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Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery and the development of expertise
Nurse Education Today (2007) 27, 627–634
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery and the development of expertise Joanne Atkinson *, Stephen Tawse Northumbria University, Coach Lane Campus, Newcastle upon Tyne NE7 7XA, United Kingdom Accepted 27 September 2006
KEYWORDS
Summary The role that educational preparation may play in the delivery of care and the development of expertise is a point of some debate [Manley, K., Garbett, R., 2000. Paying Peter and Paul reconciling concepts of expertise with competency for a clinical career structure. Journal of Clinical Nursing 9 (3), 347; King, L., Macleod Clark, J., 2002. Intuition and the development of expertise in surgical ward and intensive care nurses. Journal of Advanced Nursing 37(4), 322–329; Bonner, A., 2003. Recognition of expertise: an important concept in the acquisition of nephrology nursing expertise. Nursing & Health Sciences Journal 5, 123–131; Dunphy, B.C., Williamson, S.L., 2004. In pursuit of expertise. Advances in Health Sciences Education 9, 107–127]. Though education is a concept that may be universally valued, it may be more difficult to clearly discern the significance it has for practitioners who are developing their expertise. This research project employed an interpretive phenomenological design to explore the perceptions of specialist haematology nursing staff on the extent to which specialist education contributes to care delivery and the development of expert practice. A non-representative purposive sample of qualified nurses who had undertaken specialist education in haemopoiesis and work in specialist haematology participated in a focus group and semi-structured interviews. The report concludes that, for these specialist practitioners, specialist educational input had a beneficial impact on their levels of knowledge and confidence. Further to this, involvement in higher education had enabled them to become more active in the learning process. Perhaps the key finding of the study was the assertion by respondents that specialist educational input had enabled them to develop their specialist practice to a level that experience alone could not achieve. c 2006 Elsevier Ltd. All rights reserved.
Expertise; Experience; Specialist education; Haematology; Care delivery; Knowledge and professional confidence
* Corresponding author. Tel.: +44 191 215 6112; fax: +44 191 215 6082. E-mail address: [email protected] (J. Atkinson).
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.09.011
628
Introduction It is well evidenced in the literature that nurses have varying degrees of cancer related knowledge, some of which is as a result of their initial registration which is in turn variable in terms of quality and application (Corner, 1990; Pope, 1992; Ferguson, 1994). Haematological cancers (cancer of blood cells) together represent the fifth most common type of cancer in the UK, accounting for 7% of all cancers. Like the haematological diseases themselves, the forms of treatment vary widely (National Institute for Clinical Excellence (NICE), 2003). The specialist nature of care in haematology requires insight and knowledge not only into disease processes, but also the appropriate therapeutic interventions and their impact. The basic physiological knowledge that underpins practice in this area is that of haemopoiesis commonly known as the formation of blood. This group of patients is very vulnerable and require expert and intensive care. Practitioners working in this area should be cognisant of the impact that an altered blood picture has on the patient as a result of the disease process and treatment. This is essential knowledge on which to base care delivery and appropriate patient assessment.
Background literature The policy agenda in cancer care in recent years has become a driving factor for both education and care delivery. Prior to the Calman–Hine report (Department of Health, DOH, 1995) much of the literature examined the notion of the extended role of the nurse and their perceptions of their roles (Dool et al., 1993; Kalnins et al., 1994; Taylor, 1998). Following the Calman–Hine report, the literature reflected the increasing focus on cancer care education. Corner (1996) highlighted the need for nursing to be considered a lynch pin for the implementation of the recommendations and recognised the enormous educational need if there are to be enough qualified nurses to develop cancer nurses in the future. In addition, the National Health Service (NHS) Cancer Plan (DOH, 2000) has built on the Calman–Hine report being far more specific about the workforce and education implications, adopting a more multi-disciplinary focus. Recruiting and retaining nurses who have or are willing to develop the skills needed to deliver a comprehensive cancer service is essential. The level of expertise required to enhance and develop cancer services
J. Atkinson, S. Tawse was discussed in the document The Nursing Contribution to Cancer Care (DOH, 2000a) when expertise was firmly aligned to a career structure to fit in with the strategic overview of the NHS, this has been reaffirmed in Modernising Nursing Careers (DOH, 2006). Richardson et al. (2002) also explored the need to build skills and develop experts in cancer care advocating clear career structures and effective workforce planning. In defining expertise Dunphy and Williamson (2004) draw upon the work of Dreyfus and Dreyfus (1986, 1996) identifying the expert as having high levels of procedural knowledge and skills, identified as knowing how; declarative knowledge, identified as knowing what; and contextual flexibility, knowing when and where. A brief review of the literature demonstrates that opinions differ as to the impact that education may have on expert practice. In fact, it may be difficult to disentangle the impact of education from a range of other significant factors such as critical analysis and reflection, intuition, experience in specialist contexts and being recognised by significant others as being expert. Manley and Garbett (2000, p. 352) support the notion that education has an important part to play in the development of expertise when they state. . . ‘. . .the general point can be made that exposure to educational experience is a key feature of nurses identified as experts. Moreover, it can be suggested that higher education feeds self confidence, creativity and a willingness to take risks, which are in turn features associated with expertise’. Health care curricula in contemporary Higher Education place value on the active role of the learner in the learning process (Kelly, 2004; Caldwell, 1997). Learners are encouraged to adopt a critical, questioning stance in the development of their knowledge and skills and to collaborate in the sharing and testing of their developing understandings. Such an approach to learning embraces many of the principles of constructivist learning theory (Cust, 1995). Nurses that have been exposed to constructivist learning processes within clinical and higher education contexts are likely to have had their views of their professional worlds challenged through this experience. As Mezirow (1990) asserts, learning is essentially a process through which we arrive at a new or revised interpretation of our experiences. The use of constructivist learning principles may therefore play an important role in the development of practitioners who are able to consciously and critically consider their practice. This is an important point to note when much of the literature
Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery on expertise acknowledges the central role of intuition in expert practice. (Benner, 1984; Benner et al., 1996). It could be argued that experts may practice intuitively but only because they have been exposed to a wealth of educational and experiential interactions that have enabled them to develop and refine their cognitive abilities. King and Macleod Clark’s (2002) study explored the roles of analytical thinking and intuitive awareness at different levels of the Dreyfus and Dreyfus (1986) model of skills acquisition. The developing importance of intuition in the practical experience of nurses who move through the stages of advanced beginner, competent, proficient and expert levels has been debated at length within the nursing literature. However the need to apply conscious analytical thinking skills was also an important feature of this study. King and Macleod Clark (2002) assert that the development of expertise does not rely on experience alone, learning from experience is essential if expertise is to be developed. In complex situations the expert will use their rich theoretical and experiential knowledge of similar events to make sense of the situation, predict the outcome of the care intervention and guide their clinical decision making. Manley and Garbett (2000) have also identified experience as something that needs to be consciously processed if it is to lead to learning and action. King and Macleod Clark (2002, page 327) state. . . ‘It was the depth of the knowledge/experiential base of expert practitioners that made their use of intuition in judgment so skilful. As knowledge and experience grew, so did nurses’ ability to recognise intuitive feelings, interpret and analyse patient situations to improve their decision making and as a result, action more effective care’. It would appear therefore that the role of education and the subsequent development of knowledge might be significant factors in the development of expert practice though not all authors share this viewpoint. Dunphy and Williamson (2004) for example raise serious questions about whether the completion of a rigorous educational process is reflected in the development of expertise or whether prolonged experience in an area of speciality is a more important factor in producing expertise. Dunphy and Williamson (2004) argue that it may be necessary in the development of expertise for specialists to restrict the parameters of their clinical practice if they aspire to become experts. Only by doing this, could practitioners hope to keep up to date with relevant literature and research and develop the high level of technical
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performance that would be required from an expert. Bonner (2003) echoes this view when she states that it is now the norm for nurses to specialise in one field. Bonner (2003) claims that this enables nurses to focus in much greater depth on developing their practice. Hardy et al. (2002) also allude to the context of care in expert practice in research linked to the Royal College of Nursing (RCN) Expertise in Practice Project. The limited scope of expert practice and experience may therefore be important in producing practitioners who are perceived as experts. The extent to which specialist educational input is perceived as significant to the development of expertise is further examined in claims made by Bonner (2003) who asserts that it is the recognition of expertise by significant others that is most influential in enabling individuals to practice as experts. Being trusted, being a role model and being seen to teach others are more valued by colleagues when the recognition of expertise is explored. Being recognised as an expert, it is claimed, enabled nurses to increase the scope of their practice and gave them implicit permission to go beyond traditional nursing boundaries under certain circumstances (Bonner, 2003).
Research process This research study adopted an interpretive approach. In this approach, to research reality is seen as being mentally constructed and socially and culturally based. The approach recognises that multiple interpretations of the reality of social and professional worlds are possible. In keeping with the interpretive ethos this research adopted an inductive approach to the development of knowledge recognising this as an active and ongoing process (Robson, 2000). Phenomenology was chosen as an appropriate design for this research study. The study is concerned with understanding the world of the specialist practitioner as that world appears to the individuals that are immersed within it. (Lowenberg, 1993). According to Smith and Hunt (1997), phenomenology is a research approach that is relevant to the study of complex and nebulous concepts such as caring and expertise. The phenomenological method has value in exploring the meaning and perceived structure of any event and experience that affects human beings, Omery (1983). Phenomenology has been used to examine areas that previously have not been amenable to traditional forms of scientific research such as attitudes, experience or meaning, (Parahoo, 2006).
630 The data collection methods chosen for the research project were focus groups and semi-structured individual interviews. It was felt that both of these data collection methods would generate rich qualitative data and enable the researcher to gain access to the lived experiences of the research respondents. A robust ethical code was developed and the research went through a rigorous ethical approvals process. Participants were made aware of why they had been invited to participate. Consent was sought and information and consent forms were read by and discussed with all of the participating staff before obtaining their permission to involve them in the research study. A non-representative, purposive sample of six individual nurses was utilized within the study. This involved the deliberate selection of individuals who could provide insight into the subject under scrutiny (DePoy and Gitlin, 1998). Morse (1991) suggests that appropriate participants should have knowledge and experience of the subject being studied, ability to critically examine and articulate their experiences and a willingness to share these. The pre-requisites for inclusion in this research were that the participant had to be currently working on the regional specialist haematology unit and have undertaken specialist education in haemopoiesis. The focus group generated a wealth of relevant data, and was vital to inform the thematic construction of the semi-structured interviews and provided useful insights into this specialist area, generating key issues, which informed the next stage of the research project. The interaction between participants in the focus group was lively and productive, a fact that Kitzinger (1995) recognises as a key component of this data collection method. The focus group was tape-recorded, all participants having consented to this process. The researcher informed the respondent that the tape would be transcribed for them to review for accuracy and editing, should they so wish. The data generated by the focus group method was analysed using the principles of grounded theory adhering to the concept of open and axial coding (Glaser and Strauss, 1967). The analysis of qualitative data in a grounded theory approach is concerned with developing a rich theoretical framework concerning the research question in hand. This is done by constantly comparing and contrasting concepts and themes that emerge from the data analysis so refining the emerging theory and accounting for the story lines, incidents and other factors that are contained within the data.
J. Atkinson, S. Tawse The main themes identified from the focus group were: 1. Context and experience 2. Clinical expertise 3. Enhanced care delivery Following the focus group the six subjects were invited to participate in taped semi-structured interviews. The interview is perceived to be the primary tool of data collection in a phenomenological study. During the interview the researcher sought to gain insight into how respondents had made sense of their experience. The participants were questioned using informal semi-structured interview technique to gain information in their own words and descriptions of themes already highlighted in the focus group (Morse, 1991).
Discussion of findings Following the analysis of the focus group and interview data, the significant research themes were confirmed and are discussed below.
Theme 1: context and experience The clinical environment is becoming increasingly specialised and designed more for patient care than for learning in practice. (Glenn and Wilkie, 2000) The practitioners considered the provision of specialist education to be essential in terms of enhancing the patient’s care. The influence that specialist education has had on professional practice in the haematology context is captured in the narrative in terms of patient interaction, staff interaction, patient assessment and professional confidence. The importance of the therapeutic relationship and supportive communication in cancer care has been highlighted in many of the policy drivers including the NHS Cancer Plan (DOH, 2000). The participants of this study all identified how an increase in their knowledge led to an increase in professional confidence and so ability to better meet the patient’s informational needs. This echoes the findings of the study undertaken by Manley and Garbett (2000). Respondent one (focus group) ‘‘As a newly qualified nurse I felt horrible, sometimes patients require specialist information and I was unable to talk to them I can now apply my
Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery extra knowledge and so I am better able to meet the patients needs’’. The physiology of haemopoiesis is complex and a basic pre-requisite for understanding haematological diseases and treatment interventions is that nursing staff should be confident and competent in this area of practice. Practitioners identified that they felt vulnerable in this area and that their educational experience had helped them develop not only their knowledge but also their clinical practice. Respondent three (individual interview) ‘‘I realised I had holes in my knowledge and yes I could deliver the care but my understanding was not all there, when I had undertaken the specialist education it made me feel more confident but not only that it made me realise that we really need to make that type of knowledge a pre-requisite for working on the unit’’. Making educational achievement a pre-requisite for every qualified nurse working on the unit must be tempered with caution. King and Macleod Clark (2002) in their study discuss the notion that developing expertise is dependent, at least in part, on a sound knowledge base and an ability to critically analyse experience, though this is contested by other authors (Dunphy and Williamson, 2004; Bonner, 2003). The above excerpts from research transcripts would suggest that respondents in this research study valued the contribution that education made in enabling them to make sense of their experiences and the delivery of care within this specialist clinical context.
Theme 2: clinical expertise The development of clinical expertise emerged as a significant theme within this research study. When discussing their developing expertise, practitioners acknowledged the validity of their experience and how it helped to develop their ability to deliver effective care (Dunphy and Williamson, 2004). They also highlighted the importance of enhanced knowledge gained through specialist education stating it increased their clinical expertise and professional confidence. Practitioners recognized that the development of expertise was a process that required the active cognitive engagement of the practitioner. They also recognized that the development of their expertise had involved them in a journey. Respondents reported that their early experiences as novice practitioners in haematology had been
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challenging and that they had felt unprepared to deal with some of the clinical situations that they had encountered. . . Respondent four (focus group) ‘‘When I was a newly qualified nurse working in this department there was nobody there to help me look at what knowledge I needed to work in this specialist area. The education has made me go from strength to strength I understand the aims of treatment, care required and diseases much more’’. This excerpt suggests that education plays an important role in moving practitioners through the novice to expert continuum. As experienced practitioners, respondents in the study were able to reflect on their professional development within the haematology context and offer insights into the significance that educational preparation had had for them. . . Respondent two (individual interview) ‘‘As an expert practitioner I see that clinical expertise is essential however it is a progression and it doesn’t just come because you are sat here seeing the patient but because you have had education and read so you have an understanding as well as the experience’’. This statement reinforces the views expressed by King and Macleod Clark (2002) and Manley and Garbett (2000) who have argued in their work that the development of expertise does not rely on experience alone. Experience is something that needs to be consciously processed if it is to lead to learning. Exposure to higher education has been reported as a contributory factor to the development of confidence, creativity and a willingness to take risks (Manley and Garbett, 2000). Practitioners in this study have depicted themselves as being active in the learning process and as being motivated to want to develop their expertise and improve care for their patients. It might be suggested, from their comments, that education has played a significant role in this process.
Theme 3: enhanced care delivery Care delivery in the cancer arena is currently discussed in all of the major policy drivers. Care delivery in specialist haematology is largely concentrated and tightly controlled in secondary care in specialist centres. For many patients with haematological
632 malignancy, their care is co-coordinated from diagnosis to the palliative stage by one or two clinicians and the same team of nursing staff (National Institute for Clinical Excellence (NICE), 2003), involvement of other specialties being kept to a minimum. Whilst for the patients there is continuity of care, this promotes the notion of preciousness surrounding clinical practice in haematology. During the research process the discussions related to this theme involved debate on the difference between care delivery settings, in-patient and out-patient care, and also discussions surrounding the special skills required to care for haematology patients that other practitioners working in general areas did not possess. Respondent three (individual interview) ‘‘Sometimes patients require specialist information related to their disease, you have to be a haematology practitioner to do that, I am able to talk to them about my experience and now my application of extra knowledge through education means I am better able to meet the patients needs’’. This excerpt suggests that both the specialist care environment (Bonner, 2003; Dunphy and Williamson, 2004) and the input of specialist education (Manley and Garbett, 2000; King and Macleod Clark, 2002) are of significance when the development of expert practice is analysed. The respondent infers that educational input has complemented their contextual understanding and enabled them to develop practice to more effectively meet the needs of the patient. This is an important application of the concept of expertise, the ability to tailor care to meet the needs of the individual. Respondents in the study held strong views on the role of education in this process. . . Respondent two (focus group) ‘‘Patients want different care they want their care delivered by experienced nurses, they want it delivered in a different way in haematology, for example we have seen an increase in out-patient care for very dependent patients without the education you just wouldn’t be able to do it’’. The emergence of this theme seems to support assertions made by King and Macleod Clark (2002) who highlighted that as knowledge and experience develops so practitioners are more able to action effective care and demonstrate improved decision making. This is not to discount the role of experi-
J. Atkinson, S. Tawse ence in specialised contexts (Dunphy and Williamson, 2004) and the potential for widening the scope of practice that comes from being recognized as an expert (Bonner, 2003). It would appear though that experience and recognition, even in a specialised context, are not enough to enable nurses to develop their care to a level that is commensurate with the care needs of patients in specialist contexts such as haematology. Respondents in this study have cited education as a factor that is crucial in enabling nurses to develop appropriate and complex approaches to care. This may be viewed as a key indicator of expert practice.
Conclusions This research study set out to explore the perceptions of specialist haematology staff on the extent to which specialist education contributed to the delivery of care and the development of their expertise. It is recognised within the work that it is difficult to isolate the impact that education may have on these concepts. Other factors such as experience in specialist contexts and being recognised by significant others as expert have been cited as being important to the development of expertise. The respondents in this study described the development of their expertise as a journey. In the initial phase of this journey they had been challenged by the demands of the haematology context, stating that they had felt unprepared to deal with some of the clinical situations that they had encountered. Individuals expressed the opinion that involvement in specialist educational provision had led to an increase in their knowledge base and a subsequent increase in professional confidence that had enabled them to meet the needs of their patients more effectively. Specialist education has been perceived by this group of nurses as an important contributory factor in helping them to make sense of this specialist context and the initial feelings of vulnerability that it presented them with. It is important to note that the role of experience was not discounted by this group of nurses as being important to their developing expertise and their ability to deliver effective care (Dunphy and Williamson, 2004). The immersion of these nurses within a specialist care environment seems to have played an important role in the development of their expertise. Another point of note that is significant to the findings of this study was the self concept as learn-
Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery ers that this group of nurses held. The nursing staff involved in this study depicted themselves as being active in the learning process and being motivated to want to develop their expertise and improve the care that they were delivering to their patients. The nurses recognized that active cognitive engagement was an important part of the development of expertise and might therefore be depicted as being receptive to the influences of both experience and education. Within this study an attempt has been made to uncover the differing extents to which experience and specialist education have contributed to the development of expertise in this specialist clinical arena. The findings suggest that experience within a specialist clinical context is an important factor in the development of expertise. However, the nurses in this study have suggested that specialist educational input has complemented their contextual understandings and beyond this, it has also enabled them to develop their practice in a manner that more effectively meets the needs of their patients. The group of nurses studied here have suggested that experience by itself is not enough to enable them to develop their care to a level that is commensurate with the specialist needs of the patients in this complex clinical context. If we accept that the development of complex care interventions is indicative of expert practice then we might conclude that specialist education in areas such as specialist haematology is an important contributory factor to the development of expertise for this group of nurses.
References Benner, P., 1984. From Novice to Expert. Excellence and Power in Clinical Nursing Practice. Addison-Wesley, California. Benner, P., Tanner, C.A., Chelsea, E., 1996. Expertise in Nursing Practice: Caring Clinical Judgement and Ethics. Springer, New York. Bonner, A., 2003. Recognition of expertise: an important concept in the acquisition of nephrology nursing expertise. Nursing & Health Sciences Journal 5, 123–131. Caldwell, K., 1997. Ideological influences on curriculum development in nurse education. Nurse Education Today 17, 140– 144. Corner, J., 1990. The newly registered nurse and the cancer patient. Unpublished PhD Thesis, Kings College, University of London. Corner, J., 1996. Nursing vital to cancer care. Nursing Standard 10 (35), 17. Cust, J., 1995. Recent cognitive perspectives on learning – implications for nurse education. Nurse Education Today 15, 280–290. Department of Health, 1995. A Policy Framework for Commissioning Cancer Services. HMSO, London. Department of Health, 2000. The NHS Cancer Plan. HMSO, London.
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Department of Health, 2000a. The Nursing Contribution to Cancer Care. A Strategic Programme of Action in Support of the National Cancer Programme. NHSE, London. Department of Health, 2006. Modernising Nursing Careers, Setting the Direction. HMSO, London. DePoy, E., Gitlin, L.N., 1998. Introduction to Research. Understanding and Applying Multiple Strategies, second ed. Dool, J., Rodehaver, C.B., Fulton, J.S., 1993. Central Venous Access Devices: Issues for Staff Education and Clinical Competence. Nursing Clinics of North America 28 (4), 973–984. Dreyfus, H.L., Dreyfus, S.E., 1986. Mind over machine: The Power of Human Intuition and Expertise in the Era of the Computer. MacMillan, New York. Dreyfus, H.L., Dreyfus, S.E., 1996. The relationship of theory and practice in the acquisition of skill. In: Benner, P.A., Tanner, C.A., Chelsea, C.A. (Eds.), Expertise in Nursing Practice. Springer Publishing Company Inc., New York, pp. 29–47. Dunphy, B.C., Williamson, S.L., 2004. In pursuit of expertise. Advances in Health Sciences Education 9, 107–127. Ferguson, A., 1994. Evaluating the purpose and benefits of continuing education in nursing and the implications for the provision of continuing education for cancer nurses. Journal of Advanced Nursing 19, 640–646. Glaser, B.G., Strauss, A.L., 1967. The Discovery of Grounded Theory Strategies for Qualitative Research. Aldine, Chicago. Glenn, S., Wilkie, S., 2000. Problem Based Learning in Nursing: A New Model for a New Context. Macmillan Press, London. Hardy, S., Garbett, R., Titchen, A., Manley, K., 2002. Exploring nursing expertise: nurses talk nursing. Nursing Inquiry 9 (3), 196–202. Kalnins, I., Mahon, S.M., Casperson, D.S., 1994. Benefits of collaboration in continuing education: a partnership between a university provider and a nursing specialty organisation. Journal of Continuing Education in Nursing 25 (4), 148–151. Kelly, A.V., 2004. The Curriculum: Theory and Practice, fifth ed. Sage Publications, London. King, L., Macleod Clark, J., 2002. Intuition and the development of expertise in surgical ward and intensive care nurses. Journal of Advanced Nursing 37 (4), 322–329. Kitzinger, J., 1995. Introducing focus groups. British Medical Journal 311, 299–302. Lowenberg, J.S., 1993. Interpretive research methodology: broadening the dialogue. Advances in Nursing Science 16 (2), 57–59. Manley, K., Garbett, R., 2000. Paying Peter and Paul reconciling concepts of expertise with competency for a clinical career structure. Journal of Clinical Nursing 9 (3), 347. Mezirow, J., 1990. Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning. San Francisco Jossey Bass Publishers. Morse, J.M., 1991. Strategies for Sampling. In: Morse, J. (Ed.), Qualitative Nursing Research. Sage, London. National Institute for Clinical Excellence, 2003. Improving Outcomes in Haematological Cancers: The Manual. NICE, London. Omery, A., 1983. Phenomenology: a method for nursing research. Advances in Nursing Science 5 (2), 49–63. Parahoo, K., 2006. Nursing Research, Principles, Process and Issues. Palgrave, New York. Pope, S., 1992. Fundamentals for a new concept of oncology nursing in the professional nursing education programme. Cancer Nursing 75 (12), 137–147. Richardson, A., Miller, M., Potter, H., 2002. Developing, Delivering and Evaluating Cancer Nursing Services. Building the Evidence Base. Kings Fund, London. Robson, C., 2000. Real World Research: A Resource for Social Scientists and Practitioner Researchers. Blackwell, London.
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Nurse Education Today intl.elsevierhealth.com/journals/nedt
Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery and the development of expertise Joanne Atkinson *, Stephen Tawse Northumbria University, Coach Lane Campus, Newcastle upon Tyne NE7 7XA, United Kingdom Accepted 27 September 2006
KEYWORDS
Summary The role that educational preparation may play in the delivery of care and the development of expertise is a point of some debate [Manley, K., Garbett, R., 2000. Paying Peter and Paul reconciling concepts of expertise with competency for a clinical career structure. Journal of Clinical Nursing 9 (3), 347; King, L., Macleod Clark, J., 2002. Intuition and the development of expertise in surgical ward and intensive care nurses. Journal of Advanced Nursing 37(4), 322–329; Bonner, A., 2003. Recognition of expertise: an important concept in the acquisition of nephrology nursing expertise. Nursing & Health Sciences Journal 5, 123–131; Dunphy, B.C., Williamson, S.L., 2004. In pursuit of expertise. Advances in Health Sciences Education 9, 107–127]. Though education is a concept that may be universally valued, it may be more difficult to clearly discern the significance it has for practitioners who are developing their expertise. This research project employed an interpretive phenomenological design to explore the perceptions of specialist haematology nursing staff on the extent to which specialist education contributes to care delivery and the development of expert practice. A non-representative purposive sample of qualified nurses who had undertaken specialist education in haemopoiesis and work in specialist haematology participated in a focus group and semi-structured interviews. The report concludes that, for these specialist practitioners, specialist educational input had a beneficial impact on their levels of knowledge and confidence. Further to this, involvement in higher education had enabled them to become more active in the learning process. Perhaps the key finding of the study was the assertion by respondents that specialist educational input had enabled them to develop their specialist practice to a level that experience alone could not achieve. c 2006 Elsevier Ltd. All rights reserved.
Expertise; Experience; Specialist education; Haematology; Care delivery; Knowledge and professional confidence
* Corresponding author. Tel.: +44 191 215 6112; fax: +44 191 215 6082. E-mail address: [email protected] (J. Atkinson).
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.09.011
628
Introduction It is well evidenced in the literature that nurses have varying degrees of cancer related knowledge, some of which is as a result of their initial registration which is in turn variable in terms of quality and application (Corner, 1990; Pope, 1992; Ferguson, 1994). Haematological cancers (cancer of blood cells) together represent the fifth most common type of cancer in the UK, accounting for 7% of all cancers. Like the haematological diseases themselves, the forms of treatment vary widely (National Institute for Clinical Excellence (NICE), 2003). The specialist nature of care in haematology requires insight and knowledge not only into disease processes, but also the appropriate therapeutic interventions and their impact. The basic physiological knowledge that underpins practice in this area is that of haemopoiesis commonly known as the formation of blood. This group of patients is very vulnerable and require expert and intensive care. Practitioners working in this area should be cognisant of the impact that an altered blood picture has on the patient as a result of the disease process and treatment. This is essential knowledge on which to base care delivery and appropriate patient assessment.
Background literature The policy agenda in cancer care in recent years has become a driving factor for both education and care delivery. Prior to the Calman–Hine report (Department of Health, DOH, 1995) much of the literature examined the notion of the extended role of the nurse and their perceptions of their roles (Dool et al., 1993; Kalnins et al., 1994; Taylor, 1998). Following the Calman–Hine report, the literature reflected the increasing focus on cancer care education. Corner (1996) highlighted the need for nursing to be considered a lynch pin for the implementation of the recommendations and recognised the enormous educational need if there are to be enough qualified nurses to develop cancer nurses in the future. In addition, the National Health Service (NHS) Cancer Plan (DOH, 2000) has built on the Calman–Hine report being far more specific about the workforce and education implications, adopting a more multi-disciplinary focus. Recruiting and retaining nurses who have or are willing to develop the skills needed to deliver a comprehensive cancer service is essential. The level of expertise required to enhance and develop cancer services
J. Atkinson, S. Tawse was discussed in the document The Nursing Contribution to Cancer Care (DOH, 2000a) when expertise was firmly aligned to a career structure to fit in with the strategic overview of the NHS, this has been reaffirmed in Modernising Nursing Careers (DOH, 2006). Richardson et al. (2002) also explored the need to build skills and develop experts in cancer care advocating clear career structures and effective workforce planning. In defining expertise Dunphy and Williamson (2004) draw upon the work of Dreyfus and Dreyfus (1986, 1996) identifying the expert as having high levels of procedural knowledge and skills, identified as knowing how; declarative knowledge, identified as knowing what; and contextual flexibility, knowing when and where. A brief review of the literature demonstrates that opinions differ as to the impact that education may have on expert practice. In fact, it may be difficult to disentangle the impact of education from a range of other significant factors such as critical analysis and reflection, intuition, experience in specialist contexts and being recognised by significant others as being expert. Manley and Garbett (2000, p. 352) support the notion that education has an important part to play in the development of expertise when they state. . . ‘. . .the general point can be made that exposure to educational experience is a key feature of nurses identified as experts. Moreover, it can be suggested that higher education feeds self confidence, creativity and a willingness to take risks, which are in turn features associated with expertise’. Health care curricula in contemporary Higher Education place value on the active role of the learner in the learning process (Kelly, 2004; Caldwell, 1997). Learners are encouraged to adopt a critical, questioning stance in the development of their knowledge and skills and to collaborate in the sharing and testing of their developing understandings. Such an approach to learning embraces many of the principles of constructivist learning theory (Cust, 1995). Nurses that have been exposed to constructivist learning processes within clinical and higher education contexts are likely to have had their views of their professional worlds challenged through this experience. As Mezirow (1990) asserts, learning is essentially a process through which we arrive at a new or revised interpretation of our experiences. The use of constructivist learning principles may therefore play an important role in the development of practitioners who are able to consciously and critically consider their practice. This is an important point to note when much of the literature
Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery on expertise acknowledges the central role of intuition in expert practice. (Benner, 1984; Benner et al., 1996). It could be argued that experts may practice intuitively but only because they have been exposed to a wealth of educational and experiential interactions that have enabled them to develop and refine their cognitive abilities. King and Macleod Clark’s (2002) study explored the roles of analytical thinking and intuitive awareness at different levels of the Dreyfus and Dreyfus (1986) model of skills acquisition. The developing importance of intuition in the practical experience of nurses who move through the stages of advanced beginner, competent, proficient and expert levels has been debated at length within the nursing literature. However the need to apply conscious analytical thinking skills was also an important feature of this study. King and Macleod Clark (2002) assert that the development of expertise does not rely on experience alone, learning from experience is essential if expertise is to be developed. In complex situations the expert will use their rich theoretical and experiential knowledge of similar events to make sense of the situation, predict the outcome of the care intervention and guide their clinical decision making. Manley and Garbett (2000) have also identified experience as something that needs to be consciously processed if it is to lead to learning and action. King and Macleod Clark (2002, page 327) state. . . ‘It was the depth of the knowledge/experiential base of expert practitioners that made their use of intuition in judgment so skilful. As knowledge and experience grew, so did nurses’ ability to recognise intuitive feelings, interpret and analyse patient situations to improve their decision making and as a result, action more effective care’. It would appear therefore that the role of education and the subsequent development of knowledge might be significant factors in the development of expert practice though not all authors share this viewpoint. Dunphy and Williamson (2004) for example raise serious questions about whether the completion of a rigorous educational process is reflected in the development of expertise or whether prolonged experience in an area of speciality is a more important factor in producing expertise. Dunphy and Williamson (2004) argue that it may be necessary in the development of expertise for specialists to restrict the parameters of their clinical practice if they aspire to become experts. Only by doing this, could practitioners hope to keep up to date with relevant literature and research and develop the high level of technical
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performance that would be required from an expert. Bonner (2003) echoes this view when she states that it is now the norm for nurses to specialise in one field. Bonner (2003) claims that this enables nurses to focus in much greater depth on developing their practice. Hardy et al. (2002) also allude to the context of care in expert practice in research linked to the Royal College of Nursing (RCN) Expertise in Practice Project. The limited scope of expert practice and experience may therefore be important in producing practitioners who are perceived as experts. The extent to which specialist educational input is perceived as significant to the development of expertise is further examined in claims made by Bonner (2003) who asserts that it is the recognition of expertise by significant others that is most influential in enabling individuals to practice as experts. Being trusted, being a role model and being seen to teach others are more valued by colleagues when the recognition of expertise is explored. Being recognised as an expert, it is claimed, enabled nurses to increase the scope of their practice and gave them implicit permission to go beyond traditional nursing boundaries under certain circumstances (Bonner, 2003).
Research process This research study adopted an interpretive approach. In this approach, to research reality is seen as being mentally constructed and socially and culturally based. The approach recognises that multiple interpretations of the reality of social and professional worlds are possible. In keeping with the interpretive ethos this research adopted an inductive approach to the development of knowledge recognising this as an active and ongoing process (Robson, 2000). Phenomenology was chosen as an appropriate design for this research study. The study is concerned with understanding the world of the specialist practitioner as that world appears to the individuals that are immersed within it. (Lowenberg, 1993). According to Smith and Hunt (1997), phenomenology is a research approach that is relevant to the study of complex and nebulous concepts such as caring and expertise. The phenomenological method has value in exploring the meaning and perceived structure of any event and experience that affects human beings, Omery (1983). Phenomenology has been used to examine areas that previously have not been amenable to traditional forms of scientific research such as attitudes, experience or meaning, (Parahoo, 2006).
630 The data collection methods chosen for the research project were focus groups and semi-structured individual interviews. It was felt that both of these data collection methods would generate rich qualitative data and enable the researcher to gain access to the lived experiences of the research respondents. A robust ethical code was developed and the research went through a rigorous ethical approvals process. Participants were made aware of why they had been invited to participate. Consent was sought and information and consent forms were read by and discussed with all of the participating staff before obtaining their permission to involve them in the research study. A non-representative, purposive sample of six individual nurses was utilized within the study. This involved the deliberate selection of individuals who could provide insight into the subject under scrutiny (DePoy and Gitlin, 1998). Morse (1991) suggests that appropriate participants should have knowledge and experience of the subject being studied, ability to critically examine and articulate their experiences and a willingness to share these. The pre-requisites for inclusion in this research were that the participant had to be currently working on the regional specialist haematology unit and have undertaken specialist education in haemopoiesis. The focus group generated a wealth of relevant data, and was vital to inform the thematic construction of the semi-structured interviews and provided useful insights into this specialist area, generating key issues, which informed the next stage of the research project. The interaction between participants in the focus group was lively and productive, a fact that Kitzinger (1995) recognises as a key component of this data collection method. The focus group was tape-recorded, all participants having consented to this process. The researcher informed the respondent that the tape would be transcribed for them to review for accuracy and editing, should they so wish. The data generated by the focus group method was analysed using the principles of grounded theory adhering to the concept of open and axial coding (Glaser and Strauss, 1967). The analysis of qualitative data in a grounded theory approach is concerned with developing a rich theoretical framework concerning the research question in hand. This is done by constantly comparing and contrasting concepts and themes that emerge from the data analysis so refining the emerging theory and accounting for the story lines, incidents and other factors that are contained within the data.
J. Atkinson, S. Tawse The main themes identified from the focus group were: 1. Context and experience 2. Clinical expertise 3. Enhanced care delivery Following the focus group the six subjects were invited to participate in taped semi-structured interviews. The interview is perceived to be the primary tool of data collection in a phenomenological study. During the interview the researcher sought to gain insight into how respondents had made sense of their experience. The participants were questioned using informal semi-structured interview technique to gain information in their own words and descriptions of themes already highlighted in the focus group (Morse, 1991).
Discussion of findings Following the analysis of the focus group and interview data, the significant research themes were confirmed and are discussed below.
Theme 1: context and experience The clinical environment is becoming increasingly specialised and designed more for patient care than for learning in practice. (Glenn and Wilkie, 2000) The practitioners considered the provision of specialist education to be essential in terms of enhancing the patient’s care. The influence that specialist education has had on professional practice in the haematology context is captured in the narrative in terms of patient interaction, staff interaction, patient assessment and professional confidence. The importance of the therapeutic relationship and supportive communication in cancer care has been highlighted in many of the policy drivers including the NHS Cancer Plan (DOH, 2000). The participants of this study all identified how an increase in their knowledge led to an increase in professional confidence and so ability to better meet the patient’s informational needs. This echoes the findings of the study undertaken by Manley and Garbett (2000). Respondent one (focus group) ‘‘As a newly qualified nurse I felt horrible, sometimes patients require specialist information and I was unable to talk to them I can now apply my
Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery extra knowledge and so I am better able to meet the patients needs’’. The physiology of haemopoiesis is complex and a basic pre-requisite for understanding haematological diseases and treatment interventions is that nursing staff should be confident and competent in this area of practice. Practitioners identified that they felt vulnerable in this area and that their educational experience had helped them develop not only their knowledge but also their clinical practice. Respondent three (individual interview) ‘‘I realised I had holes in my knowledge and yes I could deliver the care but my understanding was not all there, when I had undertaken the specialist education it made me feel more confident but not only that it made me realise that we really need to make that type of knowledge a pre-requisite for working on the unit’’. Making educational achievement a pre-requisite for every qualified nurse working on the unit must be tempered with caution. King and Macleod Clark (2002) in their study discuss the notion that developing expertise is dependent, at least in part, on a sound knowledge base and an ability to critically analyse experience, though this is contested by other authors (Dunphy and Williamson, 2004; Bonner, 2003). The above excerpts from research transcripts would suggest that respondents in this research study valued the contribution that education made in enabling them to make sense of their experiences and the delivery of care within this specialist clinical context.
Theme 2: clinical expertise The development of clinical expertise emerged as a significant theme within this research study. When discussing their developing expertise, practitioners acknowledged the validity of their experience and how it helped to develop their ability to deliver effective care (Dunphy and Williamson, 2004). They also highlighted the importance of enhanced knowledge gained through specialist education stating it increased their clinical expertise and professional confidence. Practitioners recognized that the development of expertise was a process that required the active cognitive engagement of the practitioner. They also recognized that the development of their expertise had involved them in a journey. Respondents reported that their early experiences as novice practitioners in haematology had been
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challenging and that they had felt unprepared to deal with some of the clinical situations that they had encountered. . . Respondent four (focus group) ‘‘When I was a newly qualified nurse working in this department there was nobody there to help me look at what knowledge I needed to work in this specialist area. The education has made me go from strength to strength I understand the aims of treatment, care required and diseases much more’’. This excerpt suggests that education plays an important role in moving practitioners through the novice to expert continuum. As experienced practitioners, respondents in the study were able to reflect on their professional development within the haematology context and offer insights into the significance that educational preparation had had for them. . . Respondent two (individual interview) ‘‘As an expert practitioner I see that clinical expertise is essential however it is a progression and it doesn’t just come because you are sat here seeing the patient but because you have had education and read so you have an understanding as well as the experience’’. This statement reinforces the views expressed by King and Macleod Clark (2002) and Manley and Garbett (2000) who have argued in their work that the development of expertise does not rely on experience alone. Experience is something that needs to be consciously processed if it is to lead to learning. Exposure to higher education has been reported as a contributory factor to the development of confidence, creativity and a willingness to take risks (Manley and Garbett, 2000). Practitioners in this study have depicted themselves as being active in the learning process and as being motivated to want to develop their expertise and improve care for their patients. It might be suggested, from their comments, that education has played a significant role in this process.
Theme 3: enhanced care delivery Care delivery in the cancer arena is currently discussed in all of the major policy drivers. Care delivery in specialist haematology is largely concentrated and tightly controlled in secondary care in specialist centres. For many patients with haematological
632 malignancy, their care is co-coordinated from diagnosis to the palliative stage by one or two clinicians and the same team of nursing staff (National Institute for Clinical Excellence (NICE), 2003), involvement of other specialties being kept to a minimum. Whilst for the patients there is continuity of care, this promotes the notion of preciousness surrounding clinical practice in haematology. During the research process the discussions related to this theme involved debate on the difference between care delivery settings, in-patient and out-patient care, and also discussions surrounding the special skills required to care for haematology patients that other practitioners working in general areas did not possess. Respondent three (individual interview) ‘‘Sometimes patients require specialist information related to their disease, you have to be a haematology practitioner to do that, I am able to talk to them about my experience and now my application of extra knowledge through education means I am better able to meet the patients needs’’. This excerpt suggests that both the specialist care environment (Bonner, 2003; Dunphy and Williamson, 2004) and the input of specialist education (Manley and Garbett, 2000; King and Macleod Clark, 2002) are of significance when the development of expert practice is analysed. The respondent infers that educational input has complemented their contextual understanding and enabled them to develop practice to more effectively meet the needs of the patient. This is an important application of the concept of expertise, the ability to tailor care to meet the needs of the individual. Respondents in the study held strong views on the role of education in this process. . . Respondent two (focus group) ‘‘Patients want different care they want their care delivered by experienced nurses, they want it delivered in a different way in haematology, for example we have seen an increase in out-patient care for very dependent patients without the education you just wouldn’t be able to do it’’. The emergence of this theme seems to support assertions made by King and Macleod Clark (2002) who highlighted that as knowledge and experience develops so practitioners are more able to action effective care and demonstrate improved decision making. This is not to discount the role of experi-
J. Atkinson, S. Tawse ence in specialised contexts (Dunphy and Williamson, 2004) and the potential for widening the scope of practice that comes from being recognized as an expert (Bonner, 2003). It would appear though that experience and recognition, even in a specialised context, are not enough to enable nurses to develop their care to a level that is commensurate with the care needs of patients in specialist contexts such as haematology. Respondents in this study have cited education as a factor that is crucial in enabling nurses to develop appropriate and complex approaches to care. This may be viewed as a key indicator of expert practice.
Conclusions This research study set out to explore the perceptions of specialist haematology staff on the extent to which specialist education contributed to the delivery of care and the development of their expertise. It is recognised within the work that it is difficult to isolate the impact that education may have on these concepts. Other factors such as experience in specialist contexts and being recognised by significant others as expert have been cited as being important to the development of expertise. The respondents in this study described the development of their expertise as a journey. In the initial phase of this journey they had been challenged by the demands of the haematology context, stating that they had felt unprepared to deal with some of the clinical situations that they had encountered. Individuals expressed the opinion that involvement in specialist educational provision had led to an increase in their knowledge base and a subsequent increase in professional confidence that had enabled them to meet the needs of their patients more effectively. Specialist education has been perceived by this group of nurses as an important contributory factor in helping them to make sense of this specialist context and the initial feelings of vulnerability that it presented them with. It is important to note that the role of experience was not discounted by this group of nurses as being important to their developing expertise and their ability to deliver effective care (Dunphy and Williamson, 2004). The immersion of these nurses within a specialist care environment seems to have played an important role in the development of their expertise. Another point of note that is significant to the findings of this study was the self concept as learn-
Exploring haematology nurses’ perceptions of specialist education’s contribution to care delivery ers that this group of nurses held. The nursing staff involved in this study depicted themselves as being active in the learning process and being motivated to want to develop their expertise and improve the care that they were delivering to their patients. The nurses recognized that active cognitive engagement was an important part of the development of expertise and might therefore be depicted as being receptive to the influences of both experience and education. Within this study an attempt has been made to uncover the differing extents to which experience and specialist education have contributed to the development of expertise in this specialist clinical arena. The findings suggest that experience within a specialist clinical context is an important factor in the development of expertise. However, the nurses in this study have suggested that specialist educational input has complemented their contextual understandings and beyond this, it has also enabled them to develop their practice in a manner that more effectively meets the needs of their patients. The group of nurses studied here have suggested that experience by itself is not enough to enable them to develop their care to a level that is commensurate with the specialist needs of the patients in this complex clinical context. If we accept that the development of complex care interventions is indicative of expert practice then we might conclude that specialist education in areas such as specialist haematology is an important contributory factor to the development of expertise for this group of nurses.
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