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Strategies used by experienced versus novice practice teachers to enact their role with community nurse students
Nurse Education Today 31 (2011) 558–563
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Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t
Strategies used by experienced versus novice practice teachers to enact their role with community nurse students Lynn Sayer ⁎ Programme Leader Community Health Nursing, Brunel University, Uxbridge, UB8 3PH, UK
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Article history: Accepted 31 October 2010 Keywords: Community nursing Practice teaching Professional education Grounded theory
s u m m a r y This study offers an original analysis of how community nurse practice teachers learn to enact their role. A constructivist grounded theory approach was applied to a study of thirty community nurse practice teachers. Practice teachers were interviewed using a lightly structured interview approach following ethical approval. The study found that practice teachers considered relationships and nurturance to be of central importance. This led to emphasis being placed on providing experience for students and formative assessment. A number of key differences between the way novice and experienced practice teachers saw themselves functioning were discovered. These differences were theorised to explain the finding that novice practice teachers were much more likely to identify students as experiencing major difficulties than experienced practice teachers. It was discovered that practice teachers learn to enact their role within a socio-cultural context drawing upon a transformation approach to learning. This approach becomes firmly established over a period of approximately three years and is at odds with the current emphasis on competency based transmission models of learning. © 2010 Elsevier Ltd. All rights reserved.
Introduction The PhD study on which this paper is based explored the development of community nurse practice teachers. Community nurse practice teachers are qualified as nurses and community nurses, most have at least eight years nursing experience, the average for the interviewees in this study was 24 years experience. In the UK the title for the role has undergone a number of changes leading to confusion. However the title of practice teacher has now been set by the Nursing and Midwifery Council (NMC, 2006), hence this paper will use the term practice teacher. International comparisons are difficult as there are few examples of a directly equivalent in role. Nevertheless irrespective of title, developed countries like the UK require those responsible for post qualifying students in practice settings to be prepared for their role (ANMC, 2009). Practice teachers are expert practitioners who facilitate 50% of the community nursing students' practice placement, designing and providing learning opportunities and conducting assessments of the students' professional development. At the end of the students' programme they are accountable for student registration and fitness for practice (Byers and CPHVA, 2002). A range of educational programmes prepare practice teachers for this role. These programmes enable practice teachers to fulfil the mandatory requirement laid down in the NMC's Standards to support learning and assessment in practice (NMC, 2006). Overall therefore
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practice teachers are well equipped for their practitioner and practice teacher role. The NHS Plan (DoH, 2000) specifically stated the need to have appropriately qualified, high quality teaching staff that is committed to delivering education in practice (Clay and Wade, 2001). This need was reiterated in the document Preparation of Mentors and Teacher (DoH/ENB, 2001) where the importance of dedicated, appropriately qualified and supported staff to support learning in practice was stressed. However this PhD study was undertaken during a period of staff shortages with practitioners experiencing high workload pressures, a national picture which adversely impacted upon the ability to provide high quality practice placements for the education of community nurse students. A picture of staff shortages which is still in evidence today and one not limited to community nursing but is also prevalent in other spheres of public sector practice across the developed world (Janiszewski Goodin, 2003; Kin, 2009; Remery, 2003). It was recognised through a review of the literature that community nurse practice teaching was an under-researched area (Sofaer, 1999). The community nurse practice teacher literature that did exist along with the very large body of literature relating to preregistration nursing student mentorship proved to be small scale and predominantly atheoretical. However the literature did highlight that good interpersonal interaction within practice placements appear to be essential to the professional socialisation process of student nurses (Cahill, 1996; Dunn and Hansford, 1997; Lamb, 2005; Papp et al., 2003; Spouse, 1996). The interaction between mentor and student was reported to be of most significance in facilitating students' access
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to the practice community and their subsequent learning (Spouse, 1996; White et al., 1993). Thus it was the social processes within practice placements that were demonstrated to have the most significant impact on students' development. A few studies (Burkitt et al., 2000; Cope et al., 2000; Spouse, 2001) introduced the concepts cognitive apprenticeship, situated learning and communities of practice to nurse education. This literature resonated with the data collected within this study and analysis led to recognition of the fit between the categories emerging from this study and the theories within socio-cultural approaches to learning (Sfard, 1998; Hodkinson and Hodkinson, 2004; Lave and Wenger, 1991). Nurse education has always heavily relied on the transmission of knowledge and competence taking place in practice settings under the guidance of qualified practitioners. Individualistic approaches to learning abound in academic and professional practice where the learner is perceived to acquire competence through the transmission of knowledge and skills. This individualistic transmission approach is termed by Beckett and Hager (2002) the ‘standard paradigm’ of learning. However McCormick's (1999) research demonstrates that students' learning in practice cannot be adequately explained within the standard paradigm of knowledge and skill accumulation and of expert to novice transmission. Such an approach misses the cultural process of socialisation into the attitudes and values informing professional practice and the construction of a professional identity. As a consequence of this limitation educationalists started to view learning not as acquisition by an individual, but as a social phenomenon, through the learner's participation situated in a social context (Sfard, 1998; Hodkinson and Hodkinson, 2004). The result of this learning process is a transformation, whereby a learner's professional identity is changed through a process of enculturation. The transformation affects the person as a whole as the cultural practices of the group become ingrained into the learner's personality through a subconscious learning process. This is in marked contrast to a model of transmission where knowledge and skills are consciously acquired by a learner to enhance their performance or competence. Hence it is a view at odds with the standard paradigm approach currently favoured within nursing (Field, 2004). Method Strauss and Corbin's (1998) school of grounded theory was adopted whilst being influenced by Charmaz (2006), whose constructivist grounded theory approach was applied to a study of thirty community nurse practice teachers who had worked with 113 students. The practice teachers were interviewed using a lightly structured interview approach following University and NHS ethical approval. Tenets of grounded theory were applied within the study including theoretical sampling and the constant comparative method. Theoretical sampling involved both the selection of interviewees and the examination of literature. There is a recognised tension in reviewing literature within a grounded theory approach. However to reconcile this tension the concept of ‘emergent fit’ (Glaser, 1978) was deployed. Emergent fit is a complex iterative process outlined by Wuest (2000) where existing literature and theoretical frameworks can be used to support the emerging theory. This is supported by Glaser and Strauss (1967) who acknowledge that all data available to a grounded theorist can be included in the process of theory development such as the existing literature available to the researcher. Theoretical sampling involves the sample being selected throughout data collect on theoretical grounds so emerging ideas can be explored and theory built as data analysis progresses (Rice and Ezzy, 1999). By the time thirty interviews had been undertaken the critical categories appeared fully developed in the sense that patterns were recurring and no new information was forthcoming, a state termed by Dey (1999) as theoretical sufficiency. The study sought to sample from the full range and variation of practice teachers, to guide the emerging theory including professional
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discipline and level of experience. Developing categories were tested against new interview data in an attempt to verify the category and its relationships (Coyne, 1997). This process is called constant comparison, which involves concurrently collecting, coding and analysing the data. This article is focussing on one aspect of the overall study, that of the practice teacher's journey of development from novice to experienced status. For the purpose of this study a novice practice teacher was defined as someone working with their first or second community nurse student.
Findings There was overwhelming evidence that experienced practice teachers saw themselves applying a transformation model to the students learning. Narratives provided rich evidence that practice teachers saw their role as enabling students to change their identity from being a nurse to becoming a community nurse. They did this within a social context where interpersonal relationships were the key to the students' professional development. The relationship between the student and the practice teacher was raised as being very important by all interviewees. Practice teachers saw themselves as being responsible for building a good relationship which they considered to be pivotal for students learning. Interviewees stated that good relationships enhanced open communication between student and practice teacher which in turn enabled practice teachers to get to know the student better and ascertain their needs. Based on this assessment they were able to provide reassurance and experiences that could reduce the student's anxiety. Their growing trust in the student resulted in them allowing the student to undertake more experiences either alone or of a more complex nature. The link between relationships, trust and learning is also echoed in the work of Cope et al. (2000), Sellman (2006) and Snyder and Wenger (2004). Practice teachers applying the transformation approach viewed themselves not merely adding skills and knowledge but changing identities, this change of identity was considered to take time, skill and patience as the following quote demonstrates. Interviewee 1: I have to be mindful all the time that these students are mature students and some of them have had senior jobs so you've got to be mindful of that all the time, you've got to be patient with them. It could be thought that a mature student with a lot of experience would achieve competence at a quick pace and consequently would be given more responsibility, in such cases there would appear no need to be patient. However the previous interviewee is saying that these students may have further to travel to change a strong existing identity, hence the need for greater patience as the student will experience greater instability as their identity transforms. Students were seen undergoing an identity transformation from that of ‘nurse’, which they felt comfortable with to that of ‘community nurse’. As students progressed through this period of intense socialisation they reportedly felt deskilled as their existing identity of ‘nurse’ splintered, as indicated by Interviewee 18. Interviewee 18: The first term they are finding their feet getting to know things, then feeling deskilled and frustrated and cross and then setting off on their own Christmas January time. The combination of starting a new course where the change of pace from ‘hurrying and scurrying around a ward’ (Interviewee 26) to ‘observing’, the close relationship with the practice teacher and a transformation of identity reportedly provide a very unsettling environment. Not surprisingly students were reported to feel deskilled and disorientated. Interviewee 13 described students as experiencing an identity crisis at this time.
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Interviewee 13: I think a lot of people have a huge identity crisis you know, ‘what am I doing? I used to be very experienced in this field and now I know nothing, I can do nothing, I'm not allowed to do anything’. Experienced practice teachers frequently reported a high level of nurturance during this period to support the student through this tumultuous time of transformation. Evidence for the transformation approach included the following findings: • A lengthy observation period occurred where students were instilled with the values and culture of being a community nurse, this on average took the first two to three months of the placement. Students were not allowed to work unsupervised until the practice teacher had confidence that they were displaying their new identity as a community nurse. • Practice teachers concentrated on building their relationship with students rather than on the competences that needed to be learnt. • Little emphasis was placed on directly teaching the student, instead lots of experiences were provided which encourage the student to become seeped in the culture of community nursing practice. • Practice teachers viewed fitting-in to the community of practice to be a central goal for the student, so the student could fully gain from the reciprocity of the social setting. • Decisions were taken 1/3rd to 2/3rds of the way through the placement that students would pass, at a point where they were demonstrating they had sufficiently absorbed the community nurse identity and could practice alone, but had not achieved competence. As a consequence summative assessment was given little emphasis, this was an activity required for the University but did not correlate with the decision to pass the student. None of the previous findings fit a transmission approach but all fit a transformation approach to learning. Exceptions to a transformation approach were seen in the narratives of novice practice teachers; it appeared from this study that practice teachers took three years to fully embrace the transformation approach to learning. This transformation of their own facilitation style was reported to occur due to their experience of working with their first two students. All thirty interviewees said they learnt how to enact the practice teacher role by undertaking it, as Interviewee 21 highlights. Interviewee 21: Learning in action is where you gain your experience isn't it? No matter how much teaching you have in the classroom you are never quite prepared really. Practice teacher narratives indicated that the steepest learning curve was having their few students. What they learnt from these students appeared to have a significant impact upon their identity development and their perceived role with subsequent students. Three years appeared to be the point in time when the novice practice teacher took on the attributes of the experienced practice teacher. This was stated explicitly or implicitly in the narratives of twelve of the seventeen practice teachers already with three or more years' experience. The following quotes highlight that practice teachers begin to find their feet with their third student, they start to be more relaxed and flexible and the prescriptive approach of having to do things ‘by the book’ and tick all the boxes which appeared to occur in the first year or two disappeared. Interviewee 8: The first two years I was on quite a steep learning curve, especially the first year. Then I kind of got to grips with what it was all about, then I became a practice teacher.
Interviewee 11: I think you fail your first students, it is such a hard task being a CPT and you won't be the best obviously, but you look back and
think ‘Christ that's poxy’, you know what I mean? It wasn't until the third that I got into it. The experienced practice teacher previously mentioned was very forthright in her view that it takes the first two students to learn how to do the job. The later findings could be considered to support this interviewee's perception of her own development as a novice practice teacher. Out of 113 students the interviewees had worked with, 25 were identified as having difficulties. 80% of these students were based with novice practice teachers. Of the 20% with experienced practice teachers 15% had been moved from an initial placement with a novice practice teacher that had broken down. Possible explanations for novice practice teachers identifying students with difficulties include their lack of experience, lack of confidence and taking a transmission approach to learning. A transmission approach resulted in their emphasis on the student being taught in order to meet competencies and outcomes, rather than on building relationships. This study found that as practice teachers gained experience they spent more time on relationship building and nurturing their students. They took a more flexible approach to identify where the student was on their journey to becoming a community nurse and then provided them with the environment to progress on that journey. Strategies used by practice teachers Closer analysis of the correlation between student difficulties and practice teacher level of experience led to the discovery that practice teachers adopted different strategies to manage difficulties. The different strategies used could explain how experienced practice teachers prevent problems being identified or resolved at a stage before they become major problems. These different practices are listed in Table 1. Interviewees who stated they had students with difficulties whilst they were novices reported that they had not been clear in their feedback to students. Lack of clarity on the part of the novice practice teacher could be a reason for the finding that only one percent of the students with novice practice teachers acknowledged the difficulties in comparison with 67% of students with experienced practice teachers. Interviewee 3: She didn't feel she had anything to work on, that was a problem. I think what I could have done differently certainly being very much more straightforward was definitely one of them, but you want to be as nice as you can really and not smash their confidence. This interviewee gives two reasons for not being clear, wanting to be kind and not wanting the student to lose confidence. One or both of these reasons were mentioned by all novices. However by not addressing the issue clearly it was not recognised by the student and reportedly became more of a problem, with the interviewee coming to see the student in a negative light with attributes deemed to be unchangeable. Table 1 Strategies employed by experienced versus novice practice teachers. Experienced practice teacher strategies
Novice practice teachers strategies
• Clear in feeding back areas of • Not clear enough in their feedback to the student weakness student what the problems were • Constructive in feeding back • Did not confront difficulties early enough areas of student weakness • Quick in feeding back areas of • Did not access support from the university or student weakness employer at all or early enough • Unrealistic expectations of the students
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Confronting in a clear and constructive manner is a skill novice practice teachers reportedly struggled with. All interviewees with difficulties when novices criticised themselves over this area, feeling they should have been clearer and more specific in constructively confronting the difficulties. Experienced practice teachers related issues that their students needed to address. These practice teachers appeared to clearly and persistently confront the student about issues so they were resolved and never became identified as a ‘difficulty’. Experienced practice teachers seemed more willing or able to take a more directive approach than novice practice teachers. Interviewee 5 used her skills to ensure clarity without creating a defensive reaction in the student. Interviewee 5: I did have to say ‘I think you need to approach people in a more … you need to smile more when you greet people because I know you've got a fantastic sense of humour but they can't see that’. She hadn't realised and she was upset but she didn't think ‘this is awful’, she just said ‘oh dear I didn't realise’ and she did change straight away. The previous quote demonstrates the ability to confront a student about a personal issue constructively in a way that prevented the feedback being destructive. In contrast confrontation of issues by novice practice teachers were reported to create negative responses in students. As highlighted in the following quote. Interviewee 6: She got very upset, very tearful. When she calmed down she said that she always felt that I was looking over her shoulder and checking on what she was doing and she felt stressed. It sounded like she thought I was somehow creating this problem for her by being there as her CPT. The difficulty for the practice teacher was the student's reaction appearing to accuse the practice teacher of creating the problem. Whether students take constructive criticism more easily from experienced practice teachers or whether experienced practice teachers can give criticism more constructively than novice practice teachers is not possible to ascertain from this study. However as the previous analysis indicates both features were evident in interviewee narratives. A practice teacher learning point was that not only should difficulties be confronted clearly they should be addressed early. Again all novice practice teachers who said the student had difficulties expressed a view that they did not address these difficulties quickly enough. The Interviewee 3 felt that her inexperience contributed to the difficulties for her student. Interviewee 3: I've found it a very challenging year, very stressful and you know it was just the fact that I was a student as well. I felt disorganised I didn't really know what I was doing, where I was supposed to be and you know if I'd have had that student later on I would have closed down the problems a lot earlier than I did. I think I was too nice, I think I should have said it like it is a lot earlier. On reflection practice teachers said the delay in raising concerns had two effects, firstly it allowed the student to believe there wasn't a problem with what they are doing. Secondly it generated frustration and anger in the practice teacher which built up and impacted on the relationship. Interviewee 3 recognises that in her attempt to be nice she did not confront the issues, whereas experienced practice teachers did not see these as being mutually exclusive and saw themselves confronting in a direct yet gentle and effective way as highlighted by Interviewee 5. Using support mechanisms was also an issue for novice practice teachers, who frequently reported that they did not involve the university or managers because either they hoped the difficulty would resolve itself or they feared that involving the university or manager would make the situation worse. However involvement of the
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university was potentially a feature in resolving difficulties as these were frequently resolved when the tutor became involved. In all cases where interviewees had raised concerns with tutors there was a view that the student acknowledged the issues when the tutor from the university visited. Perhaps it was the clarity provided by these visits that made the student recognise the difficulty and the level of concern the practice teacher had over the issue. However eight of the novice practice teachers said that on reflection the involvement should have been earlier. Interviewee 9: With hindsight I would have actually wanted to have an earlier meeting with the tutor rather than leaving it as late as I did. Novice practice teachers appeared to have higher expectations of their students than experienced practice teachers as highlighted in the following quote. Interviewee 12: Well with my first student I don't know whether I was the one who was expecting perfection you know ... I wasn't too sure to judge what a student can do. Practice teachers had a view of the ‘ideal’ community nurse student, however experienced practice teachers recognised that students rarely meet this ‘ideal’ and will have gaps which require hard work to overcome. Whereas novice practice teachers reportedly held expectations of students closer to the ‘ideal’. When students do not fulfil these expectations anxiety levels appeared to rise, the result was an issue that was more likely to become identified as a ‘difficulty’. The novice practice teachers reluctance to address the issue then allows problems to build as does their anxiety. As a consequence absorption with their own anxiety, lack of experience and lack of confidence could make them appear unavailable or unapproachable to the student. The elements of nurturing, reciprocity and participation do not appear to become enacted and the relationship either does not develop or is undermined, resulting in a lack of mutual respect and trust. In five cases where this appeared to occur a downward spiral was embarked upon which either destroyed the relationship between practice teacher and student or prevented it from developing. For novice practice teachers whose students appeared far from the ideal there was a view that either insufficient time was available during the course to develop, or the gap related to an area which could not be learnt as stated by the following novice practice teacher. Interviewee 20: To be honest with you, in a people orientated profession I cannot see how anyone can do it without those skills to start off with. It's a difficult one but my personal opinion is that if you come into a profession where you deal with people you should have good communication skills to start off with and if you lack in certain areas it's a question of polishing and you shouldn't need much. However an experienced practice teacher faced with a student who was not an effective listener had a different view about the potential of a student to develop. The practice teacher appeared to clearly confront the student about this as she states in the following quote. Interviewee 16: He gradually got the picture. I think I just kept reminding him, ‘just listen’, ‘let them tell you’, ‘don't interject quite so much’, ‘just sit and listen’. He took it on board, but I had to repeat it for quite a while. So although this was a student with an area of weakness that needed addressing it did not become a problem for the practice teacher or the student. It would appear from the quote that the
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practice teacher was clear and persistent in working with the student and resolved the issue, so it never became identified as a ‘difficulty’. The findings from this study show that if a student had an inexperienced practice teacher there was an increased chance of them being considered to have problems. It also appeared that issues are resolved more quickly with experienced practice teachers so they are less likely to become labelled as difficulties by the practice teacher. Interviewee 1 believed it was her inexperience that in part led to her student's behaviour which caused the practice teacher difficulty through the year. Interviewee 1: It could have been my lack of experience, which is why she was reacting in the extreme. She was argumentative to the extreme where she's not hearing what you're saying at all and will not accept any other person's point of view. She thought what she thought and that was it and well she shouted at me a few times. That was completely inappropriate behaviour.
mation offers a rich resource to enhance the development of all those in the practice community. There has been a move towards socio-cultural approaches to learning within in a number of professions, where situated learning and community of practice theory has become valued (Bleakley, 2002). However this has not occurred in nursing because of the positioning of nursing within the scientific paradigm. In its push to gain professional status nursing can be argued to have distanced itself from features considered to undervalue its professionalism, such as caring, nurturing and interpersonal relationships (Davies, 1996). This distancing is short-sighted and harmful to nurse education which could gain from taking cognisance of a socio-cultural approach. An approach its practitioners appear to have already embraced in practice to good effect and one which employers could utilise as a learning resource in their organisations.
References The interviewee believed that she allowed the student to ride roughshod over her to a degree that would not be permitted with a more experienced practice teacher. From the analysis of inexperienced practice teachers' interviews this interviewee's interpretation appears credible. With inexperienced practice teachers issues were ongoing for long periods of the course, whereas with experienced practice teachers issues tended to be resolved during the first few months. From this discussion of expectations and differences between novice and experienced practice teachers it could be argued that the identification and labelling of students as ‘difficult’ is socially constructed and a significant part of this construction relates to the practice teacher, particularly their level of experience. Practice teachers reported a sense of failure if their student had ‘difficulties’, a feeling experienced by the mentors in Duffy's (2003) study. It is clear from this study that practice teachers during the first two years of working with community nurse students need more support than the majority of them receive. Support is required to help novice practice teachers use the strategies employed by experienced practice teachers, which appears to be more effective when difficulties emerge. Support mechanisms are in place for novice practice teachers including the practice teacher course, an allocated supervisory practice teacher and sometimes a practice teacher forum within an employing organisation. Twenty seven of the interviewees cited these mechanisms and in particular the course and study days as being of great value as some of the following comments indicate. It gave me support whilst working with the student (Interviewee 9)I got suggestions for alternative approaches (Interviewee 15)It was a good support, I got support from the tutors (Interviewee 20) However these mechanisms need enhancing in order to support novice practice teachers through this difficult period of their own transformation.
Conclusion Practice teachers learn to enact their role within a socio-cultural context drawing upon a transformation approach to learning. This approach becomes firmly established over a period of approximately three years and is at odds with the current emphasis on competency based transmission models of learning, advocated by Statutory Bodies. Practice teachers learnt to enact a transformation approach in order to socialise students and change their identities because they found this a more effective form of professional development than the one being advocated. This learning process resulted in practice teachers themselves being transformed. The educational skills and strategies developed by experienced practice teachers following this transfor-
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Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t
Strategies used by experienced versus novice practice teachers to enact their role with community nurse students Lynn Sayer ⁎ Programme Leader Community Health Nursing, Brunel University, Uxbridge, UB8 3PH, UK
a r t i c l e
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Article history: Accepted 31 October 2010 Keywords: Community nursing Practice teaching Professional education Grounded theory
s u m m a r y This study offers an original analysis of how community nurse practice teachers learn to enact their role. A constructivist grounded theory approach was applied to a study of thirty community nurse practice teachers. Practice teachers were interviewed using a lightly structured interview approach following ethical approval. The study found that practice teachers considered relationships and nurturance to be of central importance. This led to emphasis being placed on providing experience for students and formative assessment. A number of key differences between the way novice and experienced practice teachers saw themselves functioning were discovered. These differences were theorised to explain the finding that novice practice teachers were much more likely to identify students as experiencing major difficulties than experienced practice teachers. It was discovered that practice teachers learn to enact their role within a socio-cultural context drawing upon a transformation approach to learning. This approach becomes firmly established over a period of approximately three years and is at odds with the current emphasis on competency based transmission models of learning. © 2010 Elsevier Ltd. All rights reserved.
Introduction The PhD study on which this paper is based explored the development of community nurse practice teachers. Community nurse practice teachers are qualified as nurses and community nurses, most have at least eight years nursing experience, the average for the interviewees in this study was 24 years experience. In the UK the title for the role has undergone a number of changes leading to confusion. However the title of practice teacher has now been set by the Nursing and Midwifery Council (NMC, 2006), hence this paper will use the term practice teacher. International comparisons are difficult as there are few examples of a directly equivalent in role. Nevertheless irrespective of title, developed countries like the UK require those responsible for post qualifying students in practice settings to be prepared for their role (ANMC, 2009). Practice teachers are expert practitioners who facilitate 50% of the community nursing students' practice placement, designing and providing learning opportunities and conducting assessments of the students' professional development. At the end of the students' programme they are accountable for student registration and fitness for practice (Byers and CPHVA, 2002). A range of educational programmes prepare practice teachers for this role. These programmes enable practice teachers to fulfil the mandatory requirement laid down in the NMC's Standards to support learning and assessment in practice (NMC, 2006). Overall therefore
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practice teachers are well equipped for their practitioner and practice teacher role. The NHS Plan (DoH, 2000) specifically stated the need to have appropriately qualified, high quality teaching staff that is committed to delivering education in practice (Clay and Wade, 2001). This need was reiterated in the document Preparation of Mentors and Teacher (DoH/ENB, 2001) where the importance of dedicated, appropriately qualified and supported staff to support learning in practice was stressed. However this PhD study was undertaken during a period of staff shortages with practitioners experiencing high workload pressures, a national picture which adversely impacted upon the ability to provide high quality practice placements for the education of community nurse students. A picture of staff shortages which is still in evidence today and one not limited to community nursing but is also prevalent in other spheres of public sector practice across the developed world (Janiszewski Goodin, 2003; Kin, 2009; Remery, 2003). It was recognised through a review of the literature that community nurse practice teaching was an under-researched area (Sofaer, 1999). The community nurse practice teacher literature that did exist along with the very large body of literature relating to preregistration nursing student mentorship proved to be small scale and predominantly atheoretical. However the literature did highlight that good interpersonal interaction within practice placements appear to be essential to the professional socialisation process of student nurses (Cahill, 1996; Dunn and Hansford, 1997; Lamb, 2005; Papp et al., 2003; Spouse, 1996). The interaction between mentor and student was reported to be of most significance in facilitating students' access
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to the practice community and their subsequent learning (Spouse, 1996; White et al., 1993). Thus it was the social processes within practice placements that were demonstrated to have the most significant impact on students' development. A few studies (Burkitt et al., 2000; Cope et al., 2000; Spouse, 2001) introduced the concepts cognitive apprenticeship, situated learning and communities of practice to nurse education. This literature resonated with the data collected within this study and analysis led to recognition of the fit between the categories emerging from this study and the theories within socio-cultural approaches to learning (Sfard, 1998; Hodkinson and Hodkinson, 2004; Lave and Wenger, 1991). Nurse education has always heavily relied on the transmission of knowledge and competence taking place in practice settings under the guidance of qualified practitioners. Individualistic approaches to learning abound in academic and professional practice where the learner is perceived to acquire competence through the transmission of knowledge and skills. This individualistic transmission approach is termed by Beckett and Hager (2002) the ‘standard paradigm’ of learning. However McCormick's (1999) research demonstrates that students' learning in practice cannot be adequately explained within the standard paradigm of knowledge and skill accumulation and of expert to novice transmission. Such an approach misses the cultural process of socialisation into the attitudes and values informing professional practice and the construction of a professional identity. As a consequence of this limitation educationalists started to view learning not as acquisition by an individual, but as a social phenomenon, through the learner's participation situated in a social context (Sfard, 1998; Hodkinson and Hodkinson, 2004). The result of this learning process is a transformation, whereby a learner's professional identity is changed through a process of enculturation. The transformation affects the person as a whole as the cultural practices of the group become ingrained into the learner's personality through a subconscious learning process. This is in marked contrast to a model of transmission where knowledge and skills are consciously acquired by a learner to enhance their performance or competence. Hence it is a view at odds with the standard paradigm approach currently favoured within nursing (Field, 2004). Method Strauss and Corbin's (1998) school of grounded theory was adopted whilst being influenced by Charmaz (2006), whose constructivist grounded theory approach was applied to a study of thirty community nurse practice teachers who had worked with 113 students. The practice teachers were interviewed using a lightly structured interview approach following University and NHS ethical approval. Tenets of grounded theory were applied within the study including theoretical sampling and the constant comparative method. Theoretical sampling involved both the selection of interviewees and the examination of literature. There is a recognised tension in reviewing literature within a grounded theory approach. However to reconcile this tension the concept of ‘emergent fit’ (Glaser, 1978) was deployed. Emergent fit is a complex iterative process outlined by Wuest (2000) where existing literature and theoretical frameworks can be used to support the emerging theory. This is supported by Glaser and Strauss (1967) who acknowledge that all data available to a grounded theorist can be included in the process of theory development such as the existing literature available to the researcher. Theoretical sampling involves the sample being selected throughout data collect on theoretical grounds so emerging ideas can be explored and theory built as data analysis progresses (Rice and Ezzy, 1999). By the time thirty interviews had been undertaken the critical categories appeared fully developed in the sense that patterns were recurring and no new information was forthcoming, a state termed by Dey (1999) as theoretical sufficiency. The study sought to sample from the full range and variation of practice teachers, to guide the emerging theory including professional
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discipline and level of experience. Developing categories were tested against new interview data in an attempt to verify the category and its relationships (Coyne, 1997). This process is called constant comparison, which involves concurrently collecting, coding and analysing the data. This article is focussing on one aspect of the overall study, that of the practice teacher's journey of development from novice to experienced status. For the purpose of this study a novice practice teacher was defined as someone working with their first or second community nurse student.
Findings There was overwhelming evidence that experienced practice teachers saw themselves applying a transformation model to the students learning. Narratives provided rich evidence that practice teachers saw their role as enabling students to change their identity from being a nurse to becoming a community nurse. They did this within a social context where interpersonal relationships were the key to the students' professional development. The relationship between the student and the practice teacher was raised as being very important by all interviewees. Practice teachers saw themselves as being responsible for building a good relationship which they considered to be pivotal for students learning. Interviewees stated that good relationships enhanced open communication between student and practice teacher which in turn enabled practice teachers to get to know the student better and ascertain their needs. Based on this assessment they were able to provide reassurance and experiences that could reduce the student's anxiety. Their growing trust in the student resulted in them allowing the student to undertake more experiences either alone or of a more complex nature. The link between relationships, trust and learning is also echoed in the work of Cope et al. (2000), Sellman (2006) and Snyder and Wenger (2004). Practice teachers applying the transformation approach viewed themselves not merely adding skills and knowledge but changing identities, this change of identity was considered to take time, skill and patience as the following quote demonstrates. Interviewee 1: I have to be mindful all the time that these students are mature students and some of them have had senior jobs so you've got to be mindful of that all the time, you've got to be patient with them. It could be thought that a mature student with a lot of experience would achieve competence at a quick pace and consequently would be given more responsibility, in such cases there would appear no need to be patient. However the previous interviewee is saying that these students may have further to travel to change a strong existing identity, hence the need for greater patience as the student will experience greater instability as their identity transforms. Students were seen undergoing an identity transformation from that of ‘nurse’, which they felt comfortable with to that of ‘community nurse’. As students progressed through this period of intense socialisation they reportedly felt deskilled as their existing identity of ‘nurse’ splintered, as indicated by Interviewee 18. Interviewee 18: The first term they are finding their feet getting to know things, then feeling deskilled and frustrated and cross and then setting off on their own Christmas January time. The combination of starting a new course where the change of pace from ‘hurrying and scurrying around a ward’ (Interviewee 26) to ‘observing’, the close relationship with the practice teacher and a transformation of identity reportedly provide a very unsettling environment. Not surprisingly students were reported to feel deskilled and disorientated. Interviewee 13 described students as experiencing an identity crisis at this time.
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Interviewee 13: I think a lot of people have a huge identity crisis you know, ‘what am I doing? I used to be very experienced in this field and now I know nothing, I can do nothing, I'm not allowed to do anything’. Experienced practice teachers frequently reported a high level of nurturance during this period to support the student through this tumultuous time of transformation. Evidence for the transformation approach included the following findings: • A lengthy observation period occurred where students were instilled with the values and culture of being a community nurse, this on average took the first two to three months of the placement. Students were not allowed to work unsupervised until the practice teacher had confidence that they were displaying their new identity as a community nurse. • Practice teachers concentrated on building their relationship with students rather than on the competences that needed to be learnt. • Little emphasis was placed on directly teaching the student, instead lots of experiences were provided which encourage the student to become seeped in the culture of community nursing practice. • Practice teachers viewed fitting-in to the community of practice to be a central goal for the student, so the student could fully gain from the reciprocity of the social setting. • Decisions were taken 1/3rd to 2/3rds of the way through the placement that students would pass, at a point where they were demonstrating they had sufficiently absorbed the community nurse identity and could practice alone, but had not achieved competence. As a consequence summative assessment was given little emphasis, this was an activity required for the University but did not correlate with the decision to pass the student. None of the previous findings fit a transmission approach but all fit a transformation approach to learning. Exceptions to a transformation approach were seen in the narratives of novice practice teachers; it appeared from this study that practice teachers took three years to fully embrace the transformation approach to learning. This transformation of their own facilitation style was reported to occur due to their experience of working with their first two students. All thirty interviewees said they learnt how to enact the practice teacher role by undertaking it, as Interviewee 21 highlights. Interviewee 21: Learning in action is where you gain your experience isn't it? No matter how much teaching you have in the classroom you are never quite prepared really. Practice teacher narratives indicated that the steepest learning curve was having their few students. What they learnt from these students appeared to have a significant impact upon their identity development and their perceived role with subsequent students. Three years appeared to be the point in time when the novice practice teacher took on the attributes of the experienced practice teacher. This was stated explicitly or implicitly in the narratives of twelve of the seventeen practice teachers already with three or more years' experience. The following quotes highlight that practice teachers begin to find their feet with their third student, they start to be more relaxed and flexible and the prescriptive approach of having to do things ‘by the book’ and tick all the boxes which appeared to occur in the first year or two disappeared. Interviewee 8: The first two years I was on quite a steep learning curve, especially the first year. Then I kind of got to grips with what it was all about, then I became a practice teacher.
Interviewee 11: I think you fail your first students, it is such a hard task being a CPT and you won't be the best obviously, but you look back and
think ‘Christ that's poxy’, you know what I mean? It wasn't until the third that I got into it. The experienced practice teacher previously mentioned was very forthright in her view that it takes the first two students to learn how to do the job. The later findings could be considered to support this interviewee's perception of her own development as a novice practice teacher. Out of 113 students the interviewees had worked with, 25 were identified as having difficulties. 80% of these students were based with novice practice teachers. Of the 20% with experienced practice teachers 15% had been moved from an initial placement with a novice practice teacher that had broken down. Possible explanations for novice practice teachers identifying students with difficulties include their lack of experience, lack of confidence and taking a transmission approach to learning. A transmission approach resulted in their emphasis on the student being taught in order to meet competencies and outcomes, rather than on building relationships. This study found that as practice teachers gained experience they spent more time on relationship building and nurturing their students. They took a more flexible approach to identify where the student was on their journey to becoming a community nurse and then provided them with the environment to progress on that journey. Strategies used by practice teachers Closer analysis of the correlation between student difficulties and practice teacher level of experience led to the discovery that practice teachers adopted different strategies to manage difficulties. The different strategies used could explain how experienced practice teachers prevent problems being identified or resolved at a stage before they become major problems. These different practices are listed in Table 1. Interviewees who stated they had students with difficulties whilst they were novices reported that they had not been clear in their feedback to students. Lack of clarity on the part of the novice practice teacher could be a reason for the finding that only one percent of the students with novice practice teachers acknowledged the difficulties in comparison with 67% of students with experienced practice teachers. Interviewee 3: She didn't feel she had anything to work on, that was a problem. I think what I could have done differently certainly being very much more straightforward was definitely one of them, but you want to be as nice as you can really and not smash their confidence. This interviewee gives two reasons for not being clear, wanting to be kind and not wanting the student to lose confidence. One or both of these reasons were mentioned by all novices. However by not addressing the issue clearly it was not recognised by the student and reportedly became more of a problem, with the interviewee coming to see the student in a negative light with attributes deemed to be unchangeable. Table 1 Strategies employed by experienced versus novice practice teachers. Experienced practice teacher strategies
Novice practice teachers strategies
• Clear in feeding back areas of • Not clear enough in their feedback to the student weakness student what the problems were • Constructive in feeding back • Did not confront difficulties early enough areas of student weakness • Quick in feeding back areas of • Did not access support from the university or student weakness employer at all or early enough • Unrealistic expectations of the students
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Confronting in a clear and constructive manner is a skill novice practice teachers reportedly struggled with. All interviewees with difficulties when novices criticised themselves over this area, feeling they should have been clearer and more specific in constructively confronting the difficulties. Experienced practice teachers related issues that their students needed to address. These practice teachers appeared to clearly and persistently confront the student about issues so they were resolved and never became identified as a ‘difficulty’. Experienced practice teachers seemed more willing or able to take a more directive approach than novice practice teachers. Interviewee 5 used her skills to ensure clarity without creating a defensive reaction in the student. Interviewee 5: I did have to say ‘I think you need to approach people in a more … you need to smile more when you greet people because I know you've got a fantastic sense of humour but they can't see that’. She hadn't realised and she was upset but she didn't think ‘this is awful’, she just said ‘oh dear I didn't realise’ and she did change straight away. The previous quote demonstrates the ability to confront a student about a personal issue constructively in a way that prevented the feedback being destructive. In contrast confrontation of issues by novice practice teachers were reported to create negative responses in students. As highlighted in the following quote. Interviewee 6: She got very upset, very tearful. When she calmed down she said that she always felt that I was looking over her shoulder and checking on what she was doing and she felt stressed. It sounded like she thought I was somehow creating this problem for her by being there as her CPT. The difficulty for the practice teacher was the student's reaction appearing to accuse the practice teacher of creating the problem. Whether students take constructive criticism more easily from experienced practice teachers or whether experienced practice teachers can give criticism more constructively than novice practice teachers is not possible to ascertain from this study. However as the previous analysis indicates both features were evident in interviewee narratives. A practice teacher learning point was that not only should difficulties be confronted clearly they should be addressed early. Again all novice practice teachers who said the student had difficulties expressed a view that they did not address these difficulties quickly enough. The Interviewee 3 felt that her inexperience contributed to the difficulties for her student. Interviewee 3: I've found it a very challenging year, very stressful and you know it was just the fact that I was a student as well. I felt disorganised I didn't really know what I was doing, where I was supposed to be and you know if I'd have had that student later on I would have closed down the problems a lot earlier than I did. I think I was too nice, I think I should have said it like it is a lot earlier. On reflection practice teachers said the delay in raising concerns had two effects, firstly it allowed the student to believe there wasn't a problem with what they are doing. Secondly it generated frustration and anger in the practice teacher which built up and impacted on the relationship. Interviewee 3 recognises that in her attempt to be nice she did not confront the issues, whereas experienced practice teachers did not see these as being mutually exclusive and saw themselves confronting in a direct yet gentle and effective way as highlighted by Interviewee 5. Using support mechanisms was also an issue for novice practice teachers, who frequently reported that they did not involve the university or managers because either they hoped the difficulty would resolve itself or they feared that involving the university or manager would make the situation worse. However involvement of the
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university was potentially a feature in resolving difficulties as these were frequently resolved when the tutor became involved. In all cases where interviewees had raised concerns with tutors there was a view that the student acknowledged the issues when the tutor from the university visited. Perhaps it was the clarity provided by these visits that made the student recognise the difficulty and the level of concern the practice teacher had over the issue. However eight of the novice practice teachers said that on reflection the involvement should have been earlier. Interviewee 9: With hindsight I would have actually wanted to have an earlier meeting with the tutor rather than leaving it as late as I did. Novice practice teachers appeared to have higher expectations of their students than experienced practice teachers as highlighted in the following quote. Interviewee 12: Well with my first student I don't know whether I was the one who was expecting perfection you know ... I wasn't too sure to judge what a student can do. Practice teachers had a view of the ‘ideal’ community nurse student, however experienced practice teachers recognised that students rarely meet this ‘ideal’ and will have gaps which require hard work to overcome. Whereas novice practice teachers reportedly held expectations of students closer to the ‘ideal’. When students do not fulfil these expectations anxiety levels appeared to rise, the result was an issue that was more likely to become identified as a ‘difficulty’. The novice practice teachers reluctance to address the issue then allows problems to build as does their anxiety. As a consequence absorption with their own anxiety, lack of experience and lack of confidence could make them appear unavailable or unapproachable to the student. The elements of nurturing, reciprocity and participation do not appear to become enacted and the relationship either does not develop or is undermined, resulting in a lack of mutual respect and trust. In five cases where this appeared to occur a downward spiral was embarked upon which either destroyed the relationship between practice teacher and student or prevented it from developing. For novice practice teachers whose students appeared far from the ideal there was a view that either insufficient time was available during the course to develop, or the gap related to an area which could not be learnt as stated by the following novice practice teacher. Interviewee 20: To be honest with you, in a people orientated profession I cannot see how anyone can do it without those skills to start off with. It's a difficult one but my personal opinion is that if you come into a profession where you deal with people you should have good communication skills to start off with and if you lack in certain areas it's a question of polishing and you shouldn't need much. However an experienced practice teacher faced with a student who was not an effective listener had a different view about the potential of a student to develop. The practice teacher appeared to clearly confront the student about this as she states in the following quote. Interviewee 16: He gradually got the picture. I think I just kept reminding him, ‘just listen’, ‘let them tell you’, ‘don't interject quite so much’, ‘just sit and listen’. He took it on board, but I had to repeat it for quite a while. So although this was a student with an area of weakness that needed addressing it did not become a problem for the practice teacher or the student. It would appear from the quote that the
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practice teacher was clear and persistent in working with the student and resolved the issue, so it never became identified as a ‘difficulty’. The findings from this study show that if a student had an inexperienced practice teacher there was an increased chance of them being considered to have problems. It also appeared that issues are resolved more quickly with experienced practice teachers so they are less likely to become labelled as difficulties by the practice teacher. Interviewee 1 believed it was her inexperience that in part led to her student's behaviour which caused the practice teacher difficulty through the year. Interviewee 1: It could have been my lack of experience, which is why she was reacting in the extreme. She was argumentative to the extreme where she's not hearing what you're saying at all and will not accept any other person's point of view. She thought what she thought and that was it and well she shouted at me a few times. That was completely inappropriate behaviour.
mation offers a rich resource to enhance the development of all those in the practice community. There has been a move towards socio-cultural approaches to learning within in a number of professions, where situated learning and community of practice theory has become valued (Bleakley, 2002). However this has not occurred in nursing because of the positioning of nursing within the scientific paradigm. In its push to gain professional status nursing can be argued to have distanced itself from features considered to undervalue its professionalism, such as caring, nurturing and interpersonal relationships (Davies, 1996). This distancing is short-sighted and harmful to nurse education which could gain from taking cognisance of a socio-cultural approach. An approach its practitioners appear to have already embraced in practice to good effect and one which employers could utilise as a learning resource in their organisations.
References The interviewee believed that she allowed the student to ride roughshod over her to a degree that would not be permitted with a more experienced practice teacher. From the analysis of inexperienced practice teachers' interviews this interviewee's interpretation appears credible. With inexperienced practice teachers issues were ongoing for long periods of the course, whereas with experienced practice teachers issues tended to be resolved during the first few months. From this discussion of expectations and differences between novice and experienced practice teachers it could be argued that the identification and labelling of students as ‘difficult’ is socially constructed and a significant part of this construction relates to the practice teacher, particularly their level of experience. Practice teachers reported a sense of failure if their student had ‘difficulties’, a feeling experienced by the mentors in Duffy's (2003) study. It is clear from this study that practice teachers during the first two years of working with community nurse students need more support than the majority of them receive. Support is required to help novice practice teachers use the strategies employed by experienced practice teachers, which appears to be more effective when difficulties emerge. Support mechanisms are in place for novice practice teachers including the practice teacher course, an allocated supervisory practice teacher and sometimes a practice teacher forum within an employing organisation. Twenty seven of the interviewees cited these mechanisms and in particular the course and study days as being of great value as some of the following comments indicate. It gave me support whilst working with the student (Interviewee 9)I got suggestions for alternative approaches (Interviewee 15)It was a good support, I got support from the tutors (Interviewee 20) However these mechanisms need enhancing in order to support novice practice teachers through this difficult period of their own transformation.
Conclusion Practice teachers learn to enact their role within a socio-cultural context drawing upon a transformation approach to learning. This approach becomes firmly established over a period of approximately three years and is at odds with the current emphasis on competency based transmission models of learning, advocated by Statutory Bodies. Practice teachers learnt to enact a transformation approach in order to socialise students and change their identities because they found this a more effective form of professional development than the one being advocated. This learning process resulted in practice teachers themselves being transformed. The educational skills and strategies developed by experienced practice teachers following this transfor-
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