles through learning experiences gained in classroom and clinical practice settings. While preparing for registration, students will develop skills to work in partnership with several stakeholders, to collaborate and coordinate healthcare delivery across an increasingly complex range of settings and services. However, the partnership working focused on in this chapter is that which is needed to develop and deliver programmes of education, both in classroom and practice settings. Partners in healthcare education and delivery can be determined by educational, national healthcare and professional body imperatives. Given the improvements in healthcare delivery and the rise in the number of people living longer, managing their own long-term conditions, healthcare policies in many countries have promoted service user (people who use health and social care services) involvement in the development of health and social care delivery—and the educational development of staff who deliver care. This is seen a useful way of managing demand for healthcare services (Griffiths et al. 2011). Within higher education, there has been increasing interest and recognition that students and academic staff can benefit from students being partners in creating their own learning experiences. Cook-Sather et al. (2014) suggest that these benefits include improvements to student e­ ngagement and learning, a better sense of identity and improved experiences of teaching and being in the classroom. Such partnership working can also improve relationships S. Mehigan (*) Department of Adult, Child and Midwifery, School of Health and Education, Middlesex University, London, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 S. Cunningham (ed.), Dimensions on Nursing Teaching and Learning, https://doi.org/10.1007/978-3-030-39767-8_2

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between staff and students and help students develop their graduate employability skills. It could also be argued that these benefits also have positive outcomes for institutions relying on improved metrics for their programmes. Within the 2018 education standards, which need to be met by all institutions running Nursing and Midwifery Council (NMC)-approved programmes, the NMC emphasises the need for programme teams to demonstrate clear evidence of close partnership working and co-production between students, carers, service users, employers and HEIs at all stages of programme development, approval, delivery and evaluation. Similar emphasis on the need for partnership working in devising education programmes exists in other healthcare professions such as medicine and education. The need for partnership working in developing nursing and midwifery education programmes is clear. Speed et al. (2012) point to a wealth of research suggesting that such partnership working, particularly the contribution of service users, is a good thing for service users themselves, students, carers and academic staff. For service users, the benefits can include improvements to their health and well-being and a sense that their voices are brought to life (Rhodes et al. 2014). Some argue that there needs to be further evidence of this (Towle et al. 2010). There is less acknowledgement of challenges with involving service users. Speed et al. (2012) identify a number of these in a qualitative study of 38 service users. These included service users feeling unprepared and unsupported, not receiving feedback on their contributions and not being paid appropriately. Some of the challenges identified by Bovill et al. (2016) with involving students in co-creating learning and teaching included resistance to co-production (from students and academics), issues in navigating institutional norms and practices and issues with creating inclusive opportunities to co-produce. The level of partnership working required for programmes of education in nursing and midwifery can be challenging to develop and sustain, particularly given people’s varied workloads, priorities, roles and experiences. Partnerships between academics and healthcare employers have centred around the development and maintenance of systems of support for clinical practice settings. At the time of writing this chapter, existing Standards to Support Learning and Assessment in Practice (SLAiP) (NMC 2008) are being phased out, to be replaced by new Standards for Student Supervision and Assessment (SSSA) (NMC 2018). We are moving from an era of mentors, sign-off mentors, practice educators and teachers to one where student learning and assessment in practice is supported by practice supervisors, practice assessors and academic assessors. We are also moving from a system of NMC-approved programmes of preparation for staff taking on roles of mentor, practice educator and teacher, to processes for preparing supervisors and assessors being determined by practice partners and HEIs, with the HEI ultimately responsible for ensuring all staff meet standards set for these roles by the NMC. The requirements for staff preparation and continual update to meet the requirements of SLAiP were rigorous, but financially draining, with employer organisations having to fund large numbers of staff each year to undertake an NMC-­approved mentorship programme. The new SSSA standards do still require

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staff preparation and assurance from each HEI that all supervisors and assessors meet the NMC standards set. However, there is greater flexibility on preparation— currently no requirement to undertake HEI accredited and NMC-approved programmes of preparation. But this new preparation will come at a cost, perhaps unseen, that will need to be absorbed somehow—by those who develop resources and deliver any sessions and those who need to find time to release staff to attend any preparation. What is clear so far is that although there is an assumption and imperative for partnership working in the development and delivery of healthcare education in general and nursing and midwifery programmes specifically, this is not always straightforward. In addition to some of the challenges identified above, others include the impact that current funding of nursing and midwifery education in England has on Higher Education Institutions (HEIs)—particularly in larger cities, which can put them in direct competition with each other for students and placements. Similarly, shortages of nursing and midwifery staff or difficulties in student recruitment can place healthcare employers across a region in competition with each other. If nurses and midwives continue to develop and improve the quality of care they deliver, then the professions need to continue to work on ways of developing and maintaining high quality partnership working. The remainder of this chapter will focus on partnership working between education and practice, following the life cycle of a pre-registration nursing or midwifery programme, from development to delivery. It will explore what helps partnerships develop, and what the benefits can be, for all stakeholders. Examples will come from practice in the UK and internationally.

2.2

Developing Programmes of Learning

Any HEI or organisation wishing to run an NMC-approved programme needs to meet standards set for all such programmes, including that of being able to demonstrate clear evidence of partnership working with all stakeholders, including students, service users, carers and employers, at all stages of programme development, delivery and review (NMC 2018). This type of collaborative effort needs a clear strategy to ensure that all stakeholders are able to work together from the start of the process. All participants need to have a clear idea of what is required of them and what they can contribute to the process. One approach to the partnership working required is that of co-production. Co-creating curricula and learning experiences in partnership with students has been a subject of increasing interest over the last few years (Bovill et  al. 2016). Service users and carers are increasingly co-creating healthcare services, particularly in mental health (Meddings et al. 2014; Bradley 2015). However, in most HEIs decisions about learning and teaching are still seen as the domain of academic staff, with students unable at times to have their voices heard (Mann 2008). Similarly, the contribution that service users make can sometimes be seen as tokenistic.

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Bovill et al. (2016) acknowledge that co-creating learning and teaching with students is not straightforward. They frame the challenges they identify, of resistance from students and staff and working within existing institutional systems and practices as opportunities and present several case studies that show how various institutions have successfully overcome these. Within mental health care, successful co-production of services happens when all parties involved are equals, in terms of contribution and expertise (Slay and Stephens 2013). This means a breaking down of power relations, with a blurring of role distinction between professionals, students and service users (Meddings et al. 2014), in the creation of new programmes. Co-producing a new nursing or midwifery programme, or involving service users, students and employers in co-devising a new programme requires time, support and preparation. This needs commitment from HEI faculty to resource and provide this. It can also require a culture shift for HEIs—on an institutional and individual academic level. It needs clear channels of communication, so that everyone involved feel they can contribute to designing a curriculum that they know how their contribution is being used, and what commitments they may need to make, in terms of participating in design and validation events. For the author, even finding suitable media and methods can be challenging, especially if some institutions limit access to communications channels to those who may be based in other organisations. Given the complexity and prescriptiveness of nursing and midwifery programmes, the content of any programme may not be as negotiable as how a programme is delivered. This need to meet exacting professional body standards can be at odds with the ethos of co-production.

2.3

Partnership Working: Supporting Learning

As practice disciplines, nurses and midwives need support in clinical practice, to help them move to a stage where they can develop and use clinical reasoning skills in the practice setting. This requires much collaborative working between academics and practitioners to facilitate it. An essential step is to ensure, at the outset, that the education of nurses and midwives is a priority, at strategic level in both HEIs and clinical practice settings. There needs to be board-level support. Once support for student education is gained, then academics, clinicians, students and service users need to be clear about roles, responsibilities, expectations and on what needs to be put in place, in practice and in HEI settings to ensure that students can make the most of learning opportunities (Andrews et al. 2006; Duffy et al. 2000). If professional practitioners are to develop their ability to practice, then they need support in practice to use any knowledge and skills gained in a classroom setting while in practice—to help bridge the theory practice gap. One of the main forms of student support in practice is through mentorship. A variety of approaches to mentorship exist, among different professional groups including medicine, teaching and social work, and across different countries world-wide. In a rapid review of literature, Bazian (2016) found few studies of models or frameworks of mentorship,

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but rather descriptions of what is done in practice. Within the UK, student support for nursing and midwifery students in practice has until now been provided by practitioners, prepared to take on the role of either mentor or practice educator. Mentors and practice educators work in an intensive 1-to-1 way with students, in partnership with local HEIs. HEIs support mentors in practice in a variety of ways, using either link lecturers or staff with joint appointments as educators in both academic and clinical settings. The role of link lecturer is one where a nursing academic “links” with a designated clinical area, to support clinical staff and learners. The role of mentor has been part of nursing and midwifery education in the UK since the 1990s when the move of nursing and midwifery into higher education meant students had supernumerary status. It also moved nurse education out of the clinical setting and into higher education. At this time, the mentor took on the role of both supporting and assessing students in practice (Price et al. 2011; Myall et al. 2008). Since 2007, it has been mandatory for nursing students to be allocated a mentor during their clinical placements (NMC 2006). Interestingly, Bazian’s review (2016) found that the UK system of mentoring for nursing was the most detailed and prescriptive, in terms of policy and guidance, compared with other national regulators. They also point to the fact that among the studies reviewed, within research-based descriptions of practice, there was little explanation of the theoretical bases for approaches used for mentoring. Many assessments of any impact of mentorship reported were also based mostly on the experiences of and self-evaluation by those involved in mentoring. In a study on how managers understand the different roles of mentor, lecturer practitioner and link tutor in Wales (Carnwell et al. 2007) respondents had particular concerns about the work of mentors. They felt they did not always have enough theoretical knowledge to help students make links between theory and practice. They also gave examples of what they felt was mentors’ reluctance to give students negative reports. Other studies have shown that many mentors “failed to fail” (Duffy 2004). Where mentoring is seen to work, students identify some of the benefits of working with them in practice, including feeling supported and having someone who is interested in their learning. A good mentor acts as a role model, and can help in creating a positive learning environment by increasing a student’s feeling of belonging (Vinales 2015). Excellent mentors can leave a lasting impression on a student nurse. Some of the challenges though include poor preparation of mentors or inability to apply learning to practice. Where staff workloads are large, delivery of frontline care can take priority. Some have seen undertaking the mentorship programme as a necessary stepping stone to promotion, but have not wanted to actually mentor. For mentoring to be effective, mentors cannot work in isolation, but need support, both from their own employers and managers and by their HEI. As part of a wider project on exploring ways of enhancing learning in practice, the author worked with others in collecting data on clinical and academic perceptions of partnership working (Mehigan et al. 2019). Questions explored perceptions of the value of the role of the link lecturer, what additional resources they required to support practice learning and what staff felt worked, in terms of partnership working.

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Themes arising reflected findings from wider literature. Preparation was key—both preparation for taking on roles and working with clinical partners to ensure they had timely information about students, when they were coming and feeling updated about student assessments and their roles as mentors. Academics in this study felt that there was an assumption that they would know how to undertake their roles as link lecturers, but that this was not the case. Wider literature indicates that this role is challenging. For example, Ramage (2004) suggests that link lecturers are uncertain about what their role is in practice particularly as they transition from practice, as clinicians to working as link lecturer. They also express difficulties of how they maintain clinical credibility. Others suggest tension or difficulties in maintaining links between clinical practice and education (Carr 2008; O’Driscoll et al. 2010). For many clinicians, the need for academics and link lecturers to be visible and readily contactable are key. For link lecturers themselves, there is a transition from being expert as a clinician to taking on the role of academic and being an outsider, an “other”, with subsequent loss of feeling part of a team. There is also an assumption that new academics will be able to take up and embrace the role—however, findings from Mehigan et al. (2019) suggest that this might not be the case, and that specific preparation and ongoing support for the link lecturer can be incredibly valuable. Partnership working between HEIs and clinical practice to support students presents challenges. This includes workload demands for both academics and clinicians (Lambert and Glacken 2006; Carnwell et  al. 2007). O’Driscoll et  al.’s study (O’Driscoll et al. 2010) found uncertainty over roles, lack of support in practice for link lecturers and workloads taking precedence over supporting learners for clinical managers and mentors. Many participants in Carnwell et al.’s (2007) study of link lecturers, lecturer-practitioners and mentors expressed role conflict of some kind with a notion of serving two masters. For the mentor, this is the pull of student versus clinical needs, and a perceived lack of support from managers. For the lecturer-­ practitioner, joint appointments mean having two managers, two contracts and two different (and not necessarily clear) sets of expectations. As with mentors, link lecturers have two masters in the form of competing demands from supporting learners in practice, and HEI work of teaching, administration and research. This can mean, when pressure builds, that something must go—with student support often the part that staff relinquish.

2.4

Supporting Practice: Meeting the Challenge

The above section presents some of the challenges of supporting students in practice. From a student perspective (Andrews et  al. 2006; Brown et  al. 2005), they place great importance on having a member of the academic team visit them— whether because they feel alone in placement or feel it gives them further motivation to learn. They recognise the impact of workloads on clinicians’ abilities to be able to support them. Students in Andrew et al.’s study (Andrews et al. 2006) felt that best practice was where communication between all partners was consistent

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and clear, and where there was evidence of joint working between academics, mentors and clinical managers. Interestingly, students associated contacting academics with an inferred assumption that they were failing. One possibility to address students’ concerns is the use of roles variously described as Practice Education Facilitators (PEFs) or Clinical Practice Facilitators (CPFs). These roles have diverse responsibilities, ranging from supporting supervisory staff to conducting placement evaluations (Carlisle et  al. 2009). Benefits of these roles included the development of stronger links between universities and clinical practice settings (Carlisle et al. 2009; Sykes et al. 2014; Scott et al. 2017) and better liaison between both settings in managing placement issues. Given that role holders are physically closer to practice areas, they can respond more readily to practice issues than academics, in terms of supporting mentors and students (Carnwell et al. 2007; Scott et al. 2017). Given their familiarity with both university and clinical practice policies and processes, there is also the assumption that they have a better understanding of the learning requirements of nursing or midwifery programmes, meaning that they may be better placed to help to bridge theory practice gaps for students (Scott et  al. 2017). Given the focus, mostly, on education, CPFs have greater confidence in understanding student learning and assessment needs, and in understanding HEI processes. Challenges to these roles include the proliferation of role titles, with a lack of clarity on the remit of the role and a lack of preparation for those taking up these roles (Coates and Fraser 2014; Scott et al. 2017). Role holders can express feelings of isolation and of feeling overwhelmed with the scope of the role (Brown et al. 2002; Lambert and Glacken 2006). These roles can seem to be cost burdens to organisations, which means they can be vulnerable, despite any perceived benefits (Scott et al. 2017).

2.5

 artnership Working to Support Learning: Different P Ways of Working

When undertaking the “Raising the Bar” review, Willis (2015) highlighted what was seen as an innovative way of supporting student learning in practice. Based on a coaching model, “Real Life Learning Wards” seen in UUvm in Amsterdam, Lobo et  al. (2014) set up a similar model in the University of East Anglia. Called Collaborative Learning in Practice (CLiP), the model is premised on a team-based approach to student teaching and learning in practice. All members of the clinical team, from admin staff to medics, contribute. Each clinical area supports nursing students from all years of a programme at one time. Care in the area is managed by students, with senior students devising plans of care in liaison with a qualified nurse, to be delivered by a team of student nurses. The qualified nurse acting as coach is released from all other clinical responsibilities for a shift. The emphasis is on students stepping up to deliver care and qualified staff stepping back to support student learning through care coordination and delivery. Students are given dedicated time each day to go off the clinical area to reflect on achievement of learning objectives

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each day. Where it is identified that students would benefit from developing specific skills or gaining other experiences, then the coach will ensure a student is given the opportunity to work alongside another qualified practitioner to gain this learning experience. Additional resources include a dedicated clinical practice educator, who is assigned to just one or two clinical areas, and whose sole responsibility is on supporting student learning in those areas. Close liaison is required between clinical education teams and academic teams—to coordinate clinical learning and ensure that placement patterns are planned to ensure students from all years can be allocated to areas at the same time. The model above has been identified as a peer or team-based model, with many students allocated to one clinical facilitator. Bazian (2016) identifies similar models in the USA and Australia, including the Dedicated Education Unit, where clinicians and academics work together in practice, in research and the development and delivery of programmes of education (Moscato et al. 2007; Ranse and Grealish 2007). The other peer-based model is the Australian Clinical Facilitation model, where a facilitator is responsible for assessing students, and can also set up group supervision sessions for them. Peer learning can be provided by other students and clinical staff. Bazian (2016) suggests that these peer-based models of mentorship, with one clinical facilitator to many students, are probably the most effective. Although they conclude that peer learning, with senior students supervising junior students, can improve staff retention, this is not sufficient in itself—students need additional support from qualified experienced nurse mentors. They also suggest that clinical facilitators were preferable to University lecturers, who were likely to be more costly and seen as less clinically up-to-date. The CLiP model has been adapted in other parts of the UK.  Versions have been adopted by other organisations, including CLiPP in Plymouth, and at James Paget Hospital Trust. As with CLiP, these schemes have met with some success, not least in the perception that this approach enables organisations to support greater numbers of nursing students in clinical practice. With the current need to increase placement capacity, this is seen as desirable— however, the levels of organisation and partnership working to ensure the success of this approach to student learning in practice can be underestimated. One could also argue that being able to support additional students in practice is useful if there are generally low levels of staffing in a unit. Holbery et al. (2019) point out that staffing levels in a clinical area are critical to ensuring success. Otherwise there is a risk that the clinical facilitator steps in to become the coach, and students see peer teaching as the only form of support available to them. Holbery et al. also point out that to date there is a paucity of published evaluation of the CLiP model, and that it is needed, to assess its’ suitability across settings and with different types of students. What emerges from discussions of peer models of mentorship is that they require considerable investment, in terms of the employment of dedicated clinical practice educators. They also require careful planning of student placements, to help balance the need for sufficient numbers of students in all years to be in practice at the same time, with the need to ensure a steady supply of students over the year. The longer-­ term sustainability of these models is also worth considering.

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Broader perspectives of clinical learning point to the benefits in providing “situated learning” opportunities—where a student works with a clinical coach to consider how to draw on relevant knowledge and skills to develop “know how” of care delivery in the context of the clinical setting (Benner 2015). This links with Eraut’s (2002) notion of professional learning—he suggests that we frontload initial professional learning programmes, including those for nursing and midwifery, with so much knowledge, theories, models and facts that are needed to qualify, yet so much of this will not necessarily be used all the time. Indeed much of this knowledge will never be used. His point that professionals develop their practice throughout their career links to the notion of “situated learning”. Perhaps we need to work in partnership to re-think what is actually needed to enable someone to register—and work to the maxim of less can be more—and de-clutter our curricula.

2.6

 artnership Working to Develop and Enhance Clinical P Practice

Within the USA, The Institute of Medicine (2010) has proposed the adoption of a wider vision of academic nursing, to strengthen connections between research, education and practice. This is aimed at enhancing the adoption of evidence-based practice and the fitness for practice of newly registered nurses. The American Association of Colleges of Nursing (2016) recommends that academic and clinical nurse leaders work together with other healthcare leaders to “realise the full benefits of academic nursing” (Sebastian et al. 2018, pp. 110–116). Such working is worth promoting in the UK at a time when wider questions are being raised about the value of higher education.

2.7

Conclusion and Recommendations for the Future

Students undertaking nursing or midwifery programmes need and benefit from support from a wide range of stakeholders, including service users, clinicians and academics, to enhance their learning for and in practice. Ensuring all stakeholders are involved in developing and delivering these programmes requires close partnership working. Such partnership working can help ensure continuing excellence in healthcare practice by building consistency between learning in education and in practice. This partnership working requires commitments from all organisations so that those who support learning are given the time and recognition for undertaking support roles, or are given additional staff to support them, such as Practice Educators (Carlisle et al. 2009; Scott et al. 2017). Academics work in partnership to develop clinical staff to undertake roles as either mentors or, under the new NMC 2018 standards, as practice supervisors or practice assessors. They also bring expertise to clinical areas, in the form of access to wider research findings, and expertise about the programmes being delivered, about student support and student assessment.

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With the introduction of the new NMC standards and the lack of requirement for clinical staff to undergo NMC-approved programmes of education to prepare as either mentors or practice teachers, there is a risk that this will increase inconsistencies of preparation across regions and nationally. It is possible that while principles of preparation for roles are maintained, interpretation of roles might differ between organisations, depending on local circumstances, such as capacity, service configuration or staffing levels. However, there is also an opportunity for stakeholders to re-examine how they work together in preparing and planning for student support for learning and assessment in practice. Partnership working to support student learning in practice is essential but complicated, affected by competing demands, a range of different requirements and conflicts. However, if the quality of practice learning and, potentially, healthcare practice is to be maintained, then it is essential that all involved in the education of nurses and midwives commit to it.

2.8

Recommendations

One way of conceptualising partnership working is presented by Mehigan et  al. (2019), as PRANCE. This involves considering how staff and areas are Prepared for students coming to practice. Role definition is important—there needs to be clarity around who will be involved in student support and assessment, and what is expected from each. Given that there can already be a lack of clarity on roles, the move from mentorship to practice supervision and assessment means there is an increased risk of role confusion, particularly in the first few years of transition. Accessibility means that academics need to be present and visible in practice. Clinical staff need to know how to contact academic support if it is needed. Academics can also provide access to wider research on evidence for practice, for clinical areas. Networking refers to ensuring that connections are built and maintained between practice and academia, to enable all staff to learn from each other and to build shared approaches to teaching, learning and assessment in class and practice settings. Communication is key for any partnership working. In the case of supporting practice learning, it needs to be clear and timely. All parties need to be committed to building and maintaining relationships. Expertise is through academics sharing research and programme-­ specific expertise with clinicians, clinicians sharing practice expertise and service users bringing expertise of living with their conditions.

References American Association of Colleges of Nursing (2016) Advancing health care transformation: a new era for academic nursing. AACN, Washington, DC Andrews G, Brodie D, Andrews J, Hillan E, Gail Thomas B, Wong J, Rixon L (2006) Professional roles and communications in clinical placements: a qualitative study of nursing students’ perceptions and some models for practice. Int J Nurs Stud 43(7):861–874 Bazian (2016) Nurse mentoring: rapid evidence review. In: RCN mentorship project 2013. From today’s support in practice to tomorrow’s vision for excellence. RCN, London

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Benner P (2015) Curricular and pedagogical implications for the Carnegie study, educating nurses: a call for radical transformation. Asian Nurs Res 9(1):1–6 Bovill C, Cook-Sather A, Felten P, Millard L, Moore-Cherry N (2016) Addressing potential challenges in co-creating learning and teaching: overcoming resistance, navigating institutional norms and ensuring inclusivity in student-staff partnerships. High Educ 71(2):195–208 Bradley E (2015) Carers and co-production: enabling expertise through experience? Ment Health Rev J 20(4):232–241 Brown L, Herd K, Humphries G, Paton M (2005) ‘The role of the lecturer in practice placements: what do students think?’ Nurse Educ Pract 5(2), pp. 84–90 Brown P, Kelly D, Simpson S, Kelly D (2002) An action research project to evaluate the clinical practice facilitator role for junior nurses in an acute hospital setting. J Clin Nurs 11(1):90–98 Carlisle C, Calman L, Ibbotson T (2009) Practice-based learning: the role of practice education facilitators in supporting mentors. Nurse Educ Today 29(7):715–721 Carnwell R, Baker S, Bellis M, Murray R (2007) Managerial perceptions of mentor, lecturer practitioner and link tutor roles. Nurse Educ Today 27(8):923–932 Carr J (2008) Mentoring student nurses in the practice. Pract Nurs 19(9):465–467 Coates K, Fraser K (2014) A case for collaborative networks for clinical nurse educators. Nurse Educ Today 34(1):6–10 Cook-Sather A, Bovill C, Felten P (2014) Engaging students as partners in learning and teaching: A guide for faculty. San Francisco: Jossey-Bass Duffy K (2004) Failing students: a qualitative study of factors that influence the decisions regarding assessment of students’ competence in practice. NMC, London Duffy K, Docherty C, Cardnuff L, White M, Winters G, Greig J (2000) The nurse lecturer’s role in mentoring the mentors. Nurs Stand 15(6):35–38 Eraut M (2002) Developing professional knowledge and competence. Taylor and Francis, London Griffiths J, Speed S, Horne M, Keeley P (2011) “A caring professional attitude”: what service users and carers seek in graduate nurses and the challenges for educators. Nurse Educ Today 32(2):121–127 Holbery N, Morley D, Mitchell J (2019) Expansive learning. In: Morley D, Wilson K, Holbery N (eds) Facilitating learning in practice. Routledge, London Institute of Medicine (2010) The future of nursing: leading change, advancing health. The National Academies Press, Washington, DC Lambert V, Glacken M (2006) Clinical education facilitators’ and post-registration paediatric student nurses’ perceptions of the role of the clinical education facilitator. Nurse Educ Today 26:358–366 Lobo C, Arthur A, Lattimer V (2014) Collaborative learning in practice (CLiP) for pre-­registration nursing students: a background paper for delegates attending the CLiP conference. Collaborative Learning in Practice (CLiP), University of East Anglia NHS Health Education East of England, Norwich Mann SJ (2008) Study, power and the university. Open University Press, Maidenhead Meddings S, Byrne D, Barnicoat S, Campbell E, Locks L (2014) Co-delivered and co-produced: creating a recovery college in partnership. J Ment Health Train Educ Pract 9(1):16–25 Mehigan S, Pisaneschi L, McDermott J (2019) Academic practice partnerships. In: Morley D, Wilson K, Holbery N (eds) Facilitating learning in practice. Routledge, London Moscato S, Miller J, Logsdon K, Weinberg S, Chorpenning L (2007) Dedicated education unit: an innovative clinical partner education model. Nurs Outlook 55:31–37 Myall M, Levett-Jones T, Lathlean J (2008) Mentorship in contemporary practice: the experiences of nursing students and practice mentors. J Clin Nurs 17:1834–1842 NMC (2006) Standards to support learning and assessment in practice: NMC standards for mentors, practice teachers and teachers. Nursing and Midwifery Council, London NMC (2018) Standards for student supervision and assessment. Part 2 of Realising professionalism: Standards for education and training O’Driscoll MF, Allan HT, Smith PA (2010) Still looking for leadership – who is responsible for student nurses’ learning in practice? Nurse Educ Today 30(3):212–217

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Price L, Hastie L, Duffy K, Ness V, McCallum J (2011) Supporting students in clinical practice: pre-registration nursing students’ views on the role of the lecturer. Nurse Educ Today 31:780–784 Ramage C (2004) Negotiating multiple roles: link teachers in clinical nursing practice. J Adv Nurs 45(3):287–296 Ranse K, Grealish L (2007) Nursing students’ perceptions of learning in the clinical setting of the dedicated education unit. J Adv Nurs 58(2):171–179 Rhodes C, Hardy J, Padgett K, Symons J, Tate J, Thornton S (2014) The health and well-being of service user and carer educators: a narrative enquiry into the impact of involvement in healthcare education. Int J Practice-Based Learn Health Soc Care 2(1):51–68 Scott B, Rapson T, Allibone L, Hamilton R, Mambanje C, Pisaneschi L (2017) Practice education facilitator roles and their value to NHS organisations. Br J Nurs 26:222–227 Sebastian JG, Breslin ET, Trautman DE, Cary AH, Rosseter RJ, Vlahov D (2018) Leadership by collaboration: Nursing’s bold new vision for academic-practice partnerships. J Prof Nurs 34(2):110–116 Slay J, Stephens L (2013) Co-production in mental health: a literature review. New Economics Foundation, London Speed S, Griffiths J, Horne M, Keeley P (2012) Pitfalls, perils and payments: service user, carers and teaching staff perceptions of the barriers to involvement in nursing education. Nurse Educ Today 32(7):829–834 Sykes C, Urquhart C, Foster A (2014) Role of the practice education facilitator (PEF): the Cambridgeshire model underpinned by a literature review of educational facilitator roles. Nurse Educ Today 34(11):1395–1397 Towle A, Bainbrindge L, Godolophin W, Katz A, Kline C, Lown B, Madularus I, Solomon P, Thistlewaite J (2010) Active patient involvement in the education of health professionals. Med Educ 44:64–74 Vinales J (2015) The mentor as a role model and the importance of belongingness. Br J Nurs 24(10):532–535 Willis G (2015) Raising the bar, shape of caring: a review of the future education and training of registered nurses and care assistants. https://www.hee.nhs.uk/our-work/shape-caring-review. Accessed 28 Aug 2019

3

Clinical Learning Environments Sheila Cunningham

3.1

Clinical Environments for Learning Nursing

Nursing programmes have evolved over the last two decades to prepare professionals to meet the changing global burden of disease and positioned to take a person-­ centred, holistic view of health that considers social, psychological and environmental elements (Salvage and Stilwell 2018). Across Europe nursing programmes generally align with the Bologna process (cycles) with the preregistration nursing mostly being at level 6 (degree level); however, there are still countries with inconsistencies (Palese et al. 2014). Furthermore, the Bologna Declaration offers real opportunities for nurses to establish closer links with their European colleagues across a spectrum of clinical practice, management and academia in order to raise the profile of nursing as a graduate profession (Davies 2008). In Europe, nursing programmes preparing registered practitioners generally apply the Directive (EC/36/2005 amendment EU/55/2013) as a benchmark for professional knowledge and skills. However, there are differences in respect of technical skills and the role and position of nurses within health teams to use and support technological in order to meet local needs effectively. Requirements for practice placements also appear to vary. Preservice education requirements outlined in EU directive 2005/36/EC Annex v2 (5.2.1) (2005) and followed within the UK by the professional body the Nursing and Midwifery Council (2010, 2018a) assert the duration of practice should comprise at least half of the duration of training programme. This is overall 4600 h. In spite of the Directive’s recommendations, there remains a large variability in the amount of learning in clinical practice settings (Palese et al. 2014). That aside the issue of shortage of placements and training opportunities for nursing students affects many countries none the least in the UK (House of Commons Health Committee, Parliament 2018). Exchanges S. Cunningham (*) Department of Adult, Child and Midwifery, School of Health and Education, Middlesex University, London, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 S. Cunningham (ed.), Dimensions on Nursing Teaching and Learning, https://doi.org/10.1007/978-3-030-39767-8_3

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or placement abroad has significant benefits and is slowly being realised in UK universities and offers diversity of opportunity, experiences and locations (Council of Deans of Health 2016) while being more established in overseas universities (Warne et  al. 2010). The NMC recognised and endorsed opportunities to widen learning opportunities for all nursing courses with guidance clarifying that nurses could experience “elective” placements or conventional clinical placements inside and outside of the UK but not to exceed 26 weeks or 17.5% of the programme (NMC 2010). This also provides a benefit to meeting universities strategic goals for internationalisation while also offering an “elective” is an attractive recruitment option for universities to attract nursing candidates from a dwindling pool of undergraduates. It is well documented that study abroad confers benefits which are wide ranging including enhanced cultural awareness, sharing of best practice, idea, values, policies and practices to promote a better understanding of different health care settings. These in turn contribute to personal and professional development (Ruddock and Turner 2007; Button et al. 2005; Jacobone and Moro 2015). Furthermore, Milne and Cowie (2013) argue that through these exchange programmes, students confidence in delivering care to individuals from different cultures is increased. These links and opportunities could also have a positive impact on migration, careers, research opportunities and nursing management (Zabalegui et al. 2006). The formal mechanism for exchange is through the formalities of a bilateral institutional agreement between programme countries signed by the two universities. This forms the contractual formality and agreement to terms with the Erasmus programme for exchange and will likely be similar to any new iteration or replacement programme. However, the agreement for “traineeships” or learning in work environments does not specify more than the learning objectives and insurance and as such leaves a gap with the quality and expectations of clinical learning environments. Clinical learning environments (CLE) abroad as well as offering opportunities are also subject to the same unpredictability as placements anywhere. Safety of service users, students and staff is essential to students engaging with these areas (NMC 2011). Guidance emanating from the UK professional body asserts assuring safety for students and staff but also regular risk assessments, audits of the learning environment to confirm adequate levels of supervision and that planned experiences reflect the intended programme outcomes (Marshall 2017). This raises a question of how one assures the quality of a clinical environment for learning. While quality assurance of clinical learning environments is well established as a forward looking “prospective” approach in the UK (Nursing and Midwifery Council [NMC], 2008), there is still variation between universities in documentation and processes of educational evaluation audit of clinical learning environments. As such varied processes and approaches abound within the UK.  In Europe, this was raised in large-scale work identified by Saarikoski and Leino-Kilpi (2002) and Saarikoski et al. (2008) who developed the Clinical Learning Environment and Supervision Scale (CLES) and subsequent CLES +T which had an emphasis on retrospective measurement through their widely validated evaluation instruments (Saarikoski et  al. 2008). There remains however limited literature on proactive prospective measures or collective quality benchmarks.

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3.2

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 ackground to HEALint (Supporting B Internationalisation of Traineeships in the  Healthcare Sector)

When a nursing (or any healthcare) student elects or requires an international placement, the home organisation relies upon a placement offered by the host. Universities have to be assured that placements satisfy home regulatory bodies to achieve programme/course accreditation. However, within this there is variability and no clear collaborative means of agreeing and recording standards across Europe. Currently, each national regulatory or health organisation meets national or local standards for placements within agreed regulatory accreditation. This also includes requirements for supervising staff supporting students and facilities within clinical learning environments. Some elements are governed broadly by the European Union (EU directives) with delegated responsibility lying with the nation, e.g., for health and safety, insurance and other national regulatory criteria authorised by governments to assure the implementation of EU regulation. The HEALint project, an ERASMUS+ (KA2) funded project (Supporting Internationalisation of Traineeships in the Healthcare Sector) emerged in light of this in an aim to meet such exchange nursing placement need. This project group consisted of two UK universities, and three from Europe (Poland, Finland and Alicante—see www.healint.eu) and a project manager from Malta. It aimed to establish an International Quality Audit System for nursing and healthcare institutions who want to exchange students which will map to national and international priorities and meet agreed requirements. The outputs of HEALint are intended to provide a robust mechanism, using well-established metrics, to benchmark placement quality and support for students across health facilities and universities in different countries. Such benchmarking will offer confidence in placement quality and support the extension of placement choice for students, since partners signed up to the joint agreement could share trainee placements more easily. The key concern which arose from existing exchanges is the multiplicity of organisations conducting education audit in clinical areas using UK metrics in isolation. This led at times to some host organisations, which may have four or more UK universities exchange students, each conducting their own (so four or more) audits. The issue of cross European benchmarks also arose as to whose quality measures were being assessed and evaluated. The dearth of existing or complex benchmarks in differing countries then provided an opportunity to contribute to this area and draw together key documents and requirements and a shared joint benchmark and measuring process. In addition, this mechanism will review what a placement has to offer in respect of best practice in pedagogical support for nursing or healthcare students while also facilitating flexible opportunities to explore different cultural and practical nursing care environments. This project aimed to produce four outputs which are: • Collate benchmark of quality indicators. • Devise a clinical learning environment quality audit instrument.

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• Outline training and guidance for audit processes. • Evaluation of the instruments/tools and outputs. This chapter addresses the first two items and explores the context of clinical learning environments and the challenges of assuring quality.

3.3

What Is an Effective Clinical Learning Environment?

Prior to addressing the quality benchmarks, it is worth exploring a little what constitutes an effective clinical learning environment (CLE). Research on effective CLEs for nursing students has been in evidence since the late 1970s. Early seminal work in the UK by Fretwell and Orton identified and explored factors and characteristics involved in the learning environment and they were instrumental in defining and attempting to quantify these variables (Felstead 2016; Gopee 2015). However, the range and composition of CLEs have changed enormously since that period. Nursing roles have also evolved as well as the scope and practice of nursing. Research on CLEs to date varies in scale, setting, method and theoretical foundation. A shared finding however is that it poses a significant effect on student learning and intention to work within nursing. Variable and sometimes high attrition rates from UK and international institutions undertaking nurse education are associated with penalties and consequences (i.e., workforce provision). This intensifies the need for a comprehensive understanding of its causes as well as factors which lead to successful learning. In a UK report on standards of care in clinical areas (Francis report: 2013) it highlights that poor training environments and poor student experience are indicators of poor quality in clinical settings (Traynor and Mehigan 2014). This is unacceptable in the twenty-first century and while efforts to make improvements continue the issue of what is an optimal CLE remains and expands into the search to draw on varied sources of clinical learning. CLEs are described as “unpredictable, volatile and dynamic” (Stuart 2013, p. 5) with varied definitions of what they are. In identifying what and where a learning environment is NMC (2019, p. 23) asserts it “includes any physical location where learning takes place as well as the system of shared values, beliefs and behaviours in these places”. A recent concept analysis attempted to define the CLE (Flott and Linden 2016). They proposed a mid-range explanatory theory of attributes which impact “achievement of outcomes, development of self-confidence, and successful transition into the nurse profession” (ibid: 510). Other definitions and dimensions of the CLE are broad ranging from “multidimensional entity that directly effects the outcomes of students clinical placement” (Chan 2002, p. 70) to “Forces and elements within a clinical setting … impact on student learning outcomes” Dunn and Burntt (1995, p. 1167). This broad reaching attempt to define results in a challenge to measure and monitor for quality assurance however despite several lenses for the CLE, a core feature is that it draws on a range of attributes: physical setting, organisational processes, and socio-relational, psychological and cultural environments (Hegenbarth et al. 2015).

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Houghton et al. (2012) asserts supportive learning environments are crucial to develop the future workforce and are just as important as skills are contextualised or “situated” and developed. It is argued that professional socialisation is also crucial within a supportive CLE and the impact of supervisors and mentors on enabling students develop their “professional identity” and generic skills (e.g., teamwork, time-management, de-escalation, critical thinking (Papathanasiou et al. 2014) and becoming independent practitioners (Mansutti et al. 2017) in preparation for professional practice (McAllister 2010). Research internationally endorses the fact that negative CLE experiences impact on successful achievement of learning outcomes (Levett-Jones and Lathlean 2009; Babenko-Mould and Laschinger 2014) which is argued to have consequences on staffing and ultimately contribute to the nursing shortage. In the UK, nurse education providers (higher education institutions: HEI) are expected to work in partnership with practice placement providers in the delivery of educational programmes (NMC 2018b) However, the HEIs remain the accountable body for managing quality and controlling risk related to the practice learning environment. It is not surprising then that the risk assessment process is integrated within educational audit processes and instruments to monitor and evaluate the practice learning environment. This can also enable a means to disseminate good practice and jointly develop action plans for locations in need of development and improvement. In the UK, the Nursing and Midwifery Council (2013) Quality assurance framework (which is updated in 2018) sets out the requirement for quality monitoring of placement environments. To date, this process termed educational audit is required every 2 years when using a specific CLE. Health Education England (HEE 2016) also sets out expectations indicating that there ought to be robust processes in place to supervise and support learners and supervisor or mentor development but no clear guidance what this ought look like or how often this ought to be done. Nursing students unsurprisingly perceive the CLE as the most influential context to develop professionally (Chan 2002; Arkan et  al. 2018; O’Mara et  al. 2014). However, from the nursing students’ point of view, CLE is also one of the most anxiety-provoking components of nurse education (Moscaritolo 2009). The evolving nature of population healthcare needs and support together with the shift in nursing education to academic levels has transformed students’ clinical experiences from a traditional apprentice style of “learning by doing” to a context of practice learning underpinned by evidence. CLEs must have the capacity and resources needed to deliver safe patient care and also supportive effective learning experiences. These placements could be enrichment opportunities, or in environments where there are no registered health and social care professionals but provide an opportunity for students to learn for a variety of environments. There are consequences to poor or unsupportive CLE experiences. Students may not continue or fail to progress due to stress of inability to achieve outcomes (Brynildsen et al. 2014; Papastavrou et al. 2016). Qualified nurses may be unprepared when entering the profession with key needs such as critical thinking,

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leadership or struggle with anticipation or interventions especially recognising deterioration in patients. Furthermore, this leaves new nurses vulnerable and stressed to the point where they have been reported to leave the profession within the first year of graduation (Flott and Linden 2016). This further aggravates the acute shortage of nurses internationally. This is reported in many other countries and as such is a joint shared concern which ought to be recognised.

3.3.1 Attributes of Clinical Learning Environment In developing the benchmarks for HEALint exploration of the attributes of CLE were considered. There appear to be four main attributes integral within the CLE which include physical space, psychosocial interactions, organisational culture and pedagogical approaches (Chan 2001; Dunn and Burntt 1995; Saarioski 2005) and impact socialisation (Edgecombe et al. 2013). CLE characteristics impact not only student achievement of competency or learning outcomes but also on broader aspects: self-confidence and successful transition into the nursing profession (Flott and Linden 2016). Belongingness is highlighted as particularly important in professional socialisation to clinical learning contexts and this in turn enhances learning and performance (Edgecombe et al. 2013). UK universities offering nursing programmes have established a substantial volume of literature that has examined clinical environments and the role of mentors or lecturers (Traynor and Mehigan 2014) who are undoubtedly key they question is how they support. These individuals are instrumental in creating supportive atmospheres and strengthening the connection between the university theoretical aspects and placement experience and impact on student learning (Saarikoski et al. 2013; Sundler et al. 2014). There appear to be two supervision models primarily used in European countries: firstly the mentor or preceptor (terms are often used interchangeably) as an experienced clinical nurse as a clinical supervisor, supporting translation of knowledge and skills in a situated environment. Secondly, the nurse teacher employed by the educational institution acting as a liaison, confirming performance measures and achievements either in association with or independent of the clinical supervisor. This too raises the issues of the complexity of learning environments and assuring quality of support. In their best practice guide to clinical environments, the Australian Department of Health (Department of Health, Australia (DH) 2014, p. 3) points to a series of factors enabling quality in clinical placements include: • A culture for quality develops positive relationships, actively supports learning and rewards best practice. • Effective supervision characterised by a good supervisory relationship and facilitated through supervisor characteristics, supervisor development, and appropriate recognition and reward of desirable supervisor behaviours.

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• Learning opportunities that are diverse and appropriate for student competence comprise at least in part of supported participation in direct patient care. • Effective communication and collaboration between students, academic institutions and placement sites, in an effort to adequately prepare for the placement experience. • Resources and facilities sufficient to conduct placement activities. They also identify a series of potential barriers to placement quality which include occupational stress, workplace discourtesy and aggression. This it is argued, threatens the socio-emotional, physical safety, staffing levels and shortages, and an inclusive environment of culture, gender and physical (dis)ability. They also point to the impact of active innovations and interventions to increase placement quality and capacity. These are not unique to this part of the world but useful considerations for the development of instruments and benchmarks of CLE quality.

3.3.2 HEALint Benchmarks The initial phase and output was a desktop review of literature for the review of national and international practices and standards, including relevant research regarding student placements. This review revealed that despite copious standards, instruments, guidance documents and legislation around the student nurse experience, much of these remain country-specific resources which are not used as shared resources between countries. This resulted in several key shared areas which follow the student journey through a placement area (before, during and after). They include: • • • • •

Guidance around traineeship planning and control Allocation of trainees to traineeship placements Assignment of mentors Determining, providing and maintaining a supportive learning environment Assessment of learning

Finally, guidelines around the formal recognition of traineeships were included since this is key to the formal arrangements and agreements: • Establishment of partnerships • Certification of traineeship Although not initially planned, in devising the benchmarks the need for a c­ ommon language and understanding emerged. The project partners agreed to draw on internationally recognised standardisation terminology (ISO terminology) and ISO syntax style in the writing of the requirements and to organise them in typical ISO standard structure (Table 3.1). This was done for two main reasons:

40 Table 3.1  ISO standards and processes (ISO N.D.)

S. Cunningham ISO—Quality assurance framework outline for audit and evaluation Section 1—Scope: regulatory requirements and policies Section 2—Normative reference Section 3—Terms and definitions Section 4—Quality management system Section 5—Management responsibility Section 6—Resource management Section 7—Product realisation Section 8—Measurement, analysis and improvement

1. To make the protocol more compatible with other international standards that might be already implemented by users, therefore facilitating its integration; 2. To preventively solve any translation problems, as most ISO terminology is already translated into the languages of the partners. This was particularly welcomed by members of the team for whom translation was a challenge, e.g., Finland. The benchmarks statements were subject to peer and expert review and feedback received informed revisions and refinements. This was time consuming; however, the final agreed benchmarks met the needs of all four countries within the partnerships and those consulted and can be viewed on www.healint.eu. The next output develops these standards into the assessment instrument which acts as the vehicle to determine how the standards are met or areas which could be strengthened.

3.3.3 Instruments for Measuring CLE The next output and stage was development of an audit instrument. Multiple instruments exist which measure the CLE, its effectiveness in promoting learning and student satisfaction with their clinical experience. In the main as mentioned most of the instruments are retrospective and comprise self-report surveys (Flott and Linden 2016) with some reportedly considering student achievement as indicators. Other healthcare professional areas also have established quality CLE instruments including dietetics, physiotherapy, radiology and dentistry (Mansutti et al. 2017) and again these vary from nation to nation. The instruments confirm the attributes of the CLE; however, the perspective or lens is not well addressed since it is retrospective as opposed to establishing a preparatory process of quality assurance. Influential work by Saarikoski and Leino-Kilpi (2002), Saarikoski et al. (2008) found solutions through the comprehensive evaluation of placement experience and clinical supervision by learners already using the placements. The comprehensive nature of this work in developing metrics by which to determine the effectiveness of a placement for student learning is found by the researchers to

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have high reliability. In many countries, application of the CLES instrument is an indicator of the quality of the learning environment. Nonetheless, this research only tells part of the story as all evaluations are retrospective and require students to have been using the placements for learning a priori and then to evaluate over a period of time. Mansutti et al. (2017) in a recent systematic review point to a limited number of assessment instruments published and a range of papers around these focusing on validation or findings of the quality evaluation instruments. The eight identified instruments evaluating the quality of the CLE were devised from a variety of learning theories and were followed by second generation instruments which were a mix and revision of the first generation instruments. In the main all addressed to a greater or lesser extent the qualities and attributes of the clinical learning environment within literature. This provides a useful platform to determine structure of assessing benchmarks and instruments (Table 3.2). Further analysis of these instruments reveals common features in terms of measurement attributes. Interestingly, they also include measurements such as Likert scales, student perceived satisfaction, learning approaches and type of supervision. In general, they are all retrospective and do not include action or development plans. There are other limitations identified. Most were focused on hospital settings or unspecified settings or validated for particular setting, e.g., care homes so not adaptable. Furthermore, there were very few instruments exercised in mental health settings or paediatric areas. Few instruments included nurses, preceptors or educators and these are key stakeholders in the quality environment (Chuan and Barnett 2012). Instruments or inventories generate and capture standardised and comparable data but have limitations. It was thus a key consideration that an instrument addresses a variety of locations where clinical learning occurs but also that it was sensitive enough to provide a snapshot of the quality elements and supported ongoing development in a supportive manner.

3.4

Development of the Audit Instrument

The benchmarks formed the starting point for work on an instrument for appraising the quality of criteria with the aim of assuring the quality of the CLE. It is acknowledged that training can improve accuracy and consistency of data gathering with any instrument. The audit instrument was developed by aligning with the determined benchmarks (output 1) as criteria to be met. The audit questions were aimed at revealing the evidence and support for each benchmark statement and as such have a comprehensive view of the environment. Since this developed in response to exchange students there was a need to address the contractual and wider institutional aspects (policies, health and safety and partnership agreements) within the process of auditing. This resulted in a division of the instrument to address key contractual arrangements which a CLE may not be aware of. The perspective adopted was of self-review and then confirmation with an external “auditor”. The use of Likert scales or met/not met response set would result in an

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Table 3.2  Audit instruments for CLE (summarised and adapted from Mansutti et al. 2017) Author Dunn and Burntt (1995) Chan (2001, 2002)

Saarikoski et al. (2002, 2005) Tomietto et al. (2009) Papastavrou et al. (2015), De Witt (2011), Burrait al (2012) Saarikoski et al. (2008)

Johansson et al. (2010) Warne et al. (2010) Henriksen et al. (2012) Bergjan and Hertel (2013) Watson et al. (2014) Vizcaya-Moreno et al. (2015) Hosoda (2006)

Sand-Jeckin (2009)

Chuan and Barnett (2012) D’Souza et al. (2015)

Instrument Clinical learning environment scale (CLE scale) Clinical learning environment inventory (CLEI) CLEI-19 Clinical learning environment and supervision scale (CLES) Clinical learning environment and supervision scale (CLES)

Country Australia

Instrument characteristics 23 items (five factors) 5 point Likert scale

Australia

First and second iterations. 35 items (five factors): later abbreviated to 19 item scale (satisfaction, personalisation) First iteration 27 items(five factors) 5 point Likert scale Second iteration of the above—validation or exploration in own countries

Clinical learning environment and supervision and nurse teacher scale (CLES-T) Clinical learning environment and supervision and nurse teacher scale (CLES-T)

Finland

First iteration

Sweden Nine counties (EU) Norway German New Zealand Spain

Second iteration of the above

Clinical learning environment and diagnostic inventory (CLEDI) Student evaluation of clinical education environment (SECEE) learning environment and supervision and nurse teacher scale (CLES-T) Clinical learning environment and instrument (CLE instrument) Modified clinical learning environment and supervision and nurse teacher scale (CLES-T)

Japan

35 items—five factors: Likert scale (5 point)

USA

32 items (three factors): 5 point Likert scale

Malaysia

44 items (five factors): 4 point Likert scale

Oman

57 items (11 factors): 5 point Likert scale

Finland

Italy Cyprus Belgium Italy

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instrument which was a “judgement” and would obviate the developmental nature of this instrument. The approach then required statements (aligned to the benchmarks) and supporting evidence to demonstrate how these are achieved. The format was a key consideration aligning to best practice (HQIP 2017) and considered: layout, so it is simple to follow and flows well, font size to enable reading, terminology that is clear and readily understood and length to not deter people from completing it. The inclusion of an action plan then drew together positive points of the CLE under exploration and provides a supportive developmental outcome of the audit process. Therefore, the role of a nurse or clinician acting as an “auditor” to that of a “change agent” to allow them to take responsibility for changing their practice (HQIP 2018). The reliability of the instrument was determined through project partners testing it within their own clinical environments and with key nurse educators and clinicians involved in placement learning. Content-validity was determined through a consensus among a panel of experts who made judgments about the instrument’s content appropriateness. To test for usability and clarity and understanding of questions as well as phrasing of the instrument, two different clinical areas (Spain and Finland) and a panel of practice teachers (UK) independently reviewed the new instrument. This was followed by a panel of academics and clinicians involved previously in using audit instruments. Post-graduate nursing students (practice teacher students) were also consulted (UK) as partners in the learning environment and offered valuable insights into their perception of the instrument including the issues of safety and support and adaptability to varied settings. In one of the findings quality of mentors was mentioned. This is a concern for students; however, the team decided this is not considered something an audit instrument can include however the quality and nature of support was and this aspect was felt addressed. The instrument was revised after reports from these testings. The revisions concerned the clarification of an accompanying guidance document, providing examples of evidence which might be used to support statements and defining the roles of those completing the instruments. The division of the instrument into organisation and then local contexts was also done at this time. Various limitations to this output stage should be highlighted. Firstly, the clinical auditors were specifically selected because of their knowledge and experience in documentation, as well as in nursing. This was thought to be a necessary prerequisite when developing a new instrument. Secondly, the transferability of terminology and translation was an issue especially where some words were not known within certain languages. This necessitates a review of the terminology and simplifying or agreeing definitions accordingly. One such term was “non-conformities” and the guidance document expanded this and the sources of evidence or approaches which may be used. In the forthcoming evaluation phase of this project comparability and alignment with the retrospective measures, for example, CLES will indicate if the instrument and process is sensitive and predictive as intended. This is planned moving forward. The next stage (output 3) is to develop training materials to support auditors undertaking this process and this is in progress (Fig. 3.1).

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Higher education/Clinical partners – complete contractual aspects

Preparationself review

Local CLE – review, collate evidence and prepare for audit event

Perform audit

External confirmation and event

Measure results Implement any changes/ feedback

CLE share outcomes with partners using this location for placement/traineeship

Action plan and identification of support/resources to enable this

Review process

Fig. 3.1  Audit process and sequence

3.5

Conclusion

The clinical learning environment remains a major and global challenge in nursing education syllabus (O’Mara et al. 2014). An organisational culture that values learning offers high quality care for patients and clients, a positive supportive learning environment, and enhances the experience for any learners accessing it. Lifelong learning is key to professional development and a supportive work as well as learning environment can contribute to this. Leaders in nursing education and clinical areas have the need to work together to create meaningful clinical learning opportunities and one such means is to evaluate and measure the CLE.  The HEALint project sets out to collate and devise a set of standards to provide an internationally consistent and uniform set of measures for application across a wide variety of health care services. Thus far, this project has explored the attributes of CLE and how to best articulate quality standards of these as well as devising means to determine or record them. Nursing is ubiquitous and having core benchmarks allows wider breadth of placements within areas such as Europe and beyond. This assures the experience for the student but also act as an evidence base and quality assurance trail for professional bodies. The next phases of this project continues with the development of training and further evaluation of the whole process.

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References Arkan B, Ordin Y, Yılmaz D (2018) Undergraduate nursing students’ experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract 29:127–132. https://doi.org/10.1016/j.nepr.2017.12.005 Babenko-Mould Y, Laschinger HK (2014) Effects of incivility in clinical practice settings on nursing student burnout. Int J Nurs Educ Scholarsh 11(1):145–154. https://doi.org/10.1515/ ijnes-2014-0023 Bergjan M, Hertel F (2013) Evaluating students’ perception of their clinical placements—testing the Clinical Learning Environment and Supervision and Nurse Teacher Scale (CLES + T scale) in Germany. Nurse Educ Today 33(11):1393–1398. https://doi.org/10.1016/j.nedt.2012.11.002 Brynildsen G, Bjørk IT, Berntsen K, Hestetun M (2014) Improving the quality of nursing students’ clinical placements in nursing homes: an evaluation study. Nurse Educ Pract 14:722–728 Button L, Green B, Tengnah C, Johansson I, Baker C (2005) The impact of international placements on nurses’ personal and professional lives: literature review. J Adv Nurs 50(3):315–324 Chan D (2001) Development of an innovative tool to assess hospital learning environments. Nurse Educ Today 21(8):624–631 Chan D (2002) Development of the Clinical Learning Environment Inventory: using the theoretical framework of learning environment studies to assess nursing students’ perceptions of the hospital as a learning environment. J Nurse Educ 41(2):69–75 Chuan OL, Barnett T (2012) Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Educ Pract 12(4):192–197. https://doi.org/10.1016/j.nepr.2012.01.003 Council of Deans of Health (CoDH) (2016) Educating the future nurse – a paper for discussion. Council of Deans of Health, London Davies R (2008) The Bologna process: the quiet revolution in higher education. Nurse Educ Today 28:935–942. https://doi.org/10.1016/j.nedt.2008.05.008 Department of Health, Australia (DH) (2014) Best practice clinical learning environments framework (Department of Health, Victoria 2014) [online]. https://www.health.qld.gov.au/__data/ assets/pdf_file/0029/693335/cle-review.pdf Dunn SV, Burntt P (1995) The development of a clinical learning environment scale. J Adv Nurs 22(6):1166–1173 D’Souza MS, Karkada SN, Parahoo K, Venkatesaperumal R (2015) Perception of and satisfaction with the clinical learning environment among nursing students. Nurse Educ Today 35(6):833– 840. https://doi.org/10.1016/j.nedt.2015.02.005 Edgecombe K, Jennings M, Bowden M (2013) International nursing students and what impacts their clinical learning: literature review. Nurse Educ Today 33:138–142 EU directive 2005/36/EC Annex v2 (5.2.1) (2005) [online]. https://eur-lex.europa.eu/LexUriServ/ LexUriServ.do?uri=OJ:L:2005:255:0022:0142:EN:PDF. Accessed 28 Sept 2019 Felstead I (2016) An exploration of role model influence on adult nursing students’ professional development: a phenomenological research study. Nurse Educ Today 37:66–70. https://doi. org/10.1016/j.nedt.2015.11.014 Flott EA, Linden L (2016) The clinical learning environment in nursing education: a concept analysis. J Adv Nurs 72(3):501–513. https://doi.org/10.1111/jan.12861 Gopee N (2015) Mentoring and supervision in healthcare, 3rd edn. Sage, London Health Education England (HEE) (2016). https://www.rcpe.ac.uk/sites/default/files/files/hee_ quality-framework.pdf Healthcare Quality Improvement Partnership (HQIP) (2017) Social care audit guidelines [online]. https://www.hqip.org.uk/resource/social-care-audit-guidance/#.XX4_WmZ7lc8. Accessed 14 Sept 2019 Healthcare Quality Improvement Partnership (HQIP) (2018) Clinical audit: a simple guide for NHS Boards & partners. https://www.goodgovernance.org.uk/wp-content/uploads/2017/04/ clinical-audit-a-simple-guide-for-nhs-boards-and-partners.pdf. Accessed 1 Nov 19

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Nursing and Midwifery Council (NMC) (2018a) Standards Framework for Nursing and Midwifery Education. Available at https://www.nmc.org.uk/standards/standards-for-nurses/. Accessed 01 Oct 2019 Nursing and Midwifery Council (NMC) (2018b) Standards framework for nursing and midwifery education  – what must be in place [online]. https://www.nmc.org.uk/supporting-information-on-standards-for-student-supervision-and-assessment/learning-environments-and-experiences/designing-reviewing-safe-effective-learning-experiences/what-must-be-in-place/. Accessed 28 Sept 2019 Nursing and Midwifery Council (NMC) (2019) Quality assurance framework for nursing, midwifery and nursing associate education [online]. https://www.nmc.org.uk/globalassets/sitedocuments/edandqa/nmc-quality-assurance-framework.pdf. Accessed 28 Sept 2019 O’Mara L, McDonald J, Gillespie M, Brown H, Miles L (2014) Challenging clinical learning environments: experiences of undergraduate nursing students. Nurse Educ Pract 14(2):208–213. https://doi.org/10.1016/j.nepr.2013.08.012 Palese A, Zabalegui A, Sigurdardottir AK, Bergin M, Dobrowolska B, Gasser C, Pajnkihar M, Jackson C (2014) Bologna process, more or less: nursing education in the European economic area: a discussion paper. Int J Nurs Educ Scholarsh 2(11):63–73. https://doi.org/10.1515/ ijnes-2013-0022 Papastavrou E, Dimitriadou M, Tsangari H (2015) Psychometric testing of the Greek Version of the Clinical Learning Environment-Teacher (CLES + T). Global J Health Sci 8(5):49573. https://doi.org/10.5539/gjhs.v8n5p59 Papastavrou E, Dimitriadou M, Tsangari H, Andre C (2016) Nursing students’ satisfaction of the clinical learning environment: a research study. BMC Nurs 15:44. https://doi.org/10.1186/ s12912-016-0164-4 Papathanasiou IV, Tsaras K, Sarafis P (2014) Views and perceptions of nursing students on their clinical learning environment: teaching and learning. Nurse Educ Today 34(1):57–60. https:// doi.org/10.1016/j.nedt.2013.02.007 Ruddock H, Turner S (2007) Developing cultural sensitivity: nursing students’ experiences of a study abroad programme. J Adv Nurs 59(4):361–369 Saarikoski M, Leino-Kilpi H (2002) The clinical learning environment and supervision by staff nurses: developing the instrument. Int J Nurs Stud 39:259–267 Saarikoski M, Isoaho H, Leino-Kilpi H, Warne T (2005) Validation of the clinical learning environment and supervision scale. Int J Nurs Educ Scholarsh 2(1). https://doi.org/10.2202/1548-923X.1081. https://www.degruyter.com/view/j/ijnes.2005.2.1/ijnes.2005.2.1.1081/ijnes.2005.2.1.1081.xml Saarikoski M, Isoaho H, Warne T, Leino-Kilpi H (2008) The nurse teacher in clinical practice: developing the new sub-dimension to clinical learning environment and supervision (CLES) scale. Int J Nurs Stud 45:1233–1237 Saarikoski M, Kaila P, Lambrinou E, Pérez Cañaveras RM, Tichelaar E, Tomietto M, Warne T (2013) Students’ experiences of cooperation with nurse teacher during their clinical placements: an empirical study in a Western European context. Nurse Educ Pract 13(2):78–82. https://doi.org/10.1016/j.nepr.2012.07.013 Salvage J, Stilwell B (2018) Breaking the silence: a new story of nursing. J Clin Nurs 27 (7–8):1301–1303. http://onlinelibrary.wiley.com/wol1/doi/10.1111/jocn.14306. Accessed 2 Apr 2019 Sand-Jecklin K (2009) Assessing nursing student perceptions of the clinical learning environment: refinement and testing of the SECEE inventory. J Nurs Meas 17(3):232–246. https://doi. org/10.1891/1061-3749.17.3.232 Stuart C (2013) Mentoring, learning and assessment in clinical practice. A guide for nurses, midwives and other health professionals, 3rd edn. Churchill Livingstone, Edinburgh Sundler AJ, Björk M, Bisholt B, Ohlsson U, Engström AK, Gustafsson M (2014) Student nurses’ experiences of the clinical learning environment in relation to the organization of supervision: a questionnaire survey. Nurse Educ Today 34(4):661–666. https://doi.org/10.1016/j. nedt.2013.06.023

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Tomietto M, Saiani L, Saarikoski M, Fabris S, Cunico L, Campagna V, Palese A (2009) Assessing quality in clinical educational setting: Italian validation of the Clinical Learning Environment and Supervision (CLES) scale. G Ital Med Lav Ergon 31(3 Suppl B):B49–B55 Traynor M, Mehigan S (2014) Clinical learning environments: a scoping literature review [Online]. https://www.mdx.ac.uk/__data/assets/pdf_file/0026/198017/5.-education-in-clinical-practicereview.pdf. Accessed 08 Aug 2019 Vizcaya-Moreno MF, Pérez-Cañaveras RM, De Juan J, Saarikoski M (2015) Development and psychometric testing of the Clinical Learning Environment, Supervision and Nurse Teacher Evaluation Scale (CLES + T): the Spanish version. Int J Nurs Stud 52(1):361–367. https://doi. org/10.1016/j.ijnurstu.2014.08.008 Warne T, Johansson UB, Papastavrou E, Tichelaar E, Tomietto M, Van den Bossche K, Moreno MF, Saarikoski M (2010) An exploration of the clinical learning experience of nursing students in nine European countries. Nurse Educ Today 30(8):809–815. https://doi.org/10.1016/j. nedt.2010.03.003 ZabaleguiA, Maciá-Soler L, Márquez J, Moncho J (2006) Changes in nursing education in the European Union. J Nurs Scholarsh 38(2):114–118. https://doi.org/10.1111/j.1547-5069.2006.00087.x

4

Supervising, Supporting Learning and Coaching Kathy Wilson, Nora Cooper, and Pam Hodge

4.1

Introduction: Changes to Professional Education

The last decade has seen unprecedented NHS and Social Care changes in the UK which in turn has driven professional, educational and regulatory changes across healthcare professions. Concerns regarding the level of competence of nurses at the point of registration are widely shared, highlighting the need for improvements and innovations to ensure safe care delivery, with a specific emphasis on the pedagogy of learning in practice (Lobo et al. 2014; Morley 2015; Willis 2015; RCN 2017; CoDH 2016; NMC 2018). In 2016, Middlesex University received funding from Health Education England to build on previous work undertaken regarding learning in practice to support new insights and models of learning and the project developed into a large collective venture involving a range of stakeholders. Some of the enablers and barriers to education in practice will be briefly outlined alongside a discussion of the various activities and research-based initiatives undertaken as part of the STEP project.

4.2

The Practice Learning Context

Within the clinical learning environment, students apply their knowledge and skills while engaging in direct patient care in preparation for professional practice. The importance of the local environment in how and what students learn is widely documented (Papp et al. 2003; McCarthy and Murphy 2008; Burke et al. 2016) and

K. Wilson (*) · N. Cooper · P. Hodge Practice Based Learning Unit, School of Health and Education, Middlesex University, London, UK e-mail: [email protected]; [email protected]; [email protected] © Springer Nature Switzerland AG 2020 S. Cunningham (ed.), Dimensions on Nursing Teaching and Learning, https://doi.org/10.1007/978-3-030-39767-8_4

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can comprise a range of learning opportunities across health and social care in the NHS and in the private, voluntary and independent sector. In 2014, NHS England (2014) published its Five Year Forward review which sets out a clear direction for the NHS and encouraged the breaking down of barriers of where care is delivered. The importance of developing integrated out of hospital care and the need to plan care to meet the needs of a changing population were viewed as fundamental in this review. On 7 January 2019, the NHS long-term plan (formerly known as the 10-year plan) was published setting out key ambitions for the service over the next 10 years building on the Five Year Forward review. These significant changes in the way health services are managed and delivered inevitably impact on workforce requirements, the context of the learning environment and how and where placement opportunities can be accessed (NHS 2019). Ensuring a consistently positive learning experience in the clinical learning environment (CLE) has been found to be challenging, as learning may be hindered by the complexity of practice caused by a multitude of sociocultural and political factors (Cassidy 2009; Gopee 2014; Newton et al. 2015; Shivers et al. 2017). Learning in practice should lead to personal and professional growth and should therefore be viewed as a process and not a product (Newton et al. 2015) with a student-centred facilitative approach to learning in the CLE is consistently emphasised by the Nursing and Midwifery Council (NMC 2008, 2018). The importance of the pedagogical atmosphere, i.e., the psychosocial climate, is clearly highlighted in many studies (Chan 2003; Newton et al. 2015; Warne et al. 2010; Bisholt et al. 2013). A good learning situation is one that is variable and that corresponds to the particular students level (Johansson et al. 2010) and in which students feel appreciated and recognised as part of the team (Papp et  al. 2003). Students seek support and acknowledgement of their achievements with the importance of relationships and support rated highly by them (Shivers et al. 2017). The learning environment can have a significant impact on student satisfaction and outcomes with the high level of attrition from pre-registration programmes often being attributed to negative placement experiences and the lack of support specifically viewed as one of the key issues reported by students (Spouse 2003; Chan 2003; O’Mara et al. 2014; Flott and Linden 2015; HEE 2018). Unfamiliar and unfriendly environments create stress for students and impede their learning (De Castella 2018; Pulido-Martos et al. 2012). In a study undertaken by Nettleton and Bray (2008), students reported that a lack of time working with and learning from their mentors was one of the most significant issues impeding their learning. The complexities of contemporary nursing practice with staff shortages make effective supervision and support difficult as staff try to balance their clinical role with their educator role while ultimately the first priority always has to be the patient (Bailey-McHale and Mary Hart 2013; Lauder et al. 2008). In their analysis of the healthcare workforce in England, the Health Foundation, Kings Fund and Nuffield Trust (2018) concluded that the significant staffing shortages detailed in their report were attributed to factors such as poor workforce planning and changes in funding for education. These issues have consequently been linked to the associated problems of recruitment of new nurses as well as a shortfall in those applying to nurse education. The Care Quality Commission

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report on the state of hospitals 2014–2016 (CQC 2018) also identified the recruitment of staff as the number one challenge leading to areas relying on temporary bank and agency staff all of which have been shown to impact on the learning experience and to having a detrimental effect on student learning (Bisholt et al. 2013; Chuan and Barnett 2012). In a study undertaken by Smith (2010) students referred to the different worlds of academic and practice environments with practice described as being “out there” in the real world. Students specifically reported lack of understanding of the link lecturer role (academic link or liaison). The regularly reported role conflict experienced by the link lecturer and weakening links between link lecturers and practice (O’Driscoll et al. 2010) creates further problems for learning in practice. O’Driscoll et al. (2010) discuss a number of factors that need to be in place to provide leadership for learning in practice and hence propose the need for “recoupling education and practice”. The overwhelming message from O’Driscoll et al. (2010) is the need for us to strengthen leadership for education since the mentor who also is carrying a high patient load and no additional time to supervise, support and assess bears the brunt of the education load. With the implementation of the standards of education for nursing and midwifery (NMC 2018) and those influencing student supervision and assessment, we have been presented with an opportunity to enhance the team-based approach, support the enhanced skills needed for registration and “recouple” education and practice through enhanced partnership working.

4.3

Background to STEP

In exploring what areas of practice needed to be addressed to support practice learning, the current challenges facing contemporary practice needed to be considered and three key objectives were identified. These include: • To develop, pilot and evaluate a range of approaches to support learning in practice capitalising on existing resources. • To create a range of resources that reflect best practice to support all learners in the environment. • To develop placement opportunities in general practice, nursing homes and other independent and voluntary sector areas. To address the first two objectives, the practice-based learning team at Middlesex University facilitated several workshops with a range of partners including students, staff from practice organisations and local universities to begin to explore positive examples of learning in practice as well as perceived challenges. The Strengthening Team-based Education in Practice (STEP) project emerged to meet these needs. To support this discourse, the team drew on the expertise and doctoral findings of an external consultant and five themes were identified to provide a framework for this STEP project. These include socialisation and comprehensive orientation; the role of “helpful others”; expansive learning; partnerships working; student peer learning and support (Morley et al. 2019) and will be outlined below.

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To address the third objective, a specific project was initiated to support the development of placements for student nurses in what was viewed as non-traditional placement areas and is discussed later in this chapter. This project has been crucial in promoting student awareness of the diversity of practice and services, developing their understanding of a whole team approach to care delivery and in promoting these unique placement areas as potential future employment options. Another important outcome for the STEP project is the development of a range of learning resources aimed at both the student and their practice assessors/supervisors. These resources build on current examples of good practice to support the development of all staff involved in practice education and support the findings that emerged from the five research projects that relate to each of the below themes (see www.step-approach.org).

4.4

STEP Themes

4.4.1 Orientation and Comprehensive Orientation Orientation plays a pivotal role in ensuring that students are made to feel welcome, a part of the team and feel a sense of belonging when they are introduced to their clinical placements. This is supported by the work of Levett-Jones et al. (2009) who identified that staff–student relationships are a key influence on students’ experiences of belongingness. This theme focuses on the explicit value attached to both socialisation and comprehensive orientation in the wider health and social care sector. Data was collected via focus groups with students from four higher education institution who had undertaken placements in a range of settings. Thematic analysis of the data gathered identified eight key themes: a welcoming approach, planning, senior students, student-­friendly reading material, time, role modelling, teaching and a sense of belonging (Quinlivan et al. 2019). The project team highlights the importance of identifying a named coordinator of learners for each placement and the value placed by students on receiving a welcome letter which includes the name of supervisor allocated, an initial rota for discussion, shift patterns and who to ask for on day one. Giving students the opportunity to meet all team members and an explanation of their roles and responsibilities fosters a positive learning environment in which students feel happy to learn and ask questions to deepen the learning. A case study presented by the authors within their published work reflects good practice to support a students’ orientation to a new placement area and captures all of the recommendations made (Quinlivan et al. 2019).

4.4.2 Helpful Others “Helpful Others” are those who help in the education of other staff but who do not have a formal mentoring role (Eraut 2007). In this context, the focus is looking at all staff that can support learners except the registered nurse. This theme explored the

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relationships between the student nurses and Healthcare Assistants (HCAs), and in particular, the understanding of the HCA role in learning and teaching, student experiences of working with HCAs, and the process and value of feedback and learning together (Hodge et al. 2019). Five themes from the focus groups emerged: role relationships, accessibility, the experience of working with HCAs, feedback and learning together. Hodge et al. (2019) acknowledge the importance of a team-based, collaborative learning environment in which all members are involved and can support the students. Acknowledgment is given to the supervision that is needed to support HCAs in this role. The emergence of the role of the Nursing Associate also needs consideration as they will once qualified will be on the Nursing and Midwifery Council register and be prepared to act as Practice supervisors for pre-registration nursing students in practice (NMC 2018). Nursing Associates are new members of the nursing team in England and this role is designed to help bridge the gap between health and care assistants and registered nurses. With job vacancies at an all-time high at 100,000 (Kings Fund Nuffield Trust 2018) involving “Helpful Others” in the support from nursing students can help to offer a whole team approach, thus reducing the responsibility from only registered members of the team. This approach also ensures HCAs are recognised for their contribution which has been linked to job satisfaction. There is a risk that these valuable learning experiences with HCAs could become lost with the implementation of the standards for student supervision and assessment and the varying interpretations of the roles to support learning. It is therefore imperative that local discussion should be encouraged to ensure these potentially excellent learning opportunities continue to be used effectively.

4.4.3 Student Peer Support and Learning Academic literature extolls the value of peer learning and support in higher education. This theme focuses on the development of an in-depth understanding of student and mentor behaviours and perceptions related to peer support and learning (Wilson et al. 2019). The methodology used was qualitative and consisted of focus groups with year 3 students in their final placements, midwifery students in acute adult ward areas and the nursing students who supported them. One of the important outcomes of this research was the knowledge students gained from each other and the value they placed on this learning. The findings from this study highlight the crucial need for structured preparation and support across the student journey to ensure the approach to peer learning is effective and valued (Wilson et al. 2019). The need for organisations to specifically allocate sufficient time and resources to ensure this initiative can be embedded with the curriculum and students can benefit is clearly emphasised. Staff in the educational institutions also need to be prepared and supported to facilitate these roles for students. The role of peer learning and peer coaching has been given increasing attention with the roll out of the collaborative learning in practice model (CLIP), initially by staff at East Anglia University (Lobo et  al. 2014) with a number of adaptations emerging across the country. While there has been no formal evaluation of this

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model it must not viewed as the panacea for increasing student capacity in placement areas needed to support the increased student recruitment targets (NHS 2019) so that we do not lose sight of the learning needs of the individual student.

4.4.4 Partnership Working There is increasing emphasis on the importance of partnership working in the UK, with the Nursing and Midwifery Council requiring greater transparency of how all partners work together to prepare learners for registration under the education standards being implemented from 2019 (NMC 2018). The new roles introduced in line with the new standards for student supervision and assessment add complexity to the nature of partnership working. The role of the Practice Education Facilitator (PEF) is highlighted. This PEF role and how this role can been seen as integral in the support of learners in the clinical area working closely with Higher Education Institutions (HEIs) has been explored by Scott et al. (2017). PEFs are mainly employed by clincial trusts organisations but will also spend time in HEIs attending relevant strategic meetings and this partnership working has become even more critical with the increasing diversity of learners to include the introduction of apprenticeships. This theme explores some of the factors and processes that hinder or help partnership working for pre-registration nurses in practice and encourages individuals to think of how partnership working can be organised in stages and developed (Mehigan et al. 2019). The recommendations from this research team present the PRANCE model as a way of further developing partnership working to include Preparation, Responsibilities, Accessibility, Networking, Communication and Expertise and this model is further described in a case study presented in Mehigan et al. (2019).

4.4.5 Expansive Learning Expansive learning is led by the goal to discover what teaching and learning processes can be identified to assist all staff in practice in supporting students to develop critical dialogue, reflexive expertise and leadership for learners (Holbery et  al. 2019). Student data was collected via word cloud software to illicit their views of what constitutes good support and “mentoring” while in practice and mentor data involved three focus groups with mentors to explore their views on the attributes of coaching students to promote their expansive learning. Holbery et al. (2019) built on the work from Morley (2015) in relation to students making a connection with the person who was to supervise them in practice. Analysis of the mentor responses identified three themes that form a coaching model: “Connecting”, “Establishing” and “Expanding” and these are represented in Fig. 4.1 alongside the goal to empower learners and promote professionalism. This research team are encouraging the piloting of the model in a range of learning environments to evaluate its effectiveness and promote this model in supporting learning in practice.

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on tin mo Pro

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arn

Establishing

Le

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Expanding

g rin we po Em

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Fig. 4.1  A coaching model for expansive learning

Connecting Coaching Model for Expansive Learning

A case study by Holbery et al. (2019) illustrates how a student who is doing well in practice and being motivated by her practice supervisor to “expand” her learning. Feedback is encouraged from all members of staff and the student is encouraged to include rationale for care given (connecting). The team are also encouraged to establish what prior knowledge the student has before giving feedback (establishing). This encourages students to be self-critical. The student is also encouraged to think wider (expanding) about what policies or alternatives might be available.

4.5

Expanding Placement Opportunities

As identified earlier, one element of the STEP project focused on the expansion of nursing learner opportunities in general practice, nursing homes and other independent and voluntary sector placements. Over the past 4 years, the STEP project has collaborated closely with locality workforce development teams: the Clinical Education Provider Networks (CEPN), Local Workforce Action Boards (LWAB) and the evolving Primary Care Networks (PCN). This partnership working has enabled the number of learning opportunities for nursing learners to expand. Within this section, the expansion of placements in primary care will specifically be discussed. The World Health Organization (WHO 2004) states, “Primary care (PC) is more than just the level of care or gate keeping; it is a key process in the health system. It is first-contact, accessible, continued, comprehensive and coordinated care”. This is a broader definition than others who focus on first contact only (for example, NHS England) and can include the longer term community coordinated care within care homes. While there are other primary care services, this chapter focuses on the two key practice areas in primary care: care homes with nursing care and general practice. There are similarities in these two practice areas, both are based predominantly in the independent sector, beyond the Agenda for Change frameworks, and historically

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nursing students have not been routinely placed in these practice areas. The care home nurses and general practice nurses both have health promotion roles, manage long-term conditions and work with people experiencing multi-morbidities, often in need of complex care who are living at home. All of these aspects are included in the future nurse standards (NMC 2018) and encourage the broader contextualisation of nursing experience in expansive learning outside of the hospital context. At the beginning of this project, the learners were only accessing placements from one care home and two general practice areas. These areas mainly offered short taster or “Spoke” experiences and subsequently grew to accommodate full or “Hub” placements. The use of “Spoke” placements has been key when expanding learning opportunities. These valuable exposures to practice areas, either a number of days or a week, have enabled students to have an introduction to the practice area, and facilitated the staff to have an experience of supporting a learner without the responsibility for the whole assessment. In many cases, this has led to full or “Hub” placement being developed. The Hub and Spoke areas were usually related, for example, being based with District Nurses as the “Hub” area and spending time with the Practice Nurse as a “Spoke” placement. Please see Table 4.1 for an overview of the extended placements in care homes and general practice. This expansion was supported by funded mentorship placements and having dedicated academic link staff to engage with the relevant teams and managers. These areas were not familiar with the practicalities and process of supporting pre-­ registration learners and work was required to facilitate joint reflection on the learning opportunities on a bespoke basis incorporating the socialisation and orientation highlighted in the STEP model. For the care home teams, it has highlighted their expertise as a nurse-led service crossing the divide between health and social care, and the invaluable learning available enable students to understand the nursing roles in both sectors. The health care assistants have also been actively involved in supporting the learners within their scope of practice and feedback suggests this has been especially useful in developing relationships with the care home residents. The new standards for supervision and assessment emphasise the need for whole team support for learners and this includes the “helpful others” as defined in the STEP model (Hodge et al. 2019). Strategically, there is more interest in the primary care workforce than ever before, with a number of key documents being produced to encourage nurses to work in the sector (QNI 2018). This comes at a crucial time for staffing in the adult social care arena, where it is estimated 67% of staff (Skills for Care 2018) move from practice to practice in search of improved working terms and conditions including training and education opportunities. The Ten Point Plan for General Practice Nursing (NHS England 2018) explicitly calls for more student nurse placements in general practice. By introducing learners to these practice areas as part of their pre-registration training, it is hoped more will consider primary care as a first destination career option at the point of qualification. To aid this goal, there has been active encouragement to capitalise upon the learning available and develop final pre-qualification placements for learners.

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Table 4.1  Overview of the extended placements in care homes and general practice Type of learner

Number of learners in care homes

2015/2016 Adult branch student nurse

Number of placement weeks in care homes

Number of learners in general practice

(1 home)

Number of placement weeks in general practice (3 practices)

8

41

4

34

Mental health student nurse

1

4

0

0

Totals

9 learners

45 weeks

4 learners

34 weeks

(4 homes)

2016/2017

(7 practices)

Adult branch student nurse

16

70

9

60

Mental health student nurse

5

33

2

9

Other students (child/ transition)

2

10

0

0

Trainee nursing associate (hub)

1

Hub area

2

Hub area

Trainee nursing associate (spoke)

7

14

5

10

Totals

31 learners

127 weeks

18 learners

79 weeks

(5 homes)

2017/2018

(14 practices)

Adult branch student nurse

42

142

8

125

Mental health student nurse

20

119

0

0

Other (Erasmus/transition)

2

10

0

0

Trainee nursing associate (hub)

1

Hub area

2

Hub area

Trainee nursing associate (spoke)

10

20

7

14

Totals

75 learners

291 weeks

17 learners

139 weeks

2018/2019

(6 homes)

(10 practices)

Adult branch student nurse

53

245

11

58

Mental health student nurse

16

73

0

0

Other (child/transition/Erasmus)

3

9

0

0

Trainee nursing associate (hub)

5

Hub area

5

Hub area

Trainee nursing associate (spoke)

26

52

24

48

Totals

103 learners

389 weeks

40 learners

106 weeks

The expansive learning experiences for the students have been well evaluated by learners and the staff. Figure 4.2 provides some of the evaluations received from both a range of learners and those supporting them in care homes and general practice.

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Author

Practice Area

“This placement has been highly valuable to learn about health promotion”.

2nd year Mental Health student

General Practice

“An excellent place for training”.

1st year Adult student

Care home

General Practice Nurse

General Practice

“I really wanted to do this. Students should definitely get this type of experience as there is so much to learn.”

st “I really enjoyed the place, the staff 1 year Trainee Nursing Associate Care home are very friendly, my supervisor is an excellent lady, very helpful, willing to share her knowledge and the manager was so supportive”.

“The students are both wonderful, Care home manager proactive and interested in learning and a pleasure to work with. We will be looking forward for the next student’s placement”.

Care home

Fig. 4.2  Student and supervisor evaluations—care homes and general practice placements

Not all students could conceptualise the learning opportunities in the primary care environments ahead of the placements starting. For some, this was due to a lack of understanding of the role of the nurse outside of the acute NHS providers. Students are not alone in having a limited understanding of these roles, and this is highlighted by the need for documents such as “Transition to a Care Home Nurse” (QNI 2018), which is aimed at existing qualified nurses. The predominantly negative portrayal of care homes in the media has also been a challenge with some students being concerned at the lack of perceived learning available when the allocation is announced. This perception has been challenged in the care homes with many students reporting a fundamental shift in their thinking by the end of the experience, with the majority of student evaluations reporting they would recommend the placement to other learners. To help prepare students for these placements, we have produced learners’ guides to the practice areas and these are shared with students ahead of their first day to help prepare and begin to contextualise the roles and responsibilities and to be aware of the possible learning opportunities. These were co-produced with a selection of the nurses and students on placement in each area to add validity and value to the documents and these are available on the STEP website (www.step-approach. co.uk). The academic links for the areas further support both students and assessors during the learning experience. This level of orientation and socialisation in less well-established placement settings has been essential to ensure the learning potential is recognised and actualised, being well received by learners.

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In the care homes, where more than one learner may be placed at a time, learners from mental health and adult fields have undertaken placements and learnt together. This peer learning is a strength of the primary care areas and the opportunities to work with a diverse range of nurses and other professionals in the community setting. These reciprocal working relationships have led to broader experiences for the learners with students attending with a range of experiences and knowledge to share in the practice areas and importantly gaining a greater understanding of primary care working. There have been challenges in connecting with the independent sector. In general practice, for example, in some areas the Practice Manager is the best person to contact, in others the Practice Nurse. In both scenarios, the Practice Nurse needs to be motivated to support the students, especially in practices where there is only one nurse. The introduction of the Standards to Support Student Supervision and Assessment (NMC 2018) and the change in model to include practice supervisors is on the one hand useful to encompass the diversity of professionals in general practice; however, it can also be a challenge to accommodate if there is a lone or part-­ time nurse. In the general practice arena, while it is an established programme to support the medical students, supporting nursing learners was a new concept to many. This was complicated by the disparity in payments for hosting medical and nursing students (Hawkes 2019). With a high percentage of general practice nurses working as the only nurse or part-time, allocating learners has not been possible on a regular schedule and all the placements in this sector have needed bespoke planning to ensure these placements are possible. The expansion of the student opportunities in these alternative placements has led to a broader collaboration and engagement with learning opportunities than was originally anticipated. Engagement with primary care has also benefitted the practice partners, with access to many training and educational opportunities being facilitated and utilising the university overview of wider projects available. For example, the Teaching Care Homes initiative (Hunt 2017), Partnership into Leadership programme (Johnson et  al. 2019), and numerous events at which to showcase and highlight the advantages of working in this previously neglected sector. This is in addition to university courses and modules such as the non-medical prescribing course. These opportunities have not been limited to registered nurses, and with the introduction of the trainee nursing associates, there are ever widening roles available and differing routes into the nursing family. In the locality, some of the first qualified Nursing Associates are now supporting the next cohorts in training. The advantages of already having built good working relationships over time with the care homes and general practice have meant information regarding the progression and training opportunities available for staff at all levels can be directly shared and discussed.

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Conclusion

This chapter has provided information of the STEP project and has presented the five individual research studies attached to the identified themes as well as the extensive work undertaken to expand students learning opportunities in areas that have not traditionally supported many student placements. There is a plethora of literature documenting the complexities influencing the clinical learning environment with the research in this area consistently highlighting the importance of the pedagogical atmosphere and student support as being key factors, both of which feature strongly in the findings from the STEP themes. The NMC standards framework for nursing and midwifery education which emphasises the importance of empowering students and supporting them to become more critically in their thinking, reflection and decision making, and demonstrate more advanced clinical and leadership skills (NMC 2018) creates an exciting yet challenging prospect amidst the uncertainty and complexities of contemporary practice. Against this “changing practice landscape” STEP offers “an alternative approach to support an inclusive, social model of learning” with a “strong socio-constructivist philosophy of promoting practice education collaboratively” through the use of existing resources (Morley et al. 2019, p. 2).

References Bailey-McHale J, Mary Hart D (2013) Mastering mentorship: a practical guide for mentors of nursing, health and social care students. SAGE, London Bisholt B, Ohlsson U, Engström AK, Johansson AS, Gustafsson M (2013) Nursing students’ assessment of the learning environment in different clinical settings. Nurse Educ Pract 14(3):304–310 Burke E, Kelly M, Byrne E, Chiardha TU, Mc Nicholas M (2016) Preceptors’ experiences of using a competence assessment tool to assess undergraduate nursing students. Nurse Educ Pract 17:8–14 Care Quality Commission (CQC) (2018) The state of health care and adult social care in England 2017/18. https://www.cqc.org.uk/publications/major-report/state-care. Accessed 3 July 2019 Cassidy S (2009) Subjectivity and the valid assessment of pre-registration student nurse clinical learning outcomes: implications for mentors. Nurse Educ Today 29:33–39 Chan DS (2003) Validation of the clinical learning environment inventory. West J Nurs Res 25(5):519–532 Chuan OL, Barnett T (2012) Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Educ Pract 12(4):192–197. https://doi.org/10.1016/j.nepr.2012.01.003 Council of Deans of Health (CoDH) (2016) Educating the future nurse – a paper for discussion. Council of Deans of Health, London De Castella T (2018) Number of nursing students in England down by 500 this year. Nursing Times. https://www.nursingtimes.net/news/education/number-of-nursing-students-in-englanddown-by-500-this-year-20-09-2018/. Accessed 20 Mar 2019 Eraut M (2007) Learning from other people in the workplace. Oxf Rev Educ 33(4):403–422 Flott EA, Linden L (2015) The clinical learning environment in nursing education: a concept analysis. J Adv Nurs 72(3):501–513. https://doi.org/10.1111/jan.12861 Gopee N (2014) Mentoring and supervision in healthcare. Sage, London

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Hawkes B (2019) Pre-registration nurse placements in general practice: the picture so far. Prim Health Care 29(3):e1471. https://doi.org/10.7748/phc.2019.e1471 Health Education England (HEE) (2018) RePAIR: Reducing pre-registration attrition and improving retention report. https://www.hee.nhs.uk/our-work/reducing-pre-registration-attritionimproving-retention. Accessed 2 Nov 2018 Hodge P, Dexter A, O’Toole H (2019) “Helpful others”: recognising support networks for students in the clinical setting. In: Morley DA, Wilson K, Holbery N (eds) Facilitating learning in practice. A research-based approach to challenges and solution. Routledge, Taylor & Francis Group, London Holbery N, Morley DA, Mitchell J (2019) Expansive learning. In: Morley DA, Wilson K, Holbery N (eds) Facilitating learning in practice. A research-based approach to challenges and solution. Routledge, Taylor & Francis Group, London Hunt L (2017) Changing people’s perceptions and creating a vibrant learning environment. Nurs Older People 29(5):20–22. https://doi.org/10.7748/nop.29.5.20.s23 Johansson UB, Kaila P, Ahlner-Elmqvist M, Leksell J, Isoaho H, Saarikoski M (2010) Clinical learning environment, supervision and nurse teacher evaluation scale: psychometric evaluation of the Swedish version. J Adv Nurs 66(9):2085–2093. https://doi. org/10.1111/j.1365-2648.2010.05370.x. Johnson C, Sealy A, Masterson A, Holmes P (2019) Passport into leadership. A unique Capital Nurse/North Central London STP leadership development programme for senior nurses working in the care sector. https://healtheducationengland.sharepoint.com/sites/ CN/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FCN%2FShared%20 Documents%2FPIL2%20Evaluation%20Final%2Epdf&parent=%2Fsites%2FCN%2FSha red%20Documents&p=true. Accessed 2 July 2019 Lauder W, Watson R, Topping K, Holland K, Johnson M, Porter M, Roxburgh M, Behr A (2008) An evaluation of fitness for practice curricula: self-efficacy, support and self-reported competence in preregistration student nurses and midwives. J Clin Nurs 17(14):1858–1867. https:// doi.org/10.1111/j.1365-2702.2007.02223.x Levett-Jones T, Lathlean J, Higgins I, McMillan M (2009) Staff-student relationships and their impact on nursing students’ belongingness and learning. J Adv Nurs 65(2):316–324. https:// doi.org/10.1111/j.1365-2648.2008.04865.x Lobo C, Arthur A, Lattimer V (2014) Collaborative Learning in Practice (CLiP) for pre-­ registration nursing students. A background paper for delegates attending the CLiP conference, Collaborative Learning in Practice (CLiP). University of East Anglia, NHS Health Education East of England, Norwich McCarthy B, Murphy S (2008) Assessing undergraduate nursing students in clinical practice: do preceptors use assessment strategies? Nurse Educ Today 28(3):301–313 Mehigan S, Pisaneschi L, McDermott J (2019) Academic practice partnerships. In: Morley DA, Wilson K, Holbery N (eds) Facilitating learning in practice. A research-based approach to challenges and solution. Routledge, Taylor & Francis Group, London Morley DA (2015) A grounded theory study exploring first year nurses’ leaning in practice. PhD Thesis, Bournemouth University, Bournemouth Morley D, Wilson K, Holberry N (eds) (2019) Facilitating learning in practice: a research-based approach to challenges and solutions. Routledge, London National Health Service (NHS) England (2014) Five year forward view. https://www.england.nhs. uk/five-year-forward-view/. Accessed 20 July 2019 National Health Service (NHS) England (2018) General practice – developing confidence, capability and capacity. https://www.england.nhs.uk/publication/general-practice-developing-confidence-capability-and-capacity/. Accessed 20 July 2019 National Health Service Digital (NHS) (2019) Health and Care of people with learning disabilities, experimental statistics (PAS). https://digital.nhs.uk/data-and-information/publications/statistical/health-and-care-of-people-with-learning-disabilities/experimental-statistics-2017-to-2018. Accessed 20 July 2019

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Nettleton P, Bray L (2008) Current mentorship schemes might be doing our students a disservice. Nurse Educ Pract 8:205–212. https://doi.org/10.1016/j.nepr.2007.08.003 Newton JM, Henderson A, Jolly B, Greaves J (2015) A contemporary examination of workplace learning culture: an ethnomethodology study. Nurse Educ Today 35(1):91–96. https://doi. org/10.1016/j.nedt.2014.07.001 Nursing and Midwifery Council (NMC) (2008) Standards to support learning and assessment in practice. https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-tosupport-learning-assessment.pdf. Accessed 20 Aug 2019 Nursing and Midwifery Council (NMC) (2018) Standards framework for nursing and midwifery education. https://www.nmc.org.uk/standards/standards-for-nurses/. Accessed 20 Aug 2019 O’Driscoll MF, Allan HT, Smith PA (2010) Still looking for leadership – who is responsible for student nurses’ learning in practice? Nurse Educ Today 30(3):212–217. https://doi.org/10.1016/j. nedt.2009.12.012 O’Mara L, McDonald J, Gillespie M, Brown H, Miles L (2014) Challenging clinical learning environments: experiences of undergraduate nursing students. Nurse Educ Pract 14:208–213. https://doi.org/10.1016/j.nepr.2013.08.012 Papp I, Markkanen M, von Bonsdorff M (2003) Clinical environment as a learning environment: student nurses’ perceptions concerning clinical learning experiences. Nurse Educ Today 23(4):262–268 Pulido-Martos M, Augusto-Landa JM, Lopez-Zafra E (2012) Sources of stress in nursing students: a systematic review of quantitative studies. Int Nurs Rev 59(1):15–25. https://doi. org/10.1111/j.1466-7657.2011.00939.x Queen’s Nursing Institute (QNI) (2018) Transition to care home nursing resource. Queens Nurse Institute, London Quinlivan L, Sookraj-Bahal S, Moody J, Levington A, Taylor C (2019) Comprehensive orientation and socialisation. In: Morley DA, Wilson K, Holbery N (eds) Facilitating learning in practice. A research-based approach to challenges and solution. Routledge, Taylor & Francis Group, London Royal College of Nursing (RCN) (2017) Helping students get the best from their practice placements: a Royal College of Nursing toolkit. RCN, London Scott B, Rapson T, Allibone L, Hamilton R, Mambanje C, Piseneschi L (2017) Practice education facilitator roles and their value to NHS organisations. Br J Nurs 26(4):222–227. https://doi. org/10.12968/bjon.2017.26.4.222 Shivers E, Hasson F, Slater P (2017) Pre-registration nursing student’s quality of practice learning: clinical learning environment inventory (actual) questionnaire. Nurse Educ Today 55:58–64. https://doi.org/10.1016/j.nedt.2017.05.004 Skills for Care (2018) Work force intelligence: workforce estimates. Work force spreadsheet, sheet 4.0. https://www.skillsforcare.org.uk/NMDS-SC-intelligence/Workforce-intelligence/publications/Workforce-estimates.aspx. Accessed 28 Aug 2019 Smith P (2010) The Emotional Labour of Nursing: Do nurses still care? Palgrave Macmillan, Basingstoke Spouse J (2003) Professional learning in nursing. Blackwell, Oxford The Health Foundation The Kings Fund Nuffield Trust (2018) The health care workforce in England make or break. Kings Fund, London Warne T, Johansson UB, Papastavrou E, Tichelaar E, Tomietto M, Van den Bossche K, Moreno MFV, Saarikoski M (2010) An exploration of the clinical learning experience of nursing students in nine European countries. Nurse Educ Today 30(8):809–815. https://doi.org/10.1016/j. nedt.2010.03.003 Willis G (2015) Raising the bar. Shape of caring: A review of the future education and training of registered nurses and care assistants in England, London. https://www.hee.nhs.uk/sites/default/ files/documents/2348-Shape-of-caring-review-FINAL.pdf. Accessed 3 Oct 2019

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5

Inclusive Learning, Diversity and Nurse Education Sheila Cunningham and Nicky Lambert

5.1

Introduction: Diversity and Widening Participation

Widening participation (WP) into higher education has played a central part in educational policy and rhetoric for more than a decade, as a means to promote equality, diversity, inclusivity and social mobility. It is often used interchangeably with inclusion and equity and is thought to increase the proportion of people from reportedly underrepresented groups attending higher education. In England, the commitment to WP is demonstrated in the national strategy “Access and student success in higher education” (Department for Business Innovation and Skills 2014, p. 3), which asserts: “…anyone with the potential to succeed in Higher Education should have the equal opportunity to do so”. This is not solely linked to entry to higher education but also prospects and career trajectory and opportunities afterwards as well (Heaslip et al. 2017). Terminology varies but diversity and inclusivity and opportunity appear a global issue (Atherton 2017) with “The current approach in England is to promote greater student belonging via more inclusive teaching and learning” (ibid, p. 1). Despite the strong record for recruiting and training a diverse population of nursing students however it remains the case nationally that specific groups (such as males and students born outside of the United Kingdom) are disproportionally affected (Mulholland et al. 2008; House of Commons Health Committee 2018). Within nursing programmes, there are diverse profiles across the different fields. For example, child nursing students tend to be younger while mental health nurses are more likely to be over the age of 25 years (HEE 2017). Adult and mental health S. Cunningham (*) Department of Adult, Child and Midwifery, School of Health and Education, Middlesex University, London, UK e-mail: [email protected] N. Lambert Department of Mental Health and Social Work, School of Health and Education, Middlesex University, London, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 S. Cunningham (ed.), Dimensions on Nursing Teaching and Learning, https://doi.org/10.1007/978-3-030-39767-8_5

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nursing students are more frequently from lower socio-economic groups and low participation neighbourhoods compared with child nursing and midwifery students. These factors illustrate another difficulty with the concept of “diversity”, since few groups are uniformly diverse. Discounting gender disparities, nursing has a strong record for recruiting and training a broad range of students (Bungeroth and Fennell 2018), but completion rates emerge as lower than for other subjects (Woodfield 2014; Heaslip et al. 2017). Academic outcomes across student groups are unacceptably varied with significant attainment gaps for those with multiple disadvantage (UUK and NUS 2019). Kaehne et al. (2014) in their literature review of WP in health care programmes argued that the evidence base on WP is limited, with overall only small single sited studies cited. Research around WP identifies that while nursing broadened entry to diverse groups, it did not ensure parity of outcomes, with lower rates of academic success (Brimble 2015), poorer employment outcomes for ethnic groups (Hammond et al. 2017) and isolating clinical experiences (Sedgewick et al. 2014) among these groups. These studies highlight that the nursing programmes lack focus and an evidence base to embed WP across the student nurse lifecycle. Furthermore, there have been no published reviews which have specifically explored WP as part of nurse education programmes (Heaslip et al. 2017) or considered the specific learning and teaching or transition implications. Arguably more clarity is needed in terms of what WP is, who WP students are, how they can best be enabled to succeed shedding the deficit view of inclusivity (and WP) as extra need (Cunningham 2011; Allan et  al. 2013). While student expectations, course organisation, placements and finance (Buchan et al. 2019) all need evaluation, a conceptual shift towards institutional awareness and implementation of inclusive pedagogical approaches is required (Hockings 2010). This then moves the debate beyond additional academic support and a “deficit” amendment approach (Thomas et  al. 2017, Porteous and Machin 2018) and sense of inclusion. McKendry et  al. (2014) additionally argue that a sense of belonging is essential to feeling included and elsewhere this is cited as integral to developing resilience and promoting retention and success (Thomas 2012).

5.2

Challenges of Diversity and Inclusive Pedagogy

It has been suggested that teaching and learning strategies designed for diverse students, such as those with disabilities, benefit all students (Thomas 2012). Carey (2012) notes however that there is a disproportionally higher number of nursing students with dyslexia than on other undergraduate courses. MacFarlane et  al. (2010) indicate this population is 3–10% of the nursing population while Evans (2014) reports 12% of nursing students are diagnosed with dyslexia, which equates to around 10,000 nurses—although since this is self-disclosure it means this may only be a partial picture. While dyslexia is the most notable declared disability there are significant numbers of student experiencing mental distress. It is striking that

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these students have particularly poor completion rates and this continues to be an area for urgent improvement (Turner and McCarthy 2015). One factor here might be the apparent conflicts between the roles of nurse educators as providers of student support at the same time as being “professional gatekeepers”. Other non-disability factors are also a concern: students with non-science background, English as second language and non-traditional entry qualifications all face challenges for which extra support is needed (Oom et al. 2015). In an earlier chapter, Brown points to variations in diversity in the UK but also in London. As such institutional contexts will vary as will the associated approaches. Inclusive pedagogic practice can provide students with opportunities to explore their identity, to understand diversity in others and enable achievement (Atherton 2017). It can also polarise groups and lead to a deficit model of interventions instead of a strengthsbased, holistic approach (HEE 2014). The argument for inclusive learning is persuasive to ensure parity of outcomes for all students alongside specific professional demands, but challenges remain around the dimensions of inclusive pedagogy— specifically the individual student learning journey.

5.3

Transition

Transitioning is identified as a key issue in higher education (Pryjmachuk et  al. 2018). Brimble (2015) found that students who entered nursing programmes via varied level 3 courses prevalent in the UK fared differently. Students coming from other secondary courses such as access courses did significantly less well statistically in examination assessments in comparison to other level 3 provision: BTEC and A Levels (Brimble 2015; Hinsliff-Smith et al. 2012) however other studies indicate the opposite (Birks et al. 2013). This highlights the need for further insight into student histories and potentially support in relevant assessment preparation such as examinations or other assessments used in individual nursing courses. In relation to international students, Gopee and Deane (2013) identified that academic writing was affected by language and cultural differences impacting on both style and expression. It emerged that students experienced difficulty adapting to university conventions and lacked sufficient support to develop academic writing or assessment skills. Pedagogical approaches are evident and focus on additional interventions: clearer assignment guidelines, academic writing support centres which provided writing support resources, group work, informal peer learning, and opportunities for writing practice. To an extent these ameliorate difficulties and aid success. Both Gopee and Deane (2013) and Brimble (2015) highlight needs of students from WP backgrounds and the synergy with international students’ needs. Additionally, the provision of transparency and support to enable students to complete assessed work successfully was necessary but amounted to additional support and ‘add-on’. Allan et  al. (2013) explored a blended approach to HE delivery as e-learning which is sometimes assumed to address the needs of a more diverse student population. This research however points out starkly another issue: when staff

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were aware of students from WP backgrounds it did not really influence their teaching and learning which poses the question of how student centred staff were or do they recognise diversity and consequently how to differentiate their teaching approaches. Transition, however, is not a one-off event (Tett et al. 2017) but a steep learning curve. Pryjmachuk et al. (2018) in their study found mature students were better at transitioning to academic life than younger ones and those who had worked in healthcare prior to studying found transition easier. Furthermore, they identified mature students struggled with integration and were more self-directed and independent learners. Those embarking on second degrees were not troubled with academic demands but professional integration while younger students had no problems integrating socially but lacked self-direction in studying. This could be a feature of confidence linked to emotional and academic impacts of preparing to study or “newcomer adaptation” (Houghton 2014). It seems likely that individuals with a range of life skills and other compensatory experiences are able to draw on them to offset the challenges of unfamiliar programme expectations. This could be an area of strength for non-traditional students that nurse educators can work to amplify.

5.4

Sense of Belonging and Developing Identity

In seminal work on student attrition, Tinto (1993) described correlated themes including adjusting to social or academic demands, belongingness, possession of social capital, etc. in general but also referring to specific student groups. Grouping students by their characteristics is a divisive rather inclusive approach; however, the literature indicates attainment issues for a number of groups who are well represented in nursing (Fergy et  al. 2011; Pryjmachuk et  al. 2018). They include first generation attendees, mature students, black and ethnic minority groups, commuter students and disabled students. While pre-entry experiences as well as preparedness all feature in students successful navigation of transition, nursing programmes emerge as a stressful choice for students, for a number of reasons. Firstly, the academic year is longer than traditional university courses (Tower et  al. 2015) which can be tiring, isolating and leaves less time to earn money in the holidays. Secondly, many nursing students are the first generation to attend higher education so the “university experience” is an unknown and often navigated “blind” (McKendry et al. 2014). Another issue is that while health education is skilled at incorporating professional developments into its programmes, it can be conservative in participating in the fierce pedagogical debates that rage across higher education forums and which could result in a more inclusive learning experience for the increasing numbers of students with Black Asian and Minority Ethnic heritage. Despite Kline’s (2014) work on discrimination in healthcare and the NMC’s expectations that equality is explicitly addressed in curriculums, little has been forthcoming from health educators on decolonising health curricula despite work as far back as 2014 from Nazar et al. (2015) which was among the first to raise the issue.

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Maginnis (2018) reports a lack of research on the development of professional identity in pre-registration nursing with tension resulting from differences between ideals of professionalism versus the sometimes disappointing reality. Professional socialisation is part of learning and teaching and nurse educators are socialisation agents who can support students to negotiate this disparity and develop a professional sense of self or conversely undermine their resolve. The clinical environment however is also key with role modelling by educators initially and clinicians later. The professional identity of students is also shaped by a sense of belonging—by feelings of security, relatedness and by being a valued and accepted member of the team, which strengthens the capacity and motivation of students to learn. Worthington et  al. (2013) identified a correlation between professional identity and retention; however, most nursing education research focuses on individual elements of the student journey such as clinical placements and the mentoring role rather than seeking to foster an understanding of students emotional response to the whole. Nurse educators have a unique professional role in which the purpose, content and educative starting points of nursing knowledge are adjusted to the student. Nurse educators enable the student to apply their theoretical understanding in practice and respond ethically to the health challenges posed by an increasingly diverse and demographically challenging population. To accomplish this, nurse educators must support students to be self-aware and clear on expectations of nursing practice in the future (Benner et  al. 2010). Thus, pedagogical competence must align to inclusive approaches as it remains a significant aspect of the professional role of nurse in practice and of nurse educators (Pointdexter 2013).

5.5

Reality of Learning to Be a Professional

Student retention is linked to success. Attrition however, especially in the early stages is often due to a failure to understand role of the nurse in contemporary society and underestimating the intellectual demands of the profession. The first clinical placement is a key transition factor here (Cameron et al. 2011) and influences retention especially within the first year (DoE 2019, Jones-Berry 2018). The hard realities of practice potentially create stress (Bickhoff et al. 2016) or conflict with “virtue values” (Snowdon et al. 2018). For example, midwifery students often struggle to adjust to facing medicalisation within child birth (Coldridge and Davies 2017). In addition, the altruistic desire to help others is likely linked to the underestimation of the complexity of knowledge and scientific basis of care (Price et al. 2013). These factors may be exacerbated by unrealistic representations of nursing and midwifery in popular culture as well as continued media-fuelled debate around the necessity of nurses to be educated at degree level. Compounded by this is the perception and practice of independent learning. Hockings et al. (2019) research indicates varied student practices: initially drawing on low level reinforcing and organising skills and in later stages of their courses developing higher level extending and applying skills. This has implications for inclusive practice and motivating and enabling professional students take ownership

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of their learning espoused in most adult learning approaches. It has been reported that the concept of independent learning itself is viewed as being predominantly “Western” and makes assumptions about how this is perceived and practiced offering the potential for a lack of sensitivity to diversity and cultural frames (Thomas et al. 2015). It may also overlook the learning needs for some groups of nursing students who would benefit from additional scaffolding and encouragement at the start of their programme. Many notions of independent learning reflect the professional nursing journey: responsibility for learning, choosing and setting personal objectives, self-­monitoring progress, developing a critical view and reflective practice. As such it is appropriate it commences early in a nursing programme. However, the structures and approaches by institutions intended to be inclusive and supportive can reinforce difference. For example, extra sessions added to offer support may be interpreted by the students they are designed for as stigmatising them, or as hard to access because they frequently occur outside standard timetables and compete with other commitments (Thomas 2012).

5.6

I nclusive Curriculum and Inclusive Learning in Nurse Education

Curriculum design and resource allocation should maximise student potential (Carey 2012) as well as meet professional and academic needs and standards. The inclusive curriculum at its best is strengths-based, optimistic and student focused. It is aligned to humanist or emancipatory theories of education reflecting Knowles (1975), Hooks (1994) or Freire (1995) and should be situated with discourse of diversity, fairness and equality rather than deficiency. A framework dominated by legislative requirements can inadvertently polarise and isolate minority groups and can overlook the impact of multiple disadvantages as highlighted by intersectionality. Traditional approaches to approaching disadvantage focus on integrating or assimilating individuals into an existing context or frame. It is argued that minimising difference between individuals remains a contributory factor in creating and perpetuating disadvantage (May and Bridger 2010). Hockings (2010) tries to clarify this by defining inclusive teaching as: the ways in which pedagogy, curricula and assessment are designed and delivered to engage students in learning that is meaningful, relevant and accessible to all. It embraces a view of the individual and individual difference as the source of diversity that can enrich the lives and learning of others. (ibid, p. 1)

The UK, Advance HE organisation; the higher education teachers professional organisation, advocate for inclusive teaching and learning and argue for proactive anticipatory approach to learning and teaching in a holistic institution approach to be effective as opposed to focus from individual teachers (May and Bridger 2010; Morgan and Houghton 2011).

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In the USA, inclusive curriculum is also advocated through widespread adoption of an inclusive approach known as Universal Design for Instruction (UDI) or Universal Design for Learning (UDL) which also takes a curricular and holistic approach (McGuire 2011). The National League for Nursing (NLN) has advocated this approach within nursing education since 2003 highlighting the issue of student diversity is ongoing and clearly not just a UK phenomenon (Levey 2016). The adoption of this approach however appears poorly embedded due to lack of knowledge and a persistent reactive versus proactive instructional approach (Levey 2016, 2018). It has been argued that elements of the nursing curriculum follow the functionalist model (serving the needs of society) (Carey 2012). This positions nurse educators as gatekeeper to a profession and well as agent to professional development. This includes teaching and demonstration of specific skills or qualities for the professional functioning and is delivered in a didactic and directive manner which is in opposition to the inclusive curricular approach. This may create tensions within nurse educators as to whether the education ought meet the needs of the student or the profession. Attrition, as mentioned earlier, occurs for a number of reasons and “fit” or inclusion plays a role and the tension here is with consequent penalties of attrition balanced with risk in decision making of HE entrant diversity, and thus with actual or perceived needs these may prove a challenge to support. Research conducted by Cunningham (2013) points to HE teachers varied perceptions of diversity with limited insight into students’ backgrounds, lives or experiences, and their pedagogic practice influenced by conceptions of knowledge generation in subject communities and limited personal development of a pedagogic philosophy. They also viewed diversity (and WP) as deficiency, remedial or “someone else’s job” compounded by workload and other competing pressures. This is a challenging path nurse educators find themselves in since professional demands and standards are prescribed to ensure a skilled as well as knowledgeable workforce (Carey 2012). It is suggested that the interests and values of individual educators or lecturers determine how inclusive a curriculum is and engagement or influence on outcomes for underrepresented groups. Jessop and Williams (2009) argued that an inclusive curriculum ought provide students with the opportunity to explore their identity and the diverse the cultures they interact with and hence make sense and feel valued. Carey (2012) in his research on nurse educators perceptions of inclusive curriculum argued that nurse educators at times held a range of views of the inclusive curriculum and as such this was not discrete and cites “safe practice” as a limiter of inclusion approaches. The responses varied and addressed broadly structural aspects (professional requirements, societal demands) to being student centred or meeting needs and as such was already being practiced or needed adaptation or raised questions of the nature of nurse education. This was a small study in one university and as such the local demographics may have influenced the perspectives. One thing is evident: educators were charged with navigating their own path through an emotive and complex subject with limited support and guidance from professional bodies or leaders. Nurse educators do need an awareness of the diversity in their classrooms and to coordinate interaction between students to maximise learning for diverse groups.

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This is perhaps more prevalent in certain geographical areas (for example, the south); however, it is a wide ranging issue across the whole country (UK). Hounsell and Hounsell (2007) argued that lecturers often base their teaching on their assumptions about students’ lives and interests or about what “the average” student should know. In some instances, their approach is based on their own memorable experiences despite the time lag since their own experiences. Flexible learning and teaching strategies that allow students to apply what they are learning to their own interests are likely to engage a wider range of students (Hockings 2009; Zepke and Leach 2007). This is perhaps best approached by staff through adopting a critical self-­reflective style, self-evaluation and building and a repertoire of “craft” skills (Hockings 2011). Student learning styles while controversial give food for thought as does consideration of the wider basis of learning: emotional and sensory components and a myriad of other theoretical considerations all of which influence a positive learning experience. However, these are only achieved if lecturers’ engage with a scholarly approach to teaching and learning. However, focusing on one group may alienate others (Hounsell and Hounsell 2007) and as such a wider repertoire of engaging approaches are needed which includes feedback and strategies to enable students to see progress. E-learning has been proposed as a panacea for diverse pedagogies; however, it has also been reported to result in feelings of isolation and alienation if used extensively (Allan et al. 2013) or potentially insensitivity around cultural factors (Reeves and Reeves 2008). All of which contribute to disengagement although Corfield (2013) argues that it is academic staff in particular and not students who hold deficits in relation to learning technologies compounding this.

5.7

What Does an Inclusive Curriculum Look Like?

Thomas and May (2010) offer a framework for inclusive practice which takes into account responsibilities and actions at the macro, meso and micro level of institutional practice. At the macro level arise the legal and ethical requirements which are drivers to inclusive practices. These have been addressed earlier. The meso is the institution and the micro is individual practice (Fig. 5.2). To be inclusive, institutions should consider the diversity of the student body and the resulting learning needs. Co-production can embed principles of equality in the design, planning and evaluation of programmes, courses and modules in a way that positions diversity as a strength. These considerations should be made in relation to many aspects of the curriculum design process including the learning outcomes, content and choice of pedagogical and assessment approaches. They should also consider the ways in which the curriculum plans to engage all students and this enables some form of flexibility and diversity. It is also argued that the “hidden curriculum” persists within nurse education despite scant literature around it (Chen 2015). Elements of this include expectations, professional interactions, assessment tasks, perception of importance (topics)

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and the reality of practice (or theory-practice gap). It is not overt and as Chen (2015) asserts it “is the product of its [institution] unique history, culture, structure, and practices” mostly with negative consequences such as the difficulty of transmitting professional values and ethics and can be influenced by educator behaviour and attitudes (Karimi et al. 2014). Furthermore, it also encompasses issues of resources and how they reflect the population (of nursing) and of the student nurse so they can see connections and relevance. This may be through cultural and ethnicity examples but also cases and scenarios devised and used within teaching and has been referred to as a “decolonising” of the curricula with its roots in power and oppression (Keane et  al. 2017). It is noted that much of this literature is not UK based; however, it points to an aspect which ought be considered and reflected upon since the absence of evidence is not evidence of absence. More recently, the European Agency for Special Needs and Inclusive Education (2014) offered five key messages which are applicable across the sector for inclusive learning and are useful reflection points: • • • • •

Early detection and intervention [of need] as well as of proactive measures Inclusive education benefits all Highly qualified professionals Support systems and funding mechanisms Reliable data

While this is intended for young people this does reflect other messages promoting inclusive approaches. A number of approaches and models exist and are in development to address inclusive learning. Kingston University (2019) offers a comprehensive overview which addresses a supportive challenging approach to programme teams when developing and monitoring programmes badged as building inclusivity from “concept to review”. This offers a quality assurance approach and transparent processes. Issues identified to consider include concept, content, learning and teaching, assessment, feedback and review. Issues are overtly identified such as consideration of hidden curricula, relevance of content, involving students in development, inclusive language, accessibility, global and diverse perspectives within content and delivery and clarity and transparency in expectations and time frames. This has resonances with the approach mentioned earlier: UDI and sets out a commitment to inclusivity and student achievement. Based on these ideas, there are several inclusive learning, teaching and assessment frameworks that have been developed by universities such as York St John University’s “Inclusive learning, teaching and assessment framework” (York St John University 2016), Glasgow Caledonian University “Inclusive and Accessible Learning and Teaching Checklist” (GCU 2017) and Anglia Ruskin University’s “Inclusive Teaching Checklist” (Anglia Ruskin University 2017) all devised to indicate good practice. These are all institution wide initiatives and as such it is up to disciplines to apply them to their own professional programmes.

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• Who? • Individuals • Applicability

• Programme • Professional • Team/who Context

Preparation

Evaluation

Teaching methods

• By students • By peers • Ideas/ innovations?

• What/Where • When/Why • How

Fig. 5.1  Inclusive practice—conceptual model

In focusing on nursing, there are issues which also need consideration as mentioned earlier and ought be added to a nursing checklist and underpinned by a clear nursing pedagogy and self-reflection of practice (Fig. 5.1): 1 . Professional identity building and socialisation 2. Transition issues and positive role models 3. Theory-practice connection and continuum In essence, this draws not only on the elements indicated above but also on the practical measures such as student-centred pedagogies, with emphasis on collaborative learning to promote inclusion and peer support (Thomas and May 2010) and maximising use of support structures within institutions. Differentiated teaching and assessment strategies and effective monitoring of progress, engagement and learning gain are recommended, despite the latter being a challenge to determine (Fig. 5.2). Nursing students also need effective pastoral oversight (personal tutors) to guide their professional journey (Fergy et al. 2011; NMC 2018) and need to feel cared for by educators (Atwood 2017). This enables “knowing” students to better support and pre-empt challenges and foster a sense of belonging and value and build self-­ efficacy for resilience skills but also coping with programme demands (Fig. 5.3). It is important though to ensure that nurse educators role model good practice around gender equality when delivering pastoral care, as many discourses of care are feminised (Tuck 2018). It can be problematic in terms of teaching a curriculum based on equality if students witness the key skill of pastoral support being designated as emotional labour that only female academics undertake rather than as an important

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Recommendations for Individual contributions to an inclusive culture Understand inclusion is a shared responsibility.

Work in partnership with other services.

Recognise inclusion is incremental and ongoing.

Be proactive and seek advice /information.

Work with students as partners and change agents.

Review and alter the language you use.

Routinely consider inclusion in your practice.

Participate in activities (e.g. CPD, action groups).

Reflect on any personal prejudices or assumptions.

Fig. 5.2  Inclusive culture Exclusive

Good practice

Admissions/Induction

Language, name badge, information overload, ‘herded’ altogether, assumed skills (reading approach)

Individualised welcome, ask about experiences,

Curriculum design

Inflexible, unsociable hours, didactic

Advance notice of timetable, consideration of social responsibilities (work etc)

Assessment

Repetitive, poor range (all exam), limited skills assessment. Unclear expectations or aims

Ongoing, supportive, incremental, builds confidence and ability, involves peers

Pedagogy/Teaching approach

Language which confuses/belittles, not knowing student group (learning not meaningful)

Plain language, dialogue with students ensuring understanding of requirements, established pedagogy flexible to varied needs (constructivist approach)

Teaching materials

Obscure language, technical terms, not interactive or varied or representing varied cultures, experiences, ages.

Varied format, interactive, reusable, multisensorial to meet differing learning needs, accessible and modifiable, appropriate language and clarity of technical elements

Laboratory/Fieldtrips/ Placement

Mobility expectations, no consideration of personal responsibilities/durations/times. Link to learning unclear

Consideration of students life responsibilities, adequate notice of time/cost etc.

Fig. 5.3  Examples of inclusive actions

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part of learning and teaching—especially if male colleagues are overrepresented in academic roles that may be seen as more “prestigious” such as leadership positions and research instead.

5.8

Conclusion

Nursing has moved from an apprentice-style training in hospitals to diploma and then degree only profession within universities since 2013. Various reviews and reports have shaped the preparation of nurses. The NMC review of the nursing preregistration education standards in 2015 culminated in the 2018 standards aims to reflect the evolving nature of nursing and the healthcare workforce (HEE 2017). These standards adopted nationally for the 2019 curriculum creates the opportunity to define and articulate the role of the future nurse and nursing education and embrace diversity within and by nurses. Population changes such as ageing persons, increased prevalence of chronic disease, advances and reliance on technology all contribute to moving the emphasis from acute care towards prevention, self-management and integrated care. This latter point means it is increasingly being delivered in the community by teams of multi-professionals. To meet these challenges, registered nurses of the future will need to grow in their role as decision makers and leaders, embracing change and be equipped to meet changing patient and population needs (CoD 2016). National policy underpinning these healthcare changes address the issue population wide with implications also for nurses. Within Europe, the UK National Health Service (NHS) is the largest employer yet the diversity of the current workforce is not representative of the general population (HEE 2014). Widening participation is not only important for patient care, but it is also a fundamental mechanism to address workforce issues within the profession considering there remain concerns regarding nursing workforce numbers and diversity (HEE 2017). Internationally there is critical staff shortage of nurses but also of other healthcare professionals. This is due in part to an ageing workforce as well as a reduction in the numbers of young people entering the profession (Marangozov et al. 2016) and to some extent the global mobility of nurses and recent reliance on overseas nurses within the UK health system (Heaslip et al. 2017). It is paramount that we attract students to begin to study as nurses, and we retain them and take pride in seeing them go on to thrive in practice. It is argued that caring as a multidimensional concept is under threat of being eroded in the twenty-first century (Tjale and Bruce 2007); however, it remains central in nursing. It is a value, an attribute, a role, an act and an ethic—all embodied in professionals. Nursing is a person-centred, practical, evidence-informed profession. Nurses must use data and information from technology and research for decision making. Working and collaborating with people around the world requires greater global literacy—i.e., knowledge about people and cultures outside of one’s own country. Even within one’s own country, inclusive care is core to the profession and as such ought be core to the nurse education and preparation. The diversity of the

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workforce means it is incumbent on us as professionals to foster inclusion and respect and as nurse educators to practice this from the nascent nurse student entry to programmes (or before). It could be argued that inclusive practice starts with critical self-reflection and making education student centred, inclusive and non-­ discriminatory adopting the appropriate pedagogical approaches. This requires a conceptual shift to knowing students and practising equitably. It ought be more than just rhetoric—it must become real in the way we prepare nurses in colleges and universities for twenty-first century health care (Dobrowolska and Palese 2016).

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Hockings C (2009) Reaching the students that student centred learning cannot reach. Br J Educ Res 35(1):83–98. https://doi.org/10.1080/01411920802041640 Hockings C (2010) Inclusive learning and teaching in higher education: a synthesis of research. EvidenceNet. Higher Education Academy. https://www.advance-he.ac.uk/knowledge-hub/ inclusive-learning-and-teaching-higher-education-synthesis-research. Accessed 1 Sept 2019 Hockings C (2011) Hearing voices, creating spaces: the craft of the ‘artisan teacher’ in a mass higher education system. Crit Stud Educ 52(2):191–205. https://doi.org/10.1080/17508487.2 011.572831 Hockings C, Thomas L, Ottaway J, Jones R (2019) Independent learning  – what we do when you’re not there. Teach High Educ 23(2):145–161. https://doi.org/10.1080/13562517.2017.1 332031 Hooks B (1994) Teaching to transgress: education as the practice of freedom. Routledge, London Houghton CE (2014) ‘Newcomer adaptation’: a lens through which to understand how nursing students fit in with the real world of practice. J Clin Nurs 23(15–16):2367–2375. https://doi. org/10.1111/jocn.12451 Hounsell D, Hounsell J (2007) Teaching-learning environments in contemporary mass higher education. Br J Educ Psychol 11(4):91–111 House of Commons Health Committee (2018) The nursing workforce. Second report of session 2017–19. HC353. House of Commons, London Jessop T, Williams A (2009) Equivocal tales about identity, racism and the curriculum. Teach High Educ 14(1):95–106 Jones-Berry S (2018) Why nursing students leave: the truth about attrition. Nurs Stand 33(9):14– 16. https://doi.org/10.7748/ns.33.9.14.s11 Kaehne A, Maden M, Thomas L, Brown J, Roe B (2014) Literature Review on approaches and impact of interventions to facilitate Widening participation in Healthcare Programmes. Health Education programmes North West. https://research.edgehill.ac.uk/ws/files/20061986/ WPlitrev280514Submitted.pdf. Accessed 1 Oct 2019 Karimi Z, Ashktorab T, Mohammadi E, Abedi H (2014) Influential factors on learning through the hidden curriculum in the perspective of undergraduate baccalaureate nursing students. J Adv Med Educ Prof 2(2):53–57 Keane M, Khupe C, Seehawer M (2017) Decolonising methodology: who benefits from indigenous knowledge research? Educ Res Soc Change 6(1):12–24. https://doi.org/10.17159/22214070/2017/v6i1a2 Kingston University (2019) Inclusive curriculum framework. https://www.kingston.ac.uk/aboutkingstonuniversity/equality-diversity-and-inclusion/our-inclusive-curriculum/inclusive-curriculum-framework/. Accessed 19 Sept 2019 Kline R (2014) The snowy white peaks of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England. http://eprints.mdx. ac.uk/13201/. Accessed 28 Sept 2019 Knowles M (1975) Self-directed learning: a guide for learners and teachers. Follett, Chicago Levey J (2016) Nurse lecturers willingness to adopt inclusive teaching strategies. Nurs Educ Perspect 37(4):215–220. https://doi.org/10.1097/01.NEP.000000000000021 Levey J (2018) Universal design for instruction in nursing education: an integrative review. Nurs Educ Perspect 39(3):156–161. https://doi.org/10.1097/01.NEP.0000000000000249 MacFarlane A, Al-Wabil A, Marshall CR, Albrair A, Jones SA, Zaphiris P (2010) The effect of dyslexia on information retrieval: a pilot study. J Doc 66(3):307–326. http://openaccess.city. ac.uk/id/eprint/1694/1/dyslexia-paper-JDOC-revised-FINAL.pdf. Accessed 1 Oct 2019 Maginnis C (2018) A discussion of professional identity development in nursing students. J Perspect Appl Acad Pract 6(1):91–97 Marangozov R, Williams M, Buchan J (2016) The labour market for nurses in the UK and its relationship to the demand for, and supply of, international nurses in the NHS. Institute for Employment Studies, Brighton May H, Bridger K (2010) Developing and embedding inclusive policy and practice in higher education. Higher Education Academy, York

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McGuire JM (2011) Inclusive College Teaching: universal design for instruction and diverse learners. J Access Des All 1(1):38–54. https://core.ac.uk/download/pdf/41788695.pdf. Accessed 16 Oct 2019 McKendry S, Wright M, Stevenson K (2014) Why here and why stay? Students’ voices on the retention strategies of a widening participation university. Nurse Educ Today 34:872–877. https://doi.org/10.1016/j.nedt.2013.09.009 Morgan H, Houghton AM (2011) Inclusive curriculum design in higher education considerations for effective practice across and within subject areas. Higher Education Academy (HEA), York Mulholland J, Anionwu E, Atkins R, Tappern M, Franks P (2008) Diversity, attrition and transition into nursing. J Adv Nurs 64:49–59 Nazar M, Kendall K, Day L, Nazar H (2015) Decolonising medical curricula through diversity education: lessons from students. Med Teach 37(4):385–393 Nursing and Midwifery Council (NMC) (2018) Standards framework for nursing and midwifery education. https://www.nmc.org.uk/standards/standards-for-nurses/. Accessed 1 Oct 2019 Oom A, Fergy S, Marks-Maran D, Burke L, Sheehy K (2015) Providing learning support to nursing students: a study of two universities. Nurse Educ Pract 13:89–95 Pointdexter K (2013) Novice nurse educator entry-level competency to teach: a national study. J Nurs Educ 52(10):559–566. https://doi.org/10.3928/01484834-20130913-04 Porteous DJ, Machin A (2018) The lived experience of first year undergraduate student nurses: a hermeneutic phenomenological study. Nurse Educ Today 60:56–61 Price SL, McGillis Hall L, Angus JE, Peter E (2013) Choosing nursing as a career: a narrative analysis of millennial nurses’ career choice of virtue. Nurs Inq 20:305–316. https://doi. org/10.1111/nin.1202 Pryjmachuk S, McWilliams C, Hannity B, Ellis J, Griffiths J (2018) Transitioning to university as a nursing student: thematic analysis of written reflections. Nurse Educ Today 74:54–60. https:// doi.org/10.1016/j.nedt.2018.12.003 Reeves P, Reeves T (2008) Design considerations for online learning in health and social work education. Learn Health Soc Care 7(1):46–58. https://doi.org/10.1111/j.1473-6861.2008.00170.x Sedgewick M, Oosterbroek T, Ponomar V (2014) “It all depends”: how minority nursing students experience belonging during clinical experiences. Nurs Educ Perspect 35(2):89–93. https://doi. org/10.5480/11-707.1 Snowdon A, Stenhouse R, Duers L, Marshall S, Carver F, Brown N, Young J (2018) The relationship between emotional intelligence, previous caring experience and successful completion of a pre-registration nursing/midwifery degree. J Adv Nurs 74(2):433–442. https://doi. org/10.1111/jan.13455 Tett L, Cree VE, Christie H (2017) From further to higher education: transition as an on-going process. High Educ 73(3):389–406. https://doi.org/10.1007/s10734-016-0101-1 Thomas L (2012) Building student engagement and belonging at a time of change in higher education. Final report from the what works? Student retention & success programme. Paul Hamlyn Foundation, London Thomas L, May H (2010) Inclusive learning and teaching in higher education. Higher Education Academy, York Thomas L, Jones R, Ottaway J (2015) Effective practice in the design of directed independent learning opportunities. Higher Education Academy, York Thomas L, Hill M, O’Mahony J, Yorke M (2017) Supporting student success: strategies for institutional change. Findings and recommendations from the what works? Student retention and success programme. Paul Hamlyn Foundation, London Tinto V (1993) Leaving college: rethinking the causes and cures of student attrition, 2nd edn. University of Chicago Press, Chicago Tjale AA, Bruce J (2007) A concept analysis of holistic nursing care in paediatric nursing. Curationis 30(4):45–52 Tower M, Walker R, Wilson K, Watson B, Tronoff B (2015) Engaging, supporting and retaining academic at-risk students in a Bachelor of Nursing: setting risk markers, interventions and outcomes. Int J FYHE 6(1):121–134. https://doi.org/10.5204/intjfyhe.v6i1.251

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Tuck J (2018) “I’m nobody’s Mum in this university”: the gendering of work around student writing in UK higher education. J Engl Acad Purp 32:32–41 Turner K, McCarthy V (2015) Stress and anxiety among nursing students: a review of intervention strategies in literature between 2009 and 2015. Nurse Educ Pract 22:21–29. https://doi. org/10.1016/j.nepr.2016.11.002 Universities UK (UUK), National Union of Students (NUS) (2019) Black, Asian and minority ethnic student attainment at UK Universities. #closingthegap. https://www.universitiesuk. ac.uk/policy-and-analysis/reports/Documents/2019/bame-student-attainment-uk-universitiesclosing-the-gap.pdf. Accessed 29 Sept 2019 Woodfield R (2014) Undergraduate retention and attainment across the disciplines. Higher Education Academy, York Worthington M, Salamonson Y, Weaver R, Cleary M (2013) Predictive validity of the Macleod Clark Professional Identity Scale for undergraduate nursing students. Nurse Educ Today 33(3):187–191. https://doi.org/10.1016/j.nedt.2012.01.012 York St John University (2016) Inclusive learning, teaching and assessment framework. York St John University, York Zepke N, Leach L (2007) Improving student outcomes in higher education: New Zealand teachers’ views on teaching students from diverse backgrounds. Teach High Educ 12(5–6):655–668

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Innovative Approaches to Nurse Teaching and Learning Mariama Seray-Wurie, Clare Hawker, and Sarah Chitongo

6.1

Introduction: Authentic Learning

The role of the nurse in the twenty-first century must consider changes taking place in society and healthcare provision, and the implications these have for registered nurses role, knowledge and skill requirements (NMC 2018b). A nursing student at the point of registration will need to show that they can work independently or in interdisciplinary teams autonomously or as an equal partner with other healthcare professionals. Part of the education and training is to equip them with these skills. Practice learning makes up 50% of the undergraduate nursing programme in the UK and across many European countries as explored in Chap. 3. Nurses require an understanding of information technology and clinical technology (NMC 2018a; WHO 2013). Part of students’ practice learning therefore does need to involve technology either within practice environments or for professional development. This may include communication technology, patient records or documentation or simulation-­based learning activities. Advances and developments in technology allow nursing and midwifery educators to seek innovative teaching and learning methods to supplement actual practice. Simulation provides an authentic learning experience which replicates clinical practice (INACSL 2016). Herrington (2015) argues that the concept of “authentic learning” is more a philosophy than learning theory and is useful for designing curricula models. Authentic learning then typically focuses on a range of “real-world” scenarios: complex problems and solutions using role-play-type exercises, problem-­based activities, case studies and participation in virtual communities of M. Seray-Wurie (*) · S. Chitongo Department of Adult, Child and Midwifery, School of Health and Education, Middlesex University, London, UK e-mail: [email protected]; [email protected] C. Hawker School of Healthcare Sciences College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 S. Cunningham (ed.), Dimensions on Nursing Teaching and Learning, https://doi.org/10.1007/978-3-030-39767-8_6

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practice (Lombardi 2007). In this way, the “learning by doing” model of professional development is perpetuated with innovative contemporary means yet the real world of nursing and clinical practice is messy and unpredictable (Swartz 2016) and authentic means to gain skills and respond in such unpredictable environments is a desirable approach to learn safely yet competently. Simulation in nursing education, more than ever before, attempts to replicate “reality” to enable students to practice nursing skills and approaches and learn in a safe environment. In healthcare education, simulation aims to imitate some of the essential aspects of a clinical situation so that the situation may be more readily approached, understood and managed for when it emerges in clinical practice (Howard 2018). In a scoping review of the emergent augmented reality, Wuller et al. (2019) found that this is still an evolving area with the majority of literature currently describing pilot studies and not yet at the level of sustained or longer term impacts. Devices reported as used varied across studies ranging from smart glasses, tablets and smart watches, among others (ibid). Use of virtual reality and augmented reality are being used increasingly it appears and are reputed to enhance the simulated learning experience and provide authentic learning opportunities (Wuller et al. 2019). The phases of simulation are recommended to include a cyclic approach of preparation, instruction, simulation activity, debriefing, reflection and followed by consolidation or evaluation (INACSL 2016). Virtual communities devised and drawn on within an authentic learning experience for the learner focus on the conceptualisation of creating a real life task and environments that reflect the way in which knowledge will be applied in practice (Orneallas et  al. 2018). It must be noted, however, that in simulation authenticity occurs in conjunction with interacting components such as the learner, the learning environment and the task in a dynamic manner. As such authenticity is not a neutral component (Barab et  al. 2000). Herrington et al. (2010) propose guidelines for designing authentic learning environments in higher education institutions (HEI) that can be applied in a range of disciplines. The characteristics are that it: 1. Provides an authentic context that is relevant to how knowledge will be used in real life so activities are not just classroom based. 2. Offers authentic activities which provide complexity. 3. Requires access to expert performances and the modelling of processes to ensure that the learners have exposure to expert thinking in various levels of expertise and also observation of how real life behaviour in a real situation. 4. Involves multiple roles and perspectives whereby the opportunity to enable and encourage exploration of different perspectives from a practical and theoretical view using resources. 5. Engages collaborative construction of knowledge which will involve working together to problem solve or create a solution. 6. Involves reflection to provide the opportunity to analyse the social and individual learning experience. 7. Necessitates articulation to provide the opportunity to complete the learning activities within the social context whereby the learners are enabled to show expression, consciousness, development and refinement of thoughts.

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8. Engages coaching and scaffolding which is done mainly by the teacher but can also be done by the learners to provide the opportunity to observe activities, give feedback in different forms and support students at the metacognitive level. 9. Results in authentic assessment which needs to be integrated with the learning activities and provides the opportunity for the student to perform as would be expected in the real world of work. The use of authentic learning also facilitates development of skills for employability, a key aspect of the graduate skills within higher education (HE) that students should have gained during their study. Using simulated-based learning activities including virtual reality and augmented reality situates learning in problem-solving activities that mirror professional practice, therefore supporting learner development through enhancement of knowledge, behaviours and skills from the learning activities within the simulation.

6.2

What Is Simulation?

In the guidance report “Transforming and Scaling up Health Professionals’ Education and Training”, the WHO (2013) strongly recommends the use of simulation acknowledging there is a wide range in existence. Recommendation 5 states: “Health professionals’ education and training institutions should use simulation methods (high fidelity methods in settings with appropriate resources and lower fidelity methods in resource limited settings) of contextually appropriate fidelity levels in the education of health professionals” (WHO 2013, p. 13). Simulation is widely used in undergraduate nurse education in the UK and internationally (Cant and Cooper 2010; Norman 2012; Berragan 2011; Haraldseid et al. 2015). Simulation is a valuable learning strategy for developing students’ professional knowledge and skills, developing critical thinking, building confidence and bridging the theory practice gap (Leigh 2008; Hope et  al. 2011; Ricketts 2011; Ricketts et  al. 2012). Simulation often means different things to different people depending upon what they are trying to achieve. If you were to ask different healthcare educators what simulation is you are likely to get several different responses. There are various definitions of simulation within the literature and it is beyond the scope of this chapter to explore all possible definitions. However, it is important to be clear about what simulation is when discussing new and innovative approaches to simulation. A concept analysis of simulation in undergraduate nurse education defined simulation as “a dynamic process involving the creation of a hypothetical opportunity that incorporates an authentic representation of reality, facilitates active student engagement and integrates the complexities of practical and theoretical learning with opportunity for repetition, evaluation and reflection” (Bland et al. 2011, p. 668). A widely agreed international definition of simulation is that it is “a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions” (Lopreiato et  al. 2016, p.  33).

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Another definition presented together with the above definition is Gaba (2004) definition of simulation. Simulation is “a technique and not a technology that replaces or amplifies real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner” (Gaba 2004, p. i2). All these definitions describe simulation as an educational technique which aims to re-create a real life event or experience and requires active participation of the learner. Gaba (2004) definition stands out by making it very clear that it is not a technology. Simulation can take many different forms which may or may not involve the use of technology. There are many different types of simulation which are often referred to as ranging from low to high fidelity. Fidelity means how closely the simulation reflects reality or real life. Howard (2018) argues three differing levels of fidelity (low, mid and high) as well as types of fidelity (conceptual, physical, emotional or psychological) which align with increasing pedagogical intentions of facilitating knowledge, competence or performance and action and the dimensions of these for authentic experiences. Simulation-based education is recognised as being based on constructivism or behaviourist learning theories (Hope et al. 2011; Berragan 2011; Bland et al. 2011). Constructivism theories and therapies position human knowledge and experience as involving the “pro-active participation of an individual” (Mahoney 1995, p.  44). Behaviourist learning theories focus on observable behaviours and learning is said to occur when a learner makes an association between the reinforcement of a response to a particular stimulus (Quinn and Hughes 2013). Simulation is a learner centred approach where learners create their own reality and truth through active participation and by learning from experience. Simulation promotes learning “by doing” and is often guided by experiential learning theory (Kolb 1984).

6.3

What Makes an Innovative Simulation?

An innovative approach is considered to be an idea, practice or object that is perceived as novel by an individual or others in the community of nurse education (Rogers 2003). A simulation may not necessarily be innovative because it is using a new or emerging type of technology. Furthermore, A simulation may be innovative because it fills a particular niche or gap in current simulation provision which will enhance patient care. The Framework of Technology Enhanced Learning (TEL) published by the Department of Health (DoH) (2011) recognises the contribution technology enhanced learning, including simulation makes to healthcare and patient safety. This framework identifies that all technology enhanced learning should be innovative and evidence based as one of six core principles (Fig. 6.1). The six core principles of the TEL framework (DoH 2011) should inform the development of any simulation-based education in that is should: • Patient-centred—The purpose of simulation is to improve patient care, so therefore patients have to be at the centre of the design of simulation.

6  Innovative Approaches to Nurse Teaching and Learning Fig. 6.1  The framework of technology enhanced learning (DoH 2011)

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Patientcentred Ensure equity of access and quality of provision

Educationally coherent

Improved patient outcomes, safety and experience Deliver highquality educational outcomes

Innovative and evidence based

Deliver value for money

• Innovative and evidence-based—For simulation to enhance nurse education and training and prepare students for practice, it must be informed by the best available evidence. Practising in line with the best available evidence is a professional standard of practice and behaviour expected of nurses as part of practising effectively (NMC 2018a). • Deliver value for money—There is increasing pressure to demonstrate the efficacy of simulation in terms of patient outcomes and cost-effectiveness. High fidelity simulation using cutting edge simulators and technology come at a high cost to higher education and other healthcare organisations, without proven benefits to date compared to other approaches such as low fidelity simulation. Collaborative working, whether that be across educational providers nationally or internationally and disciplines or professions, has many benefits including helping to deliver value for money by pooling resources and reducing duplication. The decision to use simulation or any new technology should be driven by whether it will help to support learning and improve learning outcomes as well as being affordable and cost effective. • Deliver high quality educational outcomes—This would be the aim of any educational activity. The provision of high quality education is even more important than ever following the introduction of the Teaching Excellence Framework (TEF) by the government in England in 2017 (Department for Education 2018). The importance of designing and delivering high quality simulation is reinforced in the national and international standards for simulation (Association for Simulated Practice in Healthcare (ASPiH) 2016; International Nursing

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Association for Clinical Simulation and Learning (INACSL) 2016). The expected learning outcomes of simulation should be clearly identified and aligned to the target group (learners) (ASPiH 2016; INACSL 2016b). • Ensure equity of access and quality of provision—Any e-learning content should be developed according to agreed technical standards to ensure that it is accessible across different learning platforms, computers and mobile devices. • Educationally coherent—Simulation or technology should not be used for the sake of it but used as part of a blended approach to learning to meet diverse or specific learning needs. The use of simulation, e-learning and other technologies ought be achievable and like any other teaching approach mapped to specific learning curricula outcomes. National and international standards for simulation stipulate that the type or modality of simulation to be used will depend upon the learning outcomes to be achieved (ASPiH 2016; INACSL 2016c). Innovative technologies range from simulation and e-learning all have a part in nurse education as a “blended” learning approach. This enables learners to acquire, develop and maintain the essential knowledge, skills, values and behaviours for safe and effective patient care. Blended learning is defined as the combination of the use of face to face teaching with online learning methods (Karoglu et al. 2014). Blended learning is student-centred and preferable to a single teaching method, as it provides flexible learning meeting a wide range of learner preferences (Kelly et  al. 2009; Coyne et al. 2018). Keeping abreast of new or emerging technology in nurse education is challenging. The range of different educational techniques/technology available is growing and includes, but is not exclusive to, e-learning, podcasts, simulation, social networking, mobile devices/smartphones, virtual reality and augmented reality. Mobile devices are increasingly being used to support the delivery of nurse education and training. For example, the adoption of using web-based or mobile applications “apps” to complete e-portfolios/clinical assessments while on clinical placements is rising. Other web-based tools, for example, podcasts or videos, are also widely used in undergraduate education, providing comprehensive educational content in “bite size” pieces which can be easily accessed by learners at any time. Nursing and midwifery educators continue to be challenged to find accessible and innovative means of teaching and learning that transition the student from novice practitioner to expert practitioner (Butt et  al. 2018; Irwin and Coutts 2015). Advances in technology through virtual and augmented reality offer potential in promoting learning outcomes in simulation and in particular emergency response training (Jeffries 2016; Smith et al. 2016). Nursing educators however commonly employ a range of high and low fidelity or technical “hybrid” simulations to increase authenticity and impact. There are a multitude of skills which can be facilitated through simulation approaches: practical and cognitive. Skill development for nursing interventions is complex since professionals need to know how to perform a set of technical actions, but also how to apply the best available knowledge, collect and process information and make decisions regarding various contexts. Furthermore, it also includes

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adopting attitudes that which build respect for the person, person-centred care and build a therapeutic relationship (Meakim et al. 2013; Martins et al. 2018). From an ethical perspective, it would seem unfeasible that invasive procedures are either practised on real people or even omitted. The use of simulation instead, ensures students or trainees are able to be exposed to skills or processes in simulated, controlled safe environments, thereby allowing them to make errors and learn from them with no harmful consequences to real people or patients.

6.4

Virtual Reality and Augmented Reality

Virtual reality (VR) is referred to as immersive technology that attempt to reflect actual health care situations, characterised by incorporation of physical interfaces, such as haptic or motion sensors (Society for Simulation in Healthcare 2016). Augmented reality (AR) is defined as “technology that allows a live real-time direct or indirect real-­world environment to be augmented/enhanced by computer-generated virtual imagery information” (Zhu et  al. 2014, p.  3). There are differences between augmented reality and virtual reality. The former enhances the learner’s perception of the real world, while the latter replaces it with a simulated one (Ferguson et al. 2015). Virtual reality it is argued presents the ability to provide a safe accessible learning environment increasing patient safety, through repeated exposure to educational aspects such as clinical skills or critical incidents as novice practitioners (Butt et al. 2018; Chang et al. 2018; Kilmon et al. 2010). The number of research studies focusing on VR and AR in nursing is limited (Wuller et al. 2019). Thus, currently there is a limited evidence-based practice for implementing VR and AR in nursing and offers scope for a future research goal. Virtual reality has been used to describe a range of computer simulated programs and simulation devices including virtual worlds (Sherman and Craig 2018). There are immersive and non-immersive types of this. Non-immersive VR (or desktop VR) such as the early Second Life® program provides a view into a virtual world displayed on a computer screen (Irwin and Coutts 2015; Kilmon et al. 2010). The user positions themselves as an “Avatar” to interact within the virtual environment; however, this is solely manipulated through computer (portable or not) and mouse (Irwin and Coutts 2015). Immersive virtual reality (IVR) is another aspect which immerses the user who enters the computer-generated world, giving the impression that he/she has “stepped inside” this synthetic world (Furht 2008). Authenticity also comprises sensory feedback via an attached device (e.g., headset) to allow for interactivity or response and reaction from the system (Choi et al. 2015; Sherman and Craig 2018). Kilmon et al. (2010) explored the potential use of IVR technology and present a strong argument for its integration into nursing simulation education. Technical challenges are described; however, it is acknowledged this is an emergent approach at early stages of implementation. Applications in these domains take advantage of the physical, “whole-body” interactions provided by such systems and provide unique experiences for students. According to Miller and Bugnariu (2016), virtual reality environments can be

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categorised into three levels of immersion (low, moderate, high) based on five characteristics (inclusiveness, extensiveness, surrounding, vividness and matching), in order to develop a sense of presence. The level of immersion, in combination with the task and participant, affects the level of presence of the perceptual experience. There is a paucity of evidence comparing two-dimensional (2D) or moderate levels of immersion to three-dimensional (3D) or highly immersive virtual environments. Within the health care education literature, highly immersive virtual reality research has primarily focused on procedural training with mixed outcomes.

6.5

A Learning Framework for Virtual and Simulation

In a 2010 survey, Gore et al. (2012) identified simulation and AR or VR is drawn on widely globally. Areas which appear more engaged are the USA, UK and Canada although this is evident in Asian and middle eastern countries. Furthermore, differences were evident in amount, type and student engagement nonetheless key is that is more ubiquitous. Previously, simulation principles were outlined. Further to this, Jeffries (2016) proposes a framework used to guide virtual and augmented reality: the Jeffries (NLN) simulation theory. According to this theory, a user (or participant) takes part in a simulation experience characterised by an environment of trust, experiential, interactive, learner-centred, goal-oriented and collaborative in nature. The theoretical construct of the simulation learning experience including the educational strategies that are used to facilitate learning illustrates the importance of scaffolding or cueing as a positive component of the adopting virtual and augmented reality in simulation. The theoretical framework centres on the concept of immersion. Slater (2003) argues that immersion depends on the technology used to produce the virtual learning experience but that this can also be modified, controlled as an independent variable for empirical evaluation. Furthermore, the overall level of immersion is made up of many components, such as field of view and resolution pointing out that “the more that a system delivers displays (in all sensory modalities) and tracking that preserves fidelity in relation to their equivalent real-world sensory modalities, the more that it is 'immersive'” (ibid, p. 1). There are limitations to this technology: costly in terms of resources (personnel, equipment and maintenance) and physical space issues. Mobile devices for AR offer affordable possibilities (Ferguson et al. 2015). This has reported advantages in the workplace in terms of improving proficiency with “immediate and active engagement with nursing concepts and skills” (Aebersold et al. 2018). As VR technology advances and becomes increasingly affordable, the shift in focus is from technology development to content integration, and application into real-world environment ensuring an authentic experience (Sherman and Craig 2018). This will have the potential to transform theoretical and clinical learning and ultimately care in the future. Overall simulation and high or low fidelity are key to future nursing education. Consequently, low fidelity potential for simulation resulted in an EU funded

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project in which co-production across several countries strived to explore and devise simulation resources and reach previously unexplored clinical situations.

6.6

I nnovative Simulation Pedagogy for Academic Development (ISPAD): Background

The Innovative Simulation Pedagogy for Academic Development (ISPAD) was a 3 year Erasmus + Strategic partnership for Higher Education funded project which commenced in September 2016 and was completed in August 2019. There has been much greater focus on simulation in acute/hospital care scenarios than the community in undergraduate nursing programmes (Lubbers and Rossman 2017). In Cant and Cooper’s (2017) systematic review exploring the use of simulation in undergraduate nurse education, they report the majority of reviews focused upon patient safety/deterioration or establishing the effectiveness of simulation. No systematic reviews to date have explored simulation in the community setting. There has also been limited focus on preparing novice students for community-based care in undergraduate programmes (Green and Bull 2014). The consensus within this ­project was that simulation resources for all the levels would focus around the community setting situating the learning in a homecare environment in years 1 and 3 or 4 and a Health Clinic in year 2. The simulation activities would also focus on the soft skills such as communication, interpersonal skills, problem solving and ­adaptability. Each simulation kit comprised a degree of information technology and each scenario had to build on the previous year in terms of complexity as well as being universal so that any country could embed the SimNursKit in a nursing curriculum. The University of Malta instigated the project and was the lead partner. The project steering group comprised of 20 nurse educators in total, two from each university. Nurse educators came from ten universities in six different European countries (United Kingdom, Ireland, Finland, Norway, Malta and Italy). The two main goals of the ISPAD project were to: 1 . Develop a simulation champion/education programme for nurse educators. 2. Develop, implement, evaluate and disseminate a simulation kit (SimNursKit) comprising of three simulation resources for use in undergraduate nurse education. Four transnational meetings were held in Malta, Norway, Italy and Finland to progress the project. Nine universities excluding the lead partner university worked in self-selected triads (three groups of three universities). Each triad was tasked with developing a simulation resource for nursing students at: • novice level year 1 • intermediate level year 2/3 • competent level year 3/4

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It was a requirement of the project that the SimNursKit was produced in the English language with the intention was that the SimNursKit could be used universally in undergraduate nurse education. On completion of the SimNursKit, all universities tested one of the resources. Prior to development of the resources and as part of the project, a training programme was developed to enable participants to design, implement and evaluate simulation in higher education with a focus on equipping the participants with the knowledge skills and competences to act as simulation champions in their respective institutions. The simulation champion programme (1 week) was developed and completed by two nominated nurse educators from each partner university. Information seminars to disseminate the work of the ISPAD project were held in each participating country and a final conference hosted on completion of the project. The ISPAD project has been presented at national education and simulation conferences including the UK. The SimNursKit is freely available for use from the following website: https:// www.um.edu.mt/healthsciences/nursing/ispad. The differing outputs will now be explored and discussed.

6.6.1 SimNursKit 1: Year One There has been much greater focus on simulation in acute/hospital care scenarios than the community in undergraduate nursing programmes (Lubbers and Rossman 2017). SimNursKit 1 was therefore considered novel as it addressed a current gap in simulation focusing on professional values and behaviour and orientation to the community setting. Nurses need to be prepared to provide care in any healthcare setting or situation (NMC 2018b). Transforming care means that care is being brought closer to home rather than in the acute setting (Department of Health 2012). Simulation in nurse education therefore needs to be responsive to changes in healthcare provision. Obesity and preventative health are global health priorities (World Health Organization 2013, 2019). The focus of the SimNursKit 1 in addressing these issues was considered to be of international relevance. The aim of SimNursKit 1 was to prepare novice/year one undergraduate nursing students to provide care in a home environment. The key objectives therefore were that the student would be able to: a. Assess the possible environmental risk factors when providing care in the home environment. b. Identify the health behaviour risk factors in this situation. c. Explore appropriate professional behaviour and interaction in home environment. d. Reflect on own personal values, beliefs and culture in relation to observed scenario.

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6.6.2 Development of the SimNursKit 1 Simulated Scenario A short film was developed simulating a community nurse and nursing student at work in the community. The film was co-produced with educators with expertise in simulation and community nursing and nursing students. The film was designed to provide an immersive and authentic learning experience of community nursing which could be used flexibly. A facilitator and student guide (these can be downloaded from the above website) were also developed to accompany the film and assist in the delivery and use of SimNursKit 1. The short film shows a student nurse (Sylwia) accompanying a community nurse (Shirley) on visits to patients’ homes. As a novice student nurse, Sylwia has no previous experience of community care. They both approach a variety of different style homes but only proceed to engage in one patient consultation. The patient featured lives alone and is currently experiencing mobility problems due to a laceration on her lower leg which is compounded by her obesity. Two versions of the film were made (see below), with and without English language subtitles. • Version A has in screen pauses which allowed exploration of the issues as the scenario unfolds. • Version B does not have any pauses so allows uninterrupted view of the unfolding scenario. SimNursKit 1 was considered to be versatile, so that it could be used in a number of different ways as outlined below depending on resources and preferred teaching/ learning approach. a. Watch the film with students either in small or larger groups with a facilitator for discussion and reflective debrief. b. As self-study, students watch the film without a facilitator either in small groups or individually then join the facilitator for reflective debrief. c. As self-study, students watch the film without a facilitator either in small groups or individually then contribute to a discussion board where reflective debrief is monitored by a facilitator. d. Adapt the scenario to allow role-play in a simulation suite, using the simulation templates provided and conduct a reflective debrief after the simulation. The flow diagram (Fig.  6.2) below demonstrates how SimNursKit 1 might be integrated into programmes. The duration of the learning activity will depend upon how SimNursKit 1 is used, which option is selected from the above, the group size and the selection of pre- and post-learning materials. A recommendation is that 3–4 h is allocated to the total use of SimNursKit 1 which includes some pre-learning and post-learning activity.

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Facilitator identifies: • Format and version of film resource to be used • pre and post learning activities

Facilitator conveys pre-learning activities to students

Students undertake Pre-learning activities in readiness for one of the following:

Film resource used independently by students

Film resource used in situ with facilitator

Debriefing occurs online or in situ

Facilitator directs students to Post-learning activities

Students undertake postlearning activities

Student evaluation feedback

Fig. 6.2  SimNursKit 1 proposed integration into programmes

Scenario adapted for role play simulation

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6.6.3 Implementation and Evaluation of SimNursKit 1 The simulation resource was implemented and evaluated by first year nursing students in three international universities. Students completed an anonymous online survey pre (n = 96) and post-simulation (n = 110) with satisfaction measured using the Satisfaction with Simulation Experience Scale (Levett-Jones et  al. 2011) and competence with the Nurse Competence Scale (Meretoja et al. 2004). Interviews and focus groups were held with students and facilitators. Students were highly satisfied with the simulation resource and significant improvements in competence in six categories (diagnostic functions, teaching-­ coaching, managing situations, work role, therapeutic interventions, ensuring quality) and overall competence was reported from pre- to post-session (p  =