- Email: [email protected]
The role of the nurse lecturer in clinical practice in the Republic of Ireland
Nurse Education in Practice 10 (2010) 189–195
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
The role of the nurse lecturer in clinical practice in the Republic of Ireland Edel McSharry *, Helen McGloin 1, Anne Marie Frizzell 2, Lisa Winters-O’Donnell 3 Department of Nursing and Health Studies, St. Angelas College, Sligo, Ireland
a r t i c l e
i n f o
Article history: Accepted 31 August 2009
Keywords: Nurse lecturer Clinical role Clinical credibility Clinical teaching
s u m m a r y Undergraduate nurse education in Ireland transferred into the third level sector in 2002. As a result nurse lecturers are expected to develop a model of clinical practice that enables them to be involved in practice and its development while maintaining their own nursing expertise and credibility [An Bord Altranais, 2005. Requirements and Standards for Nurse Registration Education Programmes, third ed. An Bord Altranais, Dublin]. In light of this the researchers set out to explore the perceptions of the nurse lecturers’ role in clinical practice among nurse lecturers, preceptors, clinical nurse managers, clinical placement co-ordinators and students. A qualitative research design using focus groups was chosen. A purposive sampling strategy generated the sample for 5 in-depth focus group interviews with the aforementioned key stakeholders and the data was thematically analysed. Five themes emerged which centred on the maintenance of lecturers’ clinical credibility, the lecturers’ role as a resource to clinical staff, teaching and assessing students in practice, the value of fostering relationships in practice and role duplication. The findings from this study supports the anecdotal evidence that confusion exists around the role but more importantly it gives the nurse lecturer population guidance on how to develop the role in partnership with the various stakeholders in a way that supports the nursing students and clinical staff in practice in an effective manner. Ó 2009 Elsevier Ltd. All rights reserved.
Background and context Pre-registration nurse education in Ireland has undergone major transformation over the past 14 years. In 1994 the traditional 3 year apprenticeship model of training was replaced with the registration diploma programme. In 2002 the diploma programme was replaced by a 4 years honours degree programme which is currently provided in universities and colleges of higher education. These changes involved some significant differences in the way in which student nurses are educated and brought Irish nurse education in line with the UK, Canada, North America and Australia (Government of Ireland, 1998, 2000). Approved by the Irish Nursing Board (An Bord Altranais (ABA), 2005) this programme complies with EU regulations (Government of Ireland, 2000). It includes both theoretical and clinical instruction, the latter continues to be a central element of the programme making up half of the programme duration. The clinical practice component is assessed using a competency based assessment strategy set out by the Nursing Board. Students are supernumery when in clinical practice ex* Corresponding author. Tel.: +353 719143580x275. E-mail addresses: [email protected] (E. McSharry), [email protected] (H. McGloin), [email protected] (A.M. Frizzell), [email protected] (L. Winters-O’Donnell). 1 Tel.: +353 719143580x270. 2 Tel.: +353 719143580x272. 3 Tel.: +353 719143580x273. 1471-5953/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2009.08.004
cept for the nine month internship period when they are paid employees of the health services (ABA, 2005). Staff nurses providing direct patient care are responsible for facilitating learning, supervising and assessing students and are called preceptors. The mentors’ role as it is practised on nursing undergraduate programmes in the UK correlates almost exactly with the preceptors’ role in the Irish context (Neary, 2000; Phillips et al., 2000; Spouse, 2001). However in Ireland, an additional role exists, namely the Clinical Placement Co-ordinator (CPC). CPCs are employed by each training hospital and are assigned several clinical areas where students are allocated. The CPC acts as a link between the education and practice setting and contributes to the development of the clinical learning environment (DOHC, 2001). The role involves supporting and facilitating students and preceptors in clinical learning (Drennan, 2002). Furthermore Centres of Midwifery and Nurse Education (CMNE) and Practice Development Units have been set up through out the country to support the ongoing professional development of nurses. The Nurse Education Forum (Government of Ireland, 2000) was established to guide the implementation of the degree programme. This report recognised a change in the traditional link tutors role but envisaged new models of practice evolving during the course of curriculum design and course delivery. It recommended that third level institutions should develop innovative strategies for lecturers to develop link roles with clinical practice (Government of Ireland, 2000). Furthermore the Irish Nursing Board (ABA, 2005)
190
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
stipulates that nurse lecturers engage in clinical practice and its advancement and develop mechanisms for maintaining their own nursing expertise and credibility (ABA, 2005). Hence it is clear that nurse lecturers are expected to have a role in clinical practice however to date no evidence exists as to what models of practice have evolved. Empirical evidence relating to the nurse lecturers clinical role from an international perspective is examined to determine clinical models being practised and their effectiveness. Literature review Pre-registration nurse education programmes differ from country to country hence many models of practice exist in relation to teaching and supporting students in clinical practice. A major difference in practice education in Australia, Canada and North America is that clinical teaching and evaluation of students is mostly directed by faculty members, who are present at all times at the clinical site and work directly with students, these are often referred to as clinical educators (Nehls et al., 1997; Grealish and Carroll, 1998; Conway and Elwin, 2007; Kelly, 2007). Problems cited with this model include lack of role clarity and overlap with other support roles (Conway and Elwin, 2007). The fact that these educators are seasonally employed causes concern and its usefulness as a model for undergraduate education is questioned (Mannix et al., 2006; Kelly, 2007). The undergraduate nurse education programme in the UK shares many similarities with the Irish programme. Yet there is one distinct difference in practice education that is the CPC role which has being in existence for the past decade and does not exist in the UK. However in the UK similar roles known as practice educator/facilitators have been introduced in some educational facilities (Mallik and Mc Gowan, 2007). More recently as a result of a national evaluation by the NHS Education for Scotland one hundred Practice Education Facilitators were employed. The role is to support learning in practice which shares many similarities with the CPC role as it is practiced in Ireland (Mc Arthur and Burns, 2008). The lecturers’ role in clinical practice in the UK is a cause of concern and debate since the transfer of nurse education into the third level sector. The consequent increase in classroom teaching, administrative duties and research activity led to extra pressure for the nurse lecturer (Crotty, 1993; Clifford, 1995; Lee, 1996; Day et al., 1998). This resulted in nurse lecturers performing a clinical link or liaison role rather than getting involved in hands-on patient care (Crotty, 1993; Duffy and Watson, 2001; Carr, 2007). This role entailed pastoral support of students, advising clinical staff, educational audit and participation in the clinical assessment of students (Clifford, 1995; Gidman, 2001; Duffy and Watson, 2001; Carr, 2007). The maintenance of clinical competence and/or credibility is central to the debate on the nurse lecturers’ role in practice. However, both clinical credibility and competence in relation to nurse lecturers is poorly defined and no consensus exists as to how it is maintained. Clinical credibility when it is defined usually relates to the students perception of the lecturers knowledge of practice (Fisher, 2005). Recommendations in the UK have been made for the nurse lecturer to maintain a clinical caseload to ensure that theoretical teaching is based on current practice and to maintain credibility among students and clinical staff (Cave, 1994, Glen and Clark, 1999; Pegram and Robinson, 2002). Opinion is split however with other authors arguing that increased involvement in clinical practice is not necessary or realistic (Maslin-Prothero and Owen, 2001; Barrett, 2007). A number of issues are identified with maintaining a clinical role. These include poor role definition, time constraints, resistance from staff, lack of access and lack of
commitment and up-to-date skills (Day et al., 1998; Gilmore, 1999; Carr, 2007). Prior to the commencement of the undergraduate degree programme across Ireland, joint working groups where formed which included representation of the third level institutions and health service providers. Thus a partnership approach to implement the recommendations of the Forum report was advocated. Recommendations regarding the nurse lecturers’ role in practice where set out as described earlier (Government of Ireland, 2000). One could suggest the difficulties with the role experienced in the UK may have being avoided. Yet there is no evidence on how nurse lecturers are fulfilling this policy expectation. Hence the need to undertake this study to illuminate the issues experienced from an Irish perspective. Concern about the clinical competence of Project 2000 students in the UK led to a review of the pre-registration curriculum (UKCC, 1999). The physical separation of nurse education from practice and the perception that academic staff were out of touch were a source of concern. However, it was recognised that it was unrealistic to expect a nurse lecturer to be expert in the diverse number of roles expected. The development of specialist areas such as teaching, research or practice was considered a solution and Recommendation 25 stated that ‘service providers and Higher Education Institutions should work together to develop diverse teams of practice and academic staff who will offer students expertise in practice, management, assessment, mentoring and research’ (UKCC, 1999, p. 48). The recent Nursing and Midwifery Council (NMC, 2006) ‘teacher’ standard provides further clarification for nurse lecturers who are employed in higher education and are involved in supporting students in practice settings. These lecturers are required to spend a proportion of their time in clinical practice. The NMC (2006) state that this should be approximately 20% of their normal teaching hours and this aspect of the role can be fulfilled through a variety of activities. Examples of the activities outlined include, acting as a clinical teacher or link tutor, preparing and supporting mentors, research activity, practice development or in some cases maintaining a limited clinical caseload. Nurse lecturers in Ireland are expected to develop clinical roles, support clinical learning and are responsible to ensure the adequacy of the clinical learning environment and the assessment process (ABA, 2005). Yet similar guidelines in regard to a specific clinical role and formal contractual agreements have not yet being recommended by national bodies involved in the regulation of nurse education in Ireland. The uniqueness of the Irish nurse education programme and the clinical support roles may impact the nurse lecturers’ clinical role; hence it would be unwise to adopt UK guidelines without sufficient enquiry. In light of this the following aim was set for exploration. Methodology This study sets out to explore the experience, expectations and perceived understandings of the lecturers’ role in clinical practice among nurse lecturers, preceptors, clinical nurse managers, clinical placement co-ordinators’ and students. A qualitative research design informed by the tenets of phenomenology and loosely underpinned by Heideggerian hermeneutic philosophy was adopted. Data collection was obtained using focus group interviews. Heideggerian hermeneutic tradition accepts that human beings always come to a situation with a story and that the purpose of the research is to acquire new knowledge of what is assumed to be understood. It advocates that meaning is negotiated mutually between the participants and the researcher (Eckartsberg, 1998; Denzin and Lincoln, 2000). This approach allowed for descriptive, interpretative and reflective inquiry in order to explore the key
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
stakeholders understanding of the lecturers’ role in clinical practice (Streubert and Carpenter, 1995; Morse and Field, 1996; Creswell, 1998). A purposive sampling strategy generated the sample for five in-depth focus group interviews with key stakeholders. All participants had experience of the phenomenon being studied. The research proposal was submitted to the HSE Northwest research ethics committee and approval granted. Sample A letter was sent explaining the study to preceptors from a range of General and Intellectual Disability (ID) nursing practice areas. A total of one hundred were approached and eight preceptors agreed to take part based on their availability on the day of interview. The total population of nine CPCs were approached and seven volunteered to participate. Of a total of 60 CNMs from both disciplines invited, seven took part. Fifty-six undergraduate students were informed about the study and invited to take part. All students volunteered to be participants. Seven students, three from ID and four from the general discipline participated based on their availability to meet with the external facilitator and moderator who where unknown to the students. All lecturers in the Department of Nursing and Health Studies in the college were invited by letter to participate. Out of a total of 14 lecturers seven volunteered to take part. Data collection Data collection occurred over a 6 month period. The focus group interviews were facilitated by an experienced interviewer using a topic guide. See Table 1. An assistant moderator was present to handle the logistics, take notes and to audiotape the interview. Two members of the research team undertook this role except in the case of the students and lecturers focus group interviews. An external facilitator and moderator where employed to conduct these interviews which allowed participants to express their true perceptions of the role. Prior to the commencement of the interview a full explanation of the aim of the study was given again and the issue of consent and confidentiality was discussed. A consent form was signed by all participants. Following the interview, the interviewer and moderator met to discuss and write up their immediate impressions of the discussion. The interview was transcribed verbatim within 72 h by a professional typist. Analysis In keeping with the Heideggerian hermeneutic philosophy the research team adapted and applied the Diekelmann (1992) framework (Draucker, 1999). This provided a structure through which transcripts could be analysed and themes identified. See Table 2. This approach allowed the research team to articulate their pre-assumptions of the subject under study prior to commencing the study and modify them to achieve true interpretation (Eckartsberg, 1998). Table 1 Topic guide. 1. How do you see the role of the nurse lecturer in practice? 2. In what way could the nurse lecturer support you in practice? 3. What are your expectations and needs in relation to the nurse lecturers’ role in practice? 4. What factors do you think will facilitate the lecturer fulfilling this role in practice? 5. What factors do you think will inhibit the lecturer fulfilling this role in practice?
191
Table 2 Diekelmann’s (1992) frame work adapted. The research team articulated their prejudgements of the subject under study prior to commencing the study. These were interrogated and revised and extended through the process of reflection throughout the data analysis stage. To address the issue of trustworthiness an audit and decision trail is available for review 1. Interpretative summaries of each interview were written by the facilitator and moderator 2. Transcripts were then analysed by the research team leader and coded for potential themes. As themes emerged, they were built up with quotations from interviewee accounts. 3. The research team met and the analysis were read out loud and discussed 4. Disagreements were resolved by returning to the text 5. All themes were then compared. Each theme identified was present in all focus group interviews 6. One research expert outside the team studied the audit and decision trail and reviewed the final analysis. Any themes that were judged to be unsubstantiated in the text were deleted
Key findings Five themes emerged from analysis which were; the maintenance of lecturers’ clinical credibility, the lecturers’ role as a resource to clinical staff, teaching and assessing students in practice, the value of fostering relationships in practice and role duplication, Maintenance of lecturers’ clinical credibility Preceptors, CNMs, CPCs and lecturers voiced the need for lecturers to have a clinical role to improve their credibility when teaching students. One lecturer commented on the value of having a role in the clinical area: ‘‘to be able to relay the reality of the ward to students, ...To make sure that I’m up to date with practice... does practice reflect what’s in the literature? And to be able to identify any dichotomy that’s there, and maybe to bridge it, be it on my side or be it on Practice side” (Lecturer). All lecturers saw the value of spending time in practice to facilitate them to bridge both the theory practice gap and indeed the practice theory gap. Recent studies in the UK found that time spent in clinical practice improved the quality of nurse lecturers teaching (Carr, 2007; Williams and Taylor, 2008). Interestingly students had a high opinion of lecturer’s credibility and they did not comment on any deficits in their lectures. Preceptors, CPCs and CNMs strongly voiced the concern that lecturers were removed from practice and need to be exposed to the reality of practice. This perception is illustrated in the following comment by one preceptor: ‘‘If lecturers were aware of what was happening in practice, and the location students were going, students are coming out with all the theory and are unable to relate it to practice. I think if you could integrate that, more in your lectures, it would, probably, come back through, in practice” (Preceptor). No agreement existed among stakeholders or indeed within each homogenous group of a model of best practice to obtain this credibility and presence in clinical practice. Some lecturers felt in order to maintain credibility in their teaching they would like to spend time in practice working in their chosen clinical area without supporting students. Pegram and Robinson (2002) proposed a similar model namely ‘‘faculty practice”. All groups voiced that competing demands of scholarly activity would impact negatively on time being spent in clinical practice hence the need for a contractual agreement between health service
192
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
employers and the higher educational institution. This is articulated in the following comment from a lecturer: ‘‘I think ring fencing the time is important because that gives it value, otherwise it’s just, well if you have time I would go into practice but my academic commitments would come first” (Lecturer). This desire for clinical credibility yet inability to enact the role due the aforementioned academic commitments has been highlighted throughout the UK literature for over a decade (Crotty, 1993; Clifford, 1995; Lee, 1996; Griscti et al., 2005; Gillespie and Mc Fedridge, 2006; Barrett, 2007). Findings from a recent Irish qualitative study exploring the clinical role of the nurse lecturer echo the sentiment that nurse lecturers do value clinical credibility and a distinct clinical role however other work commitments take precedent (Meskell et al., 2009). Nurse lecturers in Ireland are responsible for ensuring that clinical placements provide an optimum learning environment and are expected to maintain expertise and credibility yet no model to implement this standard has being proposed (ABA, 2005). Cave (2005) alerts educators to the fact that when nurse education moved to higher education in America the practice theory gap increased and the only way that faculty members maintained a clinical role was by working in hospitals in their own time. While policy in the UK does emphasise the need for nurse educators to undertake clinical practice, contradictory visions of the role and lack of organisational and financial commitments has lead to difficulties in maintaining espoused standards (Mallik and Mc Gowan, 2007; Carr, 2007; Williams and Taylor, 2008). Therefore it is timely for nurse educators in Ireland to influence educational policy at professional and government level and propose a national model which encompasses a clinical role where the credibility and expertise of nurse lecturers can be achieved. The lecturer’s role as a resource to clinical staff All respondents perceived the lecturers role as primarily being a resource to clinical staff. Roles discussed were policy, practice, professional and clinical research development. This multifaceted resource role is demonstrated in the following quotes: ‘‘Staff nurses need support in accessing information; support in undertaking research, the link person is vital to staff nurses’ professional development” (CMN). ‘‘the lecturer could update us of the new initiatives, evidence based practice, the new relevant research” (Preceptor). ‘‘A void exists in Clinical practice staff are hungry for information, nurse lecturers are a resource, they could play a consultant role” (CPC). Lecturers recounted examples from their experiences as a link lecturer such as devising a standardised care plan and developing a rolling education programme to update staff. One lecturer discussed being involved in policy development: ‘‘. . .I was asked from the HSE perspective to go out and help them develop the policies for challenging behaviour. So I was delighted to be asked, because they recognized that I had something to offer as a lecturer, So, I contributed to that process, but I learned through that process what was happening”. In the UK literature discussions centre around redefining the lecturers role to encompass a more consultative resource approach (Humphreys et al., 2000; Aston et al., 2000; Maslin-Prothero and Owen, 2001; Griscti et al., 2005; Gillespie and Mc Fedridge, 2006; Barrett, 2007). The most recent UK NMC Standards document (NMC, 2006) sets out a versatile role for the nurse lecturer in practice which includes a variety of strategies such as contributing to practice development and undertaking practice based research.
Nurse education in Ireland is now encompassed in the university sector and support structures have been put in place for practice development and professional development of clinical staff. Participants in this study perceived clinical staff professional development needs were not fully being addressed and that lecturers were ideally placed to provide a further resource for clinical staff. Teaching and assessing students in practice The nurse lecturer’s role in relation to teaching and assessing the undergraduate student in clinical practice involved the following concepts; the pastoral role, taking a caseload and support for the preceptor. A concern regarding failure to fail the student in the clinical assessment was voiced. Participants commented on the value of visiting students regularly to ‘‘find out how they were doing”. However CPCs, students and lecturers all commented on the impossibility of accessing all students due to shift work. This pastoral role is evident in the following comment: ‘‘It was just kind of nice to know she was there to come and talk to you, if you needed any help” (Student). Students value clinical teachers who are interested in them and show empathy (Neary, 2000; Crawford et al., 2000). However difficulties were voiced in implementing such roles namely taking the students away from practical learning opportunities. This can be seen in a comment made by a preceptor: ‘‘. . .with the CPC’s, they’re gone two or three days off, or hours off the units as it is and then more time with the link lecturer and they are missing real clinical experience” (Preceptor). Overall it was felt that students were well supported in clinical practice by the CPC and preceptors and while it would be ‘‘nice” to visit it was not seen as a requirement. Chapple and Aston (2004) refer to this type of support as the ‘‘Queen Mother” method and proposed a more meaningful role where lecturers could provide reflective tutorials for both preceptors and students. All participants articulated the need to support the preceptor in their teaching role. They believed that teaching and assessing students in practice was primarily the responsibility of the preceptor. Supporting the preceptor and the student in this process was the role of the CPC. However, lecturers could assist both preceptors and CPCs in this role. This perception is demonstrated in the following quotes: ‘‘I don’t see myself hugely supporting students because CPC’s are there to support students and preceptors. Preceptors are there to teach the students in practice and CPCs are there to support them in that role. I know they’ll contact me if there’s a problem” (Lecturer). ‘‘Students have enough support and encouragement from CPC’s & staff; it is the staff nurses who require the support” (CNM). Interpretation of the preceptor and CPC role in maintaining a clinical learning environment are consistent with the forum recommendations while the lecturer role is vague and has many interpretations (Government of Ireland, 2000). One interpretation discussed was caseload management. The desire for lecturers to teach students and ‘‘deliver hands on care to clients” was expressed by only a few while the majority of participants did not see the value of this teaching strategy and were concerned with competency issues. These conflicting views are seen in the following comments: ‘‘Lecturers should don uniforms & work, teach staff & students” (CNM).
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
‘‘Nurse lecturers could not work with clients unless they where competent and confident working with clients” (CPC). This dichotomy has been debated and the literature now suggests that teaching while managing a caseload in practice is the remit of lecturer-practitioners or lecturers who have an extensive practice based role (Launders, 2000; Humphreys et al., 2000; Maslin-Prothero and Owen, 2001; NMC, 2006; Barrett, 2007). Nurse lecturers in Ireland are required to maintain expertise and credibility in clinical practice therefore those who teach the nursing management of patient care need to be offered the opportunity to take part in direct patient care (ABA, 2005). This could be achieved using a faculty practice model as was suggested in the forum report (Government of Ireland, 2000). The main area of concern expressed by participants was the assessment of students. A perception was strongly voiced that preceptors are afraid to fail students therefore there was a need to support preceptors in the assessment process. One CNM made the following comment: ‘‘Lecturers need to be involved in the assessment (of students) and the support of the preceptors, and supporting them to assess, and supporting them to fail the students” (CNM). Lecturers, CNMs and preceptors were concerned with the lack of rigour in assessment as can be seen in this comment made by a lecturer: ‘‘. . .people are getting through the system who aren’t competent. We are responsible for the assessment tool. Overall, it is the College’s responsibility, in a partnership, but we are ultimately responsible. So I do think our role does need to be developed there” (Lecturer). The reluctance to fail students who are clinically incompetent has being reported in the UK literature (Norman et al., 2002; Duffy, 2003). The Nursing and Midwifery Council (NMC, 2006) considered fitness for practice at registration and have subsequently set standards for mentors, practice teachers, and teacher (those who work in higher education). The standards focus on criteria for supporting learning and assessing in practice, and the teachers competence and outcomes. Hence a standard has been set that only suitably qualified assessors will be assessing students in clinical practice. In Ireland the students’ clinical competence is now assessed by preceptors using a competency assessment strategy (ABA, 2005). The forum report recommends that all preceptors attend a teaching and assessing course (Government of Ireland, 2000). Currently these are generally 2 day in length (Morgan and Keogh, 2005; Mc Carthy and Murphy, 2008). A recent Irish study found that preceptors were inexperienced in assessing students and did not apply the recommend competency assessment strategy as set out by the nursing board (Mc Carthy and Murphy, 2008). No standards currently exist in regards to CPC or lecturers assessing students in practice. In fact no evidence was found to suggest that either of these groups take part in the direct assessment of students in Ireland. Joint responsibilities for practice assessment between preceptors and educators has been reported as good practice hence further exploration of this concept is advocated (Mallik and Mc Gowan’s, 2007). In order to address the deficits in the assessment process voiced in this study, the role the nurse lecturer plays in the assessment process needs to be made explicit and standards need to be set for all assessors of student nurses. The value of fostering relationships in practice The need to spend dedicated structured time in practice building relationships with clinical staff was voiced. One preceptor commented:
193
‘‘Some staff may see you as a threat. . .: . . .querying their practice. . . . if you came in with all these new ideas, and we weren’t confident in that. You would need to have a good relationship with us, before you started to implement new ideas. . .” (Preceptor). It is an accepted view that nursing environments are highly socialised and in order to avoid resistance when implementing any change to the clinical environment it is important to build good working relationships (Ramage, 2004). Participants felt that the geographical removal of the schools of nursing has weakened previous good relationships. Lecturers, students and CNMs expressed the need to spend time with clinical staff in a formalised way. This perception is voiced by a CNM: ‘‘. . .any visits by the lecturer should be pre-planned & structured, ad hoc meetings or visits should be avoided as this will cause annoyance to the staff on the ward” (CNM). All participants felt there was a need to clarify and communicate the role: ‘‘Staff need to understand your role so that they are not threatened by it. They may think you are in to check up on them” (CPC). The view that infrequent visits with limited contact are not conducive to promoting working relationships with clinical staff is supported in the literature (Murphy, 2000; Gillespie and Mc Fedridge, 2006). Role duplication The uniqueness of the Irish context is evident in this theme. Lecturers, CNMs, students and preceptors perceived the clinical role of the nurse lecturer in regard to students support has been replaced by the implementation of the CPC role. The following quotes demonstrate the central role the CPCs have in regards to the clinical education of the student: ‘‘I suppose the CPC is who you see now as the link really, you know, the person you identify as the person in practice” (Preceptor). ‘‘It’s kind of hard to distinguish what we’d want from a link lecturer compared to a CPC. I think CPC’s just do so much” (Student). The participants in all interviews warned against role duplication and over-supporting the student. Lecturers felt their clinical role is already being fulfilled by the CPC as can be seen by this comment: ‘‘. . .That is why we are where we are four years on with this degree program, with no real role in there (clinical practice). It’s because of the overlap of the CPC role they are doing the (previous) link lecturers role. Link lecturers are in the UK, the same up the North (Northern Ireland), but here that doesn’t work because of the overlap with the CPC and the threat to that role as well” (Lecturer). The CPC role first came into existence with the introduction of the diploma programme and is viewed as a positive contribution to student support in the clinical area however their responsibility in clinical teaching remains unclear (Lambert and Glacken, 2004). There appears to be some similarity with this role and that of practice educators (Mallik and Mc Gowan, 2007) and lecturer practitioners in the UK (Carnwell et al., 2007). Role confusion and overlap has also being reported with these roles, researchers call for the clarification of all support roles in practice education. This could involve some roles being relinquished (Carnwell et al., 2007). Role overlap is also cited as an issue with the clinical educator role in Australia (Conway and Elwin, 2007). The findings in this study suggest that the CPCs role as it is operationalised encompasses the traditional link tutors role leaving the lecturer the opportunity to fulfil any deficits that occurs in practice learning.
194
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
All participants perceived lecturers to be in a key position to contribute to in-service and practice development however some felt the accountability for these roles lies firmly in the remit of the Practice development unit in the hospital and the CNME. Milner et al. (2005) argues that nurse educators may be an untapped resource in the facilitation of evidence based practice. Aston et al. (2000) reports nurse lecturers in the UK are involved in practice development as part of their link lecturer role. The need to negotiate a role with stakeholders and provide clarity was strongly voiced. This perception is encapsulated in the following comment shared by a lecturer:
and a suite of stand alone modules has been developed to address the identified professional development needs of clinical staff.
‘‘. . .there’s the preceptor, the CPC, and there’s practice development. So, practice development; you’re looking at the Practice Development Unit. CPC is supporting students and supporting the development of staff. The preceptor is the assessor of the student and ensuring their competencies. So, we need to actually decide exactly what the role is, because, if it’s supporting, that’s CPC, if it’s practice, its Practice Development. So, I suppose it needs discussion with preceptors and with CPCs, and Practice Development to clarify” (Lecturer).
National agreement and guidelines in relation to a specific clinical role for nurse lecturers is required to optimise the educational experience of the nursing student population. These guidelines should specify the amount of time nurse lecturers are required to be present in clinical areas and this should be documented in contracts of employment. The clinical assessment of students is an area that requires further research. Such research should incorporate the views of preceptors and their perceived needs in relation to their clinical assessment role. National bodies involved in the regulation of nurse education need to work with nurse lecturers and CPCs to develop standardised job descriptions for both these roles with clear lines of accountability in relation to teaching and assessing students in clinical practice.
All participants in all interviews perceived that the success of the role hinged on role clarity and time being dedicated to the role. To overcome the role duplication reported in this and in other studies (Carnwell et al., 2007; Conway and Elwin, 2007) National guidelines need to be developed for all practice education roles particularly CPC and link lecturers. Clear lines of accountability in relation to teaching and assessing students in clinical practice need to be specified in these guidelines. Conclusions The findings from this study support the anecdotal evidence that confusion exists among stakeholders on what constitutes the role of the nurse lecturer in clinical practice. Participants view the Clinical placement Co-ordinator role as having replaced the traditional ‘‘link lecturer role” and consequently students are adequately supported in clinical practice. The important of fostering good working relationships between nurse lecturers and clinical personnel was highlighted. Clinical credibility in classroom teaching was identified by nurse lecturers as an area that could be enhanced via a clinical practice role. A flexible, eclectic model that optimises the expertise of individual nurse lecturers is advocated. Key areas where lecturers can make a positive contribution include faculty practice, clinical research and practice development. A clinical role for the nurse lecturer must be clearly defined and formally agreed between the educational and the health care providers. It is important that clinical practice hours undertaken to operationalise the role should be included as part of the teaching commitment of nurse lecturers. The findings from this study were used to formulate a model for the clinical role of the nurse lecturer. This is currently being piloted and its efficacy and effectiveness will be evaluated. Additional support for preceptors in relation to their teaching and assessment role with students was identified as an area to be addressed. Subsequent to this study the preceptor preparation workshop has been reviewed and preceptor updates are provided. Local policies have been implemented to support preceptors in the clinical assessment of students. Ongoing professional development for clinical staff emerged as an area where nurse lecturers can contribute. Key areas for development were identified and in response a post graduate diploma
Recommendations The authors acknowledge that the findings from this study apply to a local context and therefore are not generalisable. These findings and the subsequent recommendations set out below should however contribute to the international debate surrounding the role of the nurse lecturer and practice based learning.
References An Bord Altranais, 2005. Requirements and Standards for Nurse Registration Education Programmes, third ed. An Bord Altranais, Dublin. Aston, L., Mallik, M., Day, C., Fraser, D., 2000. An exploration into the role of the teacher/lecturer in practice: findings from a case study in adult nursing. Nurse Education Today 20, 178–188. Barrett, D., 2007. The clinical role of nurse lecturers: past, present, and future. Nurse Education Today 27, 367–374. Carr, G., 2007. Changes in nurse education: being a nurse teacher. Nurse Education Today 27, 893–899. Carnwell, R., Baker, S., Bellis, M., Murray, R., 2007. Managerial perceptions of mentors, lecturer practitioner and link tutor roles. Nurse Education Today 27, 923–932. Cave, I., 1994. Nurse teachers in higher education – without clinical competence, do they have a future? Nurse Education Today 14, 394–399. Cave, I., 2005. Nurse teachers in higher education – without clinical competence, do they have a future? Nurse Education Today 25, 646–651. Chapple, M., Aston, E.S., 2004. Practice learning teams: a partnership approach supporting students’ clinical learning. Nurse Education in Practice 4 (2), 143– 149. Clifford, C., 1995. The role of the nurse teacher: concerns, conflicts and challenges. Nurse Education Today 15, 11–16. Conway, J., Elwin, C., 2007. Mistaken, misshapen and mythical images of nurse education: creating a shared identity for clinical nurse practice. Nurse Education in Practice 7, 187–194. Crawford, M.J., Dresen, S.E., Tschikota, S.E., 2000. From ‘‘getting to know” to ‘‘soloing”: the preceptor – student relationship. Nursing Times research 5 (1), 5–19. Creswell, J.W., 1998. Qualitative Inquiry and Research Design: Choosing Among Five Traditions, first ed. Sage Publications, London. Crotty, M., 1993. The changing role of the nurse teacher. Nurse Education Today 13, 415–420. Day, C., Fraser, D., Mallik, M., 1998. The Role of the Teacher Lecturer in Practice: Final Report to the ENB Research and Development Group. English National Board, London. Department of Health and Children, 2001. National Evaluation of the Role of the Clinical Placement Co-ordinator. DOHC, Dublin. Denzin, N.K., Lincoln, Y.S., 2000. Handbook of Qualitative Research, second ed. Sage Publications, London. Diekelmann, N.L., 1992. Learning as testing: a Heideggerian hermeneutical analysis of the lived experiences of students and teachers in nursing. Advances in Nursing Sciences 14 (3), 72–83. Drennan, J., 2002. An evaluation of the role of the clinical placement coordinator in students nurse support in the clinical area. Journal of Advanced Nursing 40 (4), 475–483.
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195 Duffy, K., Watson, H., 2001. An interpretive study of the nurse teacher’s role in practice placement areas. Nurse Education Today 21, 551–558. Duffy, K., 2003. Failing students: a qualitative study of factors that influence the decisions regarding the assessment of students’ competence to practice. Caledonian Nursing and Midwifery Research Centre, Glasgow Caledonian University. Draucker, C.B., 1999. The critique of Heideggerian hermeneutic nursing research. Journal of Advanced Nursing 23, 441–447. Eckartsberg, R.V., 1998. Existential – phenomenological research. In: Valle, R. (Ed.), Phenomenological Inquiry in Psychology – Existential and Transpersonal Dimensions. Plenum Press, New York, pp. 21–61. Fisher, M., 2005. Exploring how nurse lecturers maintain clinical credibility. Nurse Education in Practice 5, 21–29. Gidman, J., 2001. The role of the personal tutor: a literature review. Nurse Education Today 21, 359–365. Gillespie, M., Mc Fedridge, B., 2006. Nurse education – the role of the nurse teacher. Journal of Clinical Nursing 15, 639–644. Gilmore, A., 1999. Report of the Analysis of the Literature Evaluating PreRegistration Nursing and Midwifery Education in the United Kingdom. UKCC, London. Glen, S., Clark, A., 1999. Nurse education: a skill mix for the future. Nurse Education Today 19, 12–19. Government of Ireland, 1998. Report of the Commission on Nursing. A Blueprint for the Future. The Stationary Office, Dublin. Government of Ireland, 2000. A Strategy for a Pre-Registration Nursing Education Degree Programme. The Report of the Nursing Education Forum. The Stationary Office, Dublin. Grealish, L., Carroll, G., 1998. Beyond preceptorship and supervision: a third clinical teaching model emerges for Australian nursing education. Australian Journal of Advanced Nursing 15 (2), 3–11. Griscti, O., Jacono, B., Jacono, J., 2005. The nurse educator’s clinical role. Journal of Advanced Nursing 50 (1), 84–92. Humphreys, A., Gidman, J., Andrews, M., 2000. The nature and purpose of the role the nurse lecturer in practice settings. Nurse Education Today 20, 311–317. Kelly, K., 2007. Students perceptions of effective clinical teaching revisited. Nurse Education Today 27, 885–892. Lambert, V., Glacken, M., 2004. Clinical support roles; a review of the literature. Nurse Education in Practice 4, 177–183. Launders, M.G., 2000. The theory practice gap in nursing; the role of the nurse teacher. Journal of Advanced Nursing 32 (6), 1550–1556. Lee, D., 1996. The clinical role of the nurse teacher: a review of the dispute. Journal of Advanced Nursing 23, 1127–1134. Mallik, M., Mc Gowan, B., 2007. Issues in practice based learning in nursing in the United Kingdom and the Republic of Ireland: results from a multi professional scoping exercise. Nurse Education Today 27, 52–59. Mannix, J., Faga, P., Beale, B., Jackson, D., 2006. Towards sustainable models for clinical education in nursing: an on-going conversation. Nurse Education in Practice 6, 3–11. Maslin-Prothero, S., Owen, S., 2001. Enhancing your links and credibility: the role of nurse lecturers and teachers in clinical practice. Nurse Education in Practice 1, 189–195.
195
Meskell, P., Murphy K., Shaw, D., 2009. The clinical role of lecturers in Nursing in Ireland: perceptions from key stakeholders groups in nurse education on the role. Nurse Education Today. doi:10.1016/j.nedt.2009.03.014. McArthur, G., Burns, I., 2008. An evaluation, at the 1-year stage, of a 3-year project to introduce practice education facilitators to NHS Tayside and Fife. Nurse Education in Practice 8, 149–155. Mc Carthy, B., Murphy, S., 2008. Assessing undergraduate nursing students in clinical practice: do preceptors use assessment strategies. Nurse Education Today 28, 301–313. Milner, F.M., Estabrooks, C.A., Humphrey, C., 2005. Clinical nurse educators as agents for change: increasing research utilization. International Journal of Nursing Studies 42, 899–914. Morgan, R., Keogh, B., 2005. Preceptorship in nursing: an Irish perspective. Clinical Excellence for Nurse practitioners 9 (4), 181–185. Morse, J.M., Field, P.A., 1996. Nursing Research: The Application of Qualitative Approaches, second ed. Stanley Thornes Publishers, Cheltenham. Murphy, P., 2000. Collaborating with practitioners in teaching and research: a model for developing the role of the nurse lecturer in practice areas. Journal of Advanced Nursing 31 (3), 704–714. Neary, M., 2000. Supporting student’s learning and professional development through the process of continuous assessment and mentorship. Nurse Education Today 20, 463–474. Nehls, R., Rather, M., Guyette, M., 1997. The preceptor model of clinical instruction: the lived experiences of students, preceptors, and faculty of record. Journal of Nursing Education 36 (5), 220–227. Norman, I., Watson, R., Murrells, T., Calman, L., Redfern, S., 2002. The validity and reliability of methods to assess competence to practice of pre registration nursing and midwifery students. International Journal of Nursing Studies 39, 133–145. Nursing and Midwifery Council, 2006. Standards to Support Learning and Assessment in Practice – NMC Standards for Mentors, Practice Teachers and Teachers. NMC, London. Pegram, A., Robinson, L., 2002. The experience of untaking faculty practice. Nurse Education in Practice 2, 30–34. Phillips, T., Schostak, J., Tyler, J., 2000. Practice and Assessment in Nursing and Midwifery: Doing it for Real The English National Board for Nursing. Midwifery and Health Visiting, London. Ramage, C., 2004. Negotiating multiple roles: link teachers in clinical nursing practice. Journal of Advanced Nursing 45 (3), 287–296. Spouse, J., 2001. Bridging theory and practice in the supervisory relationship: a sociocultural perspective. Journal of Advanced Nursing 33 (4), 512– 522. Streubert, H.J., Carpenter, D.R., 1995. Qualitative Research in Nursing Advancing the Human Perspective. Lippincott Company, Philadelphia. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1999. Fitness for Practice – The UKCC Commission for Nursing and Midwifery Education. UKCC, London. Williams, A., Taylor, C., 2008. An investigation of nurse educators perceptions and experiences of undertaking clinical practice. Nurse Education Today. doi:10.1016/j.nedt.2008.05.012.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
The role of the nurse lecturer in clinical practice in the Republic of Ireland Edel McSharry *, Helen McGloin 1, Anne Marie Frizzell 2, Lisa Winters-O’Donnell 3 Department of Nursing and Health Studies, St. Angelas College, Sligo, Ireland
a r t i c l e
i n f o
Article history: Accepted 31 August 2009
Keywords: Nurse lecturer Clinical role Clinical credibility Clinical teaching
s u m m a r y Undergraduate nurse education in Ireland transferred into the third level sector in 2002. As a result nurse lecturers are expected to develop a model of clinical practice that enables them to be involved in practice and its development while maintaining their own nursing expertise and credibility [An Bord Altranais, 2005. Requirements and Standards for Nurse Registration Education Programmes, third ed. An Bord Altranais, Dublin]. In light of this the researchers set out to explore the perceptions of the nurse lecturers’ role in clinical practice among nurse lecturers, preceptors, clinical nurse managers, clinical placement co-ordinators and students. A qualitative research design using focus groups was chosen. A purposive sampling strategy generated the sample for 5 in-depth focus group interviews with the aforementioned key stakeholders and the data was thematically analysed. Five themes emerged which centred on the maintenance of lecturers’ clinical credibility, the lecturers’ role as a resource to clinical staff, teaching and assessing students in practice, the value of fostering relationships in practice and role duplication. The findings from this study supports the anecdotal evidence that confusion exists around the role but more importantly it gives the nurse lecturer population guidance on how to develop the role in partnership with the various stakeholders in a way that supports the nursing students and clinical staff in practice in an effective manner. Ó 2009 Elsevier Ltd. All rights reserved.
Background and context Pre-registration nurse education in Ireland has undergone major transformation over the past 14 years. In 1994 the traditional 3 year apprenticeship model of training was replaced with the registration diploma programme. In 2002 the diploma programme was replaced by a 4 years honours degree programme which is currently provided in universities and colleges of higher education. These changes involved some significant differences in the way in which student nurses are educated and brought Irish nurse education in line with the UK, Canada, North America and Australia (Government of Ireland, 1998, 2000). Approved by the Irish Nursing Board (An Bord Altranais (ABA), 2005) this programme complies with EU regulations (Government of Ireland, 2000). It includes both theoretical and clinical instruction, the latter continues to be a central element of the programme making up half of the programme duration. The clinical practice component is assessed using a competency based assessment strategy set out by the Nursing Board. Students are supernumery when in clinical practice ex* Corresponding author. Tel.: +353 719143580x275. E-mail addresses: [email protected] (E. McSharry), [email protected] (H. McGloin), [email protected] (A.M. Frizzell), [email protected] (L. Winters-O’Donnell). 1 Tel.: +353 719143580x270. 2 Tel.: +353 719143580x272. 3 Tel.: +353 719143580x273. 1471-5953/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2009.08.004
cept for the nine month internship period when they are paid employees of the health services (ABA, 2005). Staff nurses providing direct patient care are responsible for facilitating learning, supervising and assessing students and are called preceptors. The mentors’ role as it is practised on nursing undergraduate programmes in the UK correlates almost exactly with the preceptors’ role in the Irish context (Neary, 2000; Phillips et al., 2000; Spouse, 2001). However in Ireland, an additional role exists, namely the Clinical Placement Co-ordinator (CPC). CPCs are employed by each training hospital and are assigned several clinical areas where students are allocated. The CPC acts as a link between the education and practice setting and contributes to the development of the clinical learning environment (DOHC, 2001). The role involves supporting and facilitating students and preceptors in clinical learning (Drennan, 2002). Furthermore Centres of Midwifery and Nurse Education (CMNE) and Practice Development Units have been set up through out the country to support the ongoing professional development of nurses. The Nurse Education Forum (Government of Ireland, 2000) was established to guide the implementation of the degree programme. This report recognised a change in the traditional link tutors role but envisaged new models of practice evolving during the course of curriculum design and course delivery. It recommended that third level institutions should develop innovative strategies for lecturers to develop link roles with clinical practice (Government of Ireland, 2000). Furthermore the Irish Nursing Board (ABA, 2005)
190
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
stipulates that nurse lecturers engage in clinical practice and its advancement and develop mechanisms for maintaining their own nursing expertise and credibility (ABA, 2005). Hence it is clear that nurse lecturers are expected to have a role in clinical practice however to date no evidence exists as to what models of practice have evolved. Empirical evidence relating to the nurse lecturers clinical role from an international perspective is examined to determine clinical models being practised and their effectiveness. Literature review Pre-registration nurse education programmes differ from country to country hence many models of practice exist in relation to teaching and supporting students in clinical practice. A major difference in practice education in Australia, Canada and North America is that clinical teaching and evaluation of students is mostly directed by faculty members, who are present at all times at the clinical site and work directly with students, these are often referred to as clinical educators (Nehls et al., 1997; Grealish and Carroll, 1998; Conway and Elwin, 2007; Kelly, 2007). Problems cited with this model include lack of role clarity and overlap with other support roles (Conway and Elwin, 2007). The fact that these educators are seasonally employed causes concern and its usefulness as a model for undergraduate education is questioned (Mannix et al., 2006; Kelly, 2007). The undergraduate nurse education programme in the UK shares many similarities with the Irish programme. Yet there is one distinct difference in practice education that is the CPC role which has being in existence for the past decade and does not exist in the UK. However in the UK similar roles known as practice educator/facilitators have been introduced in some educational facilities (Mallik and Mc Gowan, 2007). More recently as a result of a national evaluation by the NHS Education for Scotland one hundred Practice Education Facilitators were employed. The role is to support learning in practice which shares many similarities with the CPC role as it is practiced in Ireland (Mc Arthur and Burns, 2008). The lecturers’ role in clinical practice in the UK is a cause of concern and debate since the transfer of nurse education into the third level sector. The consequent increase in classroom teaching, administrative duties and research activity led to extra pressure for the nurse lecturer (Crotty, 1993; Clifford, 1995; Lee, 1996; Day et al., 1998). This resulted in nurse lecturers performing a clinical link or liaison role rather than getting involved in hands-on patient care (Crotty, 1993; Duffy and Watson, 2001; Carr, 2007). This role entailed pastoral support of students, advising clinical staff, educational audit and participation in the clinical assessment of students (Clifford, 1995; Gidman, 2001; Duffy and Watson, 2001; Carr, 2007). The maintenance of clinical competence and/or credibility is central to the debate on the nurse lecturers’ role in practice. However, both clinical credibility and competence in relation to nurse lecturers is poorly defined and no consensus exists as to how it is maintained. Clinical credibility when it is defined usually relates to the students perception of the lecturers knowledge of practice (Fisher, 2005). Recommendations in the UK have been made for the nurse lecturer to maintain a clinical caseload to ensure that theoretical teaching is based on current practice and to maintain credibility among students and clinical staff (Cave, 1994, Glen and Clark, 1999; Pegram and Robinson, 2002). Opinion is split however with other authors arguing that increased involvement in clinical practice is not necessary or realistic (Maslin-Prothero and Owen, 2001; Barrett, 2007). A number of issues are identified with maintaining a clinical role. These include poor role definition, time constraints, resistance from staff, lack of access and lack of
commitment and up-to-date skills (Day et al., 1998; Gilmore, 1999; Carr, 2007). Prior to the commencement of the undergraduate degree programme across Ireland, joint working groups where formed which included representation of the third level institutions and health service providers. Thus a partnership approach to implement the recommendations of the Forum report was advocated. Recommendations regarding the nurse lecturers’ role in practice where set out as described earlier (Government of Ireland, 2000). One could suggest the difficulties with the role experienced in the UK may have being avoided. Yet there is no evidence on how nurse lecturers are fulfilling this policy expectation. Hence the need to undertake this study to illuminate the issues experienced from an Irish perspective. Concern about the clinical competence of Project 2000 students in the UK led to a review of the pre-registration curriculum (UKCC, 1999). The physical separation of nurse education from practice and the perception that academic staff were out of touch were a source of concern. However, it was recognised that it was unrealistic to expect a nurse lecturer to be expert in the diverse number of roles expected. The development of specialist areas such as teaching, research or practice was considered a solution and Recommendation 25 stated that ‘service providers and Higher Education Institutions should work together to develop diverse teams of practice and academic staff who will offer students expertise in practice, management, assessment, mentoring and research’ (UKCC, 1999, p. 48). The recent Nursing and Midwifery Council (NMC, 2006) ‘teacher’ standard provides further clarification for nurse lecturers who are employed in higher education and are involved in supporting students in practice settings. These lecturers are required to spend a proportion of their time in clinical practice. The NMC (2006) state that this should be approximately 20% of their normal teaching hours and this aspect of the role can be fulfilled through a variety of activities. Examples of the activities outlined include, acting as a clinical teacher or link tutor, preparing and supporting mentors, research activity, practice development or in some cases maintaining a limited clinical caseload. Nurse lecturers in Ireland are expected to develop clinical roles, support clinical learning and are responsible to ensure the adequacy of the clinical learning environment and the assessment process (ABA, 2005). Yet similar guidelines in regard to a specific clinical role and formal contractual agreements have not yet being recommended by national bodies involved in the regulation of nurse education in Ireland. The uniqueness of the Irish nurse education programme and the clinical support roles may impact the nurse lecturers’ clinical role; hence it would be unwise to adopt UK guidelines without sufficient enquiry. In light of this the following aim was set for exploration. Methodology This study sets out to explore the experience, expectations and perceived understandings of the lecturers’ role in clinical practice among nurse lecturers, preceptors, clinical nurse managers, clinical placement co-ordinators’ and students. A qualitative research design informed by the tenets of phenomenology and loosely underpinned by Heideggerian hermeneutic philosophy was adopted. Data collection was obtained using focus group interviews. Heideggerian hermeneutic tradition accepts that human beings always come to a situation with a story and that the purpose of the research is to acquire new knowledge of what is assumed to be understood. It advocates that meaning is negotiated mutually between the participants and the researcher (Eckartsberg, 1998; Denzin and Lincoln, 2000). This approach allowed for descriptive, interpretative and reflective inquiry in order to explore the key
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
stakeholders understanding of the lecturers’ role in clinical practice (Streubert and Carpenter, 1995; Morse and Field, 1996; Creswell, 1998). A purposive sampling strategy generated the sample for five in-depth focus group interviews with key stakeholders. All participants had experience of the phenomenon being studied. The research proposal was submitted to the HSE Northwest research ethics committee and approval granted. Sample A letter was sent explaining the study to preceptors from a range of General and Intellectual Disability (ID) nursing practice areas. A total of one hundred were approached and eight preceptors agreed to take part based on their availability on the day of interview. The total population of nine CPCs were approached and seven volunteered to participate. Of a total of 60 CNMs from both disciplines invited, seven took part. Fifty-six undergraduate students were informed about the study and invited to take part. All students volunteered to be participants. Seven students, three from ID and four from the general discipline participated based on their availability to meet with the external facilitator and moderator who where unknown to the students. All lecturers in the Department of Nursing and Health Studies in the college were invited by letter to participate. Out of a total of 14 lecturers seven volunteered to take part. Data collection Data collection occurred over a 6 month period. The focus group interviews were facilitated by an experienced interviewer using a topic guide. See Table 1. An assistant moderator was present to handle the logistics, take notes and to audiotape the interview. Two members of the research team undertook this role except in the case of the students and lecturers focus group interviews. An external facilitator and moderator where employed to conduct these interviews which allowed participants to express their true perceptions of the role. Prior to the commencement of the interview a full explanation of the aim of the study was given again and the issue of consent and confidentiality was discussed. A consent form was signed by all participants. Following the interview, the interviewer and moderator met to discuss and write up their immediate impressions of the discussion. The interview was transcribed verbatim within 72 h by a professional typist. Analysis In keeping with the Heideggerian hermeneutic philosophy the research team adapted and applied the Diekelmann (1992) framework (Draucker, 1999). This provided a structure through which transcripts could be analysed and themes identified. See Table 2. This approach allowed the research team to articulate their pre-assumptions of the subject under study prior to commencing the study and modify them to achieve true interpretation (Eckartsberg, 1998). Table 1 Topic guide. 1. How do you see the role of the nurse lecturer in practice? 2. In what way could the nurse lecturer support you in practice? 3. What are your expectations and needs in relation to the nurse lecturers’ role in practice? 4. What factors do you think will facilitate the lecturer fulfilling this role in practice? 5. What factors do you think will inhibit the lecturer fulfilling this role in practice?
191
Table 2 Diekelmann’s (1992) frame work adapted. The research team articulated their prejudgements of the subject under study prior to commencing the study. These were interrogated and revised and extended through the process of reflection throughout the data analysis stage. To address the issue of trustworthiness an audit and decision trail is available for review 1. Interpretative summaries of each interview were written by the facilitator and moderator 2. Transcripts were then analysed by the research team leader and coded for potential themes. As themes emerged, they were built up with quotations from interviewee accounts. 3. The research team met and the analysis were read out loud and discussed 4. Disagreements were resolved by returning to the text 5. All themes were then compared. Each theme identified was present in all focus group interviews 6. One research expert outside the team studied the audit and decision trail and reviewed the final analysis. Any themes that were judged to be unsubstantiated in the text were deleted
Key findings Five themes emerged from analysis which were; the maintenance of lecturers’ clinical credibility, the lecturers’ role as a resource to clinical staff, teaching and assessing students in practice, the value of fostering relationships in practice and role duplication, Maintenance of lecturers’ clinical credibility Preceptors, CNMs, CPCs and lecturers voiced the need for lecturers to have a clinical role to improve their credibility when teaching students. One lecturer commented on the value of having a role in the clinical area: ‘‘to be able to relay the reality of the ward to students, ...To make sure that I’m up to date with practice... does practice reflect what’s in the literature? And to be able to identify any dichotomy that’s there, and maybe to bridge it, be it on my side or be it on Practice side” (Lecturer). All lecturers saw the value of spending time in practice to facilitate them to bridge both the theory practice gap and indeed the practice theory gap. Recent studies in the UK found that time spent in clinical practice improved the quality of nurse lecturers teaching (Carr, 2007; Williams and Taylor, 2008). Interestingly students had a high opinion of lecturer’s credibility and they did not comment on any deficits in their lectures. Preceptors, CPCs and CNMs strongly voiced the concern that lecturers were removed from practice and need to be exposed to the reality of practice. This perception is illustrated in the following comment by one preceptor: ‘‘If lecturers were aware of what was happening in practice, and the location students were going, students are coming out with all the theory and are unable to relate it to practice. I think if you could integrate that, more in your lectures, it would, probably, come back through, in practice” (Preceptor). No agreement existed among stakeholders or indeed within each homogenous group of a model of best practice to obtain this credibility and presence in clinical practice. Some lecturers felt in order to maintain credibility in their teaching they would like to spend time in practice working in their chosen clinical area without supporting students. Pegram and Robinson (2002) proposed a similar model namely ‘‘faculty practice”. All groups voiced that competing demands of scholarly activity would impact negatively on time being spent in clinical practice hence the need for a contractual agreement between health service
192
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
employers and the higher educational institution. This is articulated in the following comment from a lecturer: ‘‘I think ring fencing the time is important because that gives it value, otherwise it’s just, well if you have time I would go into practice but my academic commitments would come first” (Lecturer). This desire for clinical credibility yet inability to enact the role due the aforementioned academic commitments has been highlighted throughout the UK literature for over a decade (Crotty, 1993; Clifford, 1995; Lee, 1996; Griscti et al., 2005; Gillespie and Mc Fedridge, 2006; Barrett, 2007). Findings from a recent Irish qualitative study exploring the clinical role of the nurse lecturer echo the sentiment that nurse lecturers do value clinical credibility and a distinct clinical role however other work commitments take precedent (Meskell et al., 2009). Nurse lecturers in Ireland are responsible for ensuring that clinical placements provide an optimum learning environment and are expected to maintain expertise and credibility yet no model to implement this standard has being proposed (ABA, 2005). Cave (2005) alerts educators to the fact that when nurse education moved to higher education in America the practice theory gap increased and the only way that faculty members maintained a clinical role was by working in hospitals in their own time. While policy in the UK does emphasise the need for nurse educators to undertake clinical practice, contradictory visions of the role and lack of organisational and financial commitments has lead to difficulties in maintaining espoused standards (Mallik and Mc Gowan, 2007; Carr, 2007; Williams and Taylor, 2008). Therefore it is timely for nurse educators in Ireland to influence educational policy at professional and government level and propose a national model which encompasses a clinical role where the credibility and expertise of nurse lecturers can be achieved. The lecturer’s role as a resource to clinical staff All respondents perceived the lecturers role as primarily being a resource to clinical staff. Roles discussed were policy, practice, professional and clinical research development. This multifaceted resource role is demonstrated in the following quotes: ‘‘Staff nurses need support in accessing information; support in undertaking research, the link person is vital to staff nurses’ professional development” (CMN). ‘‘the lecturer could update us of the new initiatives, evidence based practice, the new relevant research” (Preceptor). ‘‘A void exists in Clinical practice staff are hungry for information, nurse lecturers are a resource, they could play a consultant role” (CPC). Lecturers recounted examples from their experiences as a link lecturer such as devising a standardised care plan and developing a rolling education programme to update staff. One lecturer discussed being involved in policy development: ‘‘. . .I was asked from the HSE perspective to go out and help them develop the policies for challenging behaviour. So I was delighted to be asked, because they recognized that I had something to offer as a lecturer, So, I contributed to that process, but I learned through that process what was happening”. In the UK literature discussions centre around redefining the lecturers role to encompass a more consultative resource approach (Humphreys et al., 2000; Aston et al., 2000; Maslin-Prothero and Owen, 2001; Griscti et al., 2005; Gillespie and Mc Fedridge, 2006; Barrett, 2007). The most recent UK NMC Standards document (NMC, 2006) sets out a versatile role for the nurse lecturer in practice which includes a variety of strategies such as contributing to practice development and undertaking practice based research.
Nurse education in Ireland is now encompassed in the university sector and support structures have been put in place for practice development and professional development of clinical staff. Participants in this study perceived clinical staff professional development needs were not fully being addressed and that lecturers were ideally placed to provide a further resource for clinical staff. Teaching and assessing students in practice The nurse lecturer’s role in relation to teaching and assessing the undergraduate student in clinical practice involved the following concepts; the pastoral role, taking a caseload and support for the preceptor. A concern regarding failure to fail the student in the clinical assessment was voiced. Participants commented on the value of visiting students regularly to ‘‘find out how they were doing”. However CPCs, students and lecturers all commented on the impossibility of accessing all students due to shift work. This pastoral role is evident in the following comment: ‘‘It was just kind of nice to know she was there to come and talk to you, if you needed any help” (Student). Students value clinical teachers who are interested in them and show empathy (Neary, 2000; Crawford et al., 2000). However difficulties were voiced in implementing such roles namely taking the students away from practical learning opportunities. This can be seen in a comment made by a preceptor: ‘‘. . .with the CPC’s, they’re gone two or three days off, or hours off the units as it is and then more time with the link lecturer and they are missing real clinical experience” (Preceptor). Overall it was felt that students were well supported in clinical practice by the CPC and preceptors and while it would be ‘‘nice” to visit it was not seen as a requirement. Chapple and Aston (2004) refer to this type of support as the ‘‘Queen Mother” method and proposed a more meaningful role where lecturers could provide reflective tutorials for both preceptors and students. All participants articulated the need to support the preceptor in their teaching role. They believed that teaching and assessing students in practice was primarily the responsibility of the preceptor. Supporting the preceptor and the student in this process was the role of the CPC. However, lecturers could assist both preceptors and CPCs in this role. This perception is demonstrated in the following quotes: ‘‘I don’t see myself hugely supporting students because CPC’s are there to support students and preceptors. Preceptors are there to teach the students in practice and CPCs are there to support them in that role. I know they’ll contact me if there’s a problem” (Lecturer). ‘‘Students have enough support and encouragement from CPC’s & staff; it is the staff nurses who require the support” (CNM). Interpretation of the preceptor and CPC role in maintaining a clinical learning environment are consistent with the forum recommendations while the lecturer role is vague and has many interpretations (Government of Ireland, 2000). One interpretation discussed was caseload management. The desire for lecturers to teach students and ‘‘deliver hands on care to clients” was expressed by only a few while the majority of participants did not see the value of this teaching strategy and were concerned with competency issues. These conflicting views are seen in the following comments: ‘‘Lecturers should don uniforms & work, teach staff & students” (CNM).
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
‘‘Nurse lecturers could not work with clients unless they where competent and confident working with clients” (CPC). This dichotomy has been debated and the literature now suggests that teaching while managing a caseload in practice is the remit of lecturer-practitioners or lecturers who have an extensive practice based role (Launders, 2000; Humphreys et al., 2000; Maslin-Prothero and Owen, 2001; NMC, 2006; Barrett, 2007). Nurse lecturers in Ireland are required to maintain expertise and credibility in clinical practice therefore those who teach the nursing management of patient care need to be offered the opportunity to take part in direct patient care (ABA, 2005). This could be achieved using a faculty practice model as was suggested in the forum report (Government of Ireland, 2000). The main area of concern expressed by participants was the assessment of students. A perception was strongly voiced that preceptors are afraid to fail students therefore there was a need to support preceptors in the assessment process. One CNM made the following comment: ‘‘Lecturers need to be involved in the assessment (of students) and the support of the preceptors, and supporting them to assess, and supporting them to fail the students” (CNM). Lecturers, CNMs and preceptors were concerned with the lack of rigour in assessment as can be seen in this comment made by a lecturer: ‘‘. . .people are getting through the system who aren’t competent. We are responsible for the assessment tool. Overall, it is the College’s responsibility, in a partnership, but we are ultimately responsible. So I do think our role does need to be developed there” (Lecturer). The reluctance to fail students who are clinically incompetent has being reported in the UK literature (Norman et al., 2002; Duffy, 2003). The Nursing and Midwifery Council (NMC, 2006) considered fitness for practice at registration and have subsequently set standards for mentors, practice teachers, and teacher (those who work in higher education). The standards focus on criteria for supporting learning and assessing in practice, and the teachers competence and outcomes. Hence a standard has been set that only suitably qualified assessors will be assessing students in clinical practice. In Ireland the students’ clinical competence is now assessed by preceptors using a competency assessment strategy (ABA, 2005). The forum report recommends that all preceptors attend a teaching and assessing course (Government of Ireland, 2000). Currently these are generally 2 day in length (Morgan and Keogh, 2005; Mc Carthy and Murphy, 2008). A recent Irish study found that preceptors were inexperienced in assessing students and did not apply the recommend competency assessment strategy as set out by the nursing board (Mc Carthy and Murphy, 2008). No standards currently exist in regards to CPC or lecturers assessing students in practice. In fact no evidence was found to suggest that either of these groups take part in the direct assessment of students in Ireland. Joint responsibilities for practice assessment between preceptors and educators has been reported as good practice hence further exploration of this concept is advocated (Mallik and Mc Gowan’s, 2007). In order to address the deficits in the assessment process voiced in this study, the role the nurse lecturer plays in the assessment process needs to be made explicit and standards need to be set for all assessors of student nurses. The value of fostering relationships in practice The need to spend dedicated structured time in practice building relationships with clinical staff was voiced. One preceptor commented:
193
‘‘Some staff may see you as a threat. . .: . . .querying their practice. . . . if you came in with all these new ideas, and we weren’t confident in that. You would need to have a good relationship with us, before you started to implement new ideas. . .” (Preceptor). It is an accepted view that nursing environments are highly socialised and in order to avoid resistance when implementing any change to the clinical environment it is important to build good working relationships (Ramage, 2004). Participants felt that the geographical removal of the schools of nursing has weakened previous good relationships. Lecturers, students and CNMs expressed the need to spend time with clinical staff in a formalised way. This perception is voiced by a CNM: ‘‘. . .any visits by the lecturer should be pre-planned & structured, ad hoc meetings or visits should be avoided as this will cause annoyance to the staff on the ward” (CNM). All participants felt there was a need to clarify and communicate the role: ‘‘Staff need to understand your role so that they are not threatened by it. They may think you are in to check up on them” (CPC). The view that infrequent visits with limited contact are not conducive to promoting working relationships with clinical staff is supported in the literature (Murphy, 2000; Gillespie and Mc Fedridge, 2006). Role duplication The uniqueness of the Irish context is evident in this theme. Lecturers, CNMs, students and preceptors perceived the clinical role of the nurse lecturer in regard to students support has been replaced by the implementation of the CPC role. The following quotes demonstrate the central role the CPCs have in regards to the clinical education of the student: ‘‘I suppose the CPC is who you see now as the link really, you know, the person you identify as the person in practice” (Preceptor). ‘‘It’s kind of hard to distinguish what we’d want from a link lecturer compared to a CPC. I think CPC’s just do so much” (Student). The participants in all interviews warned against role duplication and over-supporting the student. Lecturers felt their clinical role is already being fulfilled by the CPC as can be seen by this comment: ‘‘. . .That is why we are where we are four years on with this degree program, with no real role in there (clinical practice). It’s because of the overlap of the CPC role they are doing the (previous) link lecturers role. Link lecturers are in the UK, the same up the North (Northern Ireland), but here that doesn’t work because of the overlap with the CPC and the threat to that role as well” (Lecturer). The CPC role first came into existence with the introduction of the diploma programme and is viewed as a positive contribution to student support in the clinical area however their responsibility in clinical teaching remains unclear (Lambert and Glacken, 2004). There appears to be some similarity with this role and that of practice educators (Mallik and Mc Gowan, 2007) and lecturer practitioners in the UK (Carnwell et al., 2007). Role confusion and overlap has also being reported with these roles, researchers call for the clarification of all support roles in practice education. This could involve some roles being relinquished (Carnwell et al., 2007). Role overlap is also cited as an issue with the clinical educator role in Australia (Conway and Elwin, 2007). The findings in this study suggest that the CPCs role as it is operationalised encompasses the traditional link tutors role leaving the lecturer the opportunity to fulfil any deficits that occurs in practice learning.
194
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195
All participants perceived lecturers to be in a key position to contribute to in-service and practice development however some felt the accountability for these roles lies firmly in the remit of the Practice development unit in the hospital and the CNME. Milner et al. (2005) argues that nurse educators may be an untapped resource in the facilitation of evidence based practice. Aston et al. (2000) reports nurse lecturers in the UK are involved in practice development as part of their link lecturer role. The need to negotiate a role with stakeholders and provide clarity was strongly voiced. This perception is encapsulated in the following comment shared by a lecturer:
and a suite of stand alone modules has been developed to address the identified professional development needs of clinical staff.
‘‘. . .there’s the preceptor, the CPC, and there’s practice development. So, practice development; you’re looking at the Practice Development Unit. CPC is supporting students and supporting the development of staff. The preceptor is the assessor of the student and ensuring their competencies. So, we need to actually decide exactly what the role is, because, if it’s supporting, that’s CPC, if it’s practice, its Practice Development. So, I suppose it needs discussion with preceptors and with CPCs, and Practice Development to clarify” (Lecturer).
National agreement and guidelines in relation to a specific clinical role for nurse lecturers is required to optimise the educational experience of the nursing student population. These guidelines should specify the amount of time nurse lecturers are required to be present in clinical areas and this should be documented in contracts of employment. The clinical assessment of students is an area that requires further research. Such research should incorporate the views of preceptors and their perceived needs in relation to their clinical assessment role. National bodies involved in the regulation of nurse education need to work with nurse lecturers and CPCs to develop standardised job descriptions for both these roles with clear lines of accountability in relation to teaching and assessing students in clinical practice.
All participants in all interviews perceived that the success of the role hinged on role clarity and time being dedicated to the role. To overcome the role duplication reported in this and in other studies (Carnwell et al., 2007; Conway and Elwin, 2007) National guidelines need to be developed for all practice education roles particularly CPC and link lecturers. Clear lines of accountability in relation to teaching and assessing students in clinical practice need to be specified in these guidelines. Conclusions The findings from this study support the anecdotal evidence that confusion exists among stakeholders on what constitutes the role of the nurse lecturer in clinical practice. Participants view the Clinical placement Co-ordinator role as having replaced the traditional ‘‘link lecturer role” and consequently students are adequately supported in clinical practice. The important of fostering good working relationships between nurse lecturers and clinical personnel was highlighted. Clinical credibility in classroom teaching was identified by nurse lecturers as an area that could be enhanced via a clinical practice role. A flexible, eclectic model that optimises the expertise of individual nurse lecturers is advocated. Key areas where lecturers can make a positive contribution include faculty practice, clinical research and practice development. A clinical role for the nurse lecturer must be clearly defined and formally agreed between the educational and the health care providers. It is important that clinical practice hours undertaken to operationalise the role should be included as part of the teaching commitment of nurse lecturers. The findings from this study were used to formulate a model for the clinical role of the nurse lecturer. This is currently being piloted and its efficacy and effectiveness will be evaluated. Additional support for preceptors in relation to their teaching and assessment role with students was identified as an area to be addressed. Subsequent to this study the preceptor preparation workshop has been reviewed and preceptor updates are provided. Local policies have been implemented to support preceptors in the clinical assessment of students. Ongoing professional development for clinical staff emerged as an area where nurse lecturers can contribute. Key areas for development were identified and in response a post graduate diploma
Recommendations The authors acknowledge that the findings from this study apply to a local context and therefore are not generalisable. These findings and the subsequent recommendations set out below should however contribute to the international debate surrounding the role of the nurse lecturer and practice based learning.
References An Bord Altranais, 2005. Requirements and Standards for Nurse Registration Education Programmes, third ed. An Bord Altranais, Dublin. Aston, L., Mallik, M., Day, C., Fraser, D., 2000. An exploration into the role of the teacher/lecturer in practice: findings from a case study in adult nursing. Nurse Education Today 20, 178–188. Barrett, D., 2007. The clinical role of nurse lecturers: past, present, and future. Nurse Education Today 27, 367–374. Carr, G., 2007. Changes in nurse education: being a nurse teacher. Nurse Education Today 27, 893–899. Carnwell, R., Baker, S., Bellis, M., Murray, R., 2007. Managerial perceptions of mentors, lecturer practitioner and link tutor roles. Nurse Education Today 27, 923–932. Cave, I., 1994. Nurse teachers in higher education – without clinical competence, do they have a future? Nurse Education Today 14, 394–399. Cave, I., 2005. Nurse teachers in higher education – without clinical competence, do they have a future? Nurse Education Today 25, 646–651. Chapple, M., Aston, E.S., 2004. Practice learning teams: a partnership approach supporting students’ clinical learning. Nurse Education in Practice 4 (2), 143– 149. Clifford, C., 1995. The role of the nurse teacher: concerns, conflicts and challenges. Nurse Education Today 15, 11–16. Conway, J., Elwin, C., 2007. Mistaken, misshapen and mythical images of nurse education: creating a shared identity for clinical nurse practice. Nurse Education in Practice 7, 187–194. Crawford, M.J., Dresen, S.E., Tschikota, S.E., 2000. From ‘‘getting to know” to ‘‘soloing”: the preceptor – student relationship. Nursing Times research 5 (1), 5–19. Creswell, J.W., 1998. Qualitative Inquiry and Research Design: Choosing Among Five Traditions, first ed. Sage Publications, London. Crotty, M., 1993. The changing role of the nurse teacher. Nurse Education Today 13, 415–420. Day, C., Fraser, D., Mallik, M., 1998. The Role of the Teacher Lecturer in Practice: Final Report to the ENB Research and Development Group. English National Board, London. Department of Health and Children, 2001. National Evaluation of the Role of the Clinical Placement Co-ordinator. DOHC, Dublin. Denzin, N.K., Lincoln, Y.S., 2000. Handbook of Qualitative Research, second ed. Sage Publications, London. Diekelmann, N.L., 1992. Learning as testing: a Heideggerian hermeneutical analysis of the lived experiences of students and teachers in nursing. Advances in Nursing Sciences 14 (3), 72–83. Drennan, J., 2002. An evaluation of the role of the clinical placement coordinator in students nurse support in the clinical area. Journal of Advanced Nursing 40 (4), 475–483.
E. McSharry et al. / Nurse Education in Practice 10 (2010) 189–195 Duffy, K., Watson, H., 2001. An interpretive study of the nurse teacher’s role in practice placement areas. Nurse Education Today 21, 551–558. Duffy, K., 2003. Failing students: a qualitative study of factors that influence the decisions regarding the assessment of students’ competence to practice. Caledonian Nursing and Midwifery Research Centre, Glasgow Caledonian University. Draucker, C.B., 1999. The critique of Heideggerian hermeneutic nursing research. Journal of Advanced Nursing 23, 441–447. Eckartsberg, R.V., 1998. Existential – phenomenological research. In: Valle, R. (Ed.), Phenomenological Inquiry in Psychology – Existential and Transpersonal Dimensions. Plenum Press, New York, pp. 21–61. Fisher, M., 2005. Exploring how nurse lecturers maintain clinical credibility. Nurse Education in Practice 5, 21–29. Gidman, J., 2001. The role of the personal tutor: a literature review. Nurse Education Today 21, 359–365. Gillespie, M., Mc Fedridge, B., 2006. Nurse education – the role of the nurse teacher. Journal of Clinical Nursing 15, 639–644. Gilmore, A., 1999. Report of the Analysis of the Literature Evaluating PreRegistration Nursing and Midwifery Education in the United Kingdom. UKCC, London. Glen, S., Clark, A., 1999. Nurse education: a skill mix for the future. Nurse Education Today 19, 12–19. Government of Ireland, 1998. Report of the Commission on Nursing. A Blueprint for the Future. The Stationary Office, Dublin. Government of Ireland, 2000. A Strategy for a Pre-Registration Nursing Education Degree Programme. The Report of the Nursing Education Forum. The Stationary Office, Dublin. Grealish, L., Carroll, G., 1998. Beyond preceptorship and supervision: a third clinical teaching model emerges for Australian nursing education. Australian Journal of Advanced Nursing 15 (2), 3–11. Griscti, O., Jacono, B., Jacono, J., 2005. The nurse educator’s clinical role. Journal of Advanced Nursing 50 (1), 84–92. Humphreys, A., Gidman, J., Andrews, M., 2000. The nature and purpose of the role the nurse lecturer in practice settings. Nurse Education Today 20, 311–317. Kelly, K., 2007. Students perceptions of effective clinical teaching revisited. Nurse Education Today 27, 885–892. Lambert, V., Glacken, M., 2004. Clinical support roles; a review of the literature. Nurse Education in Practice 4, 177–183. Launders, M.G., 2000. The theory practice gap in nursing; the role of the nurse teacher. Journal of Advanced Nursing 32 (6), 1550–1556. Lee, D., 1996. The clinical role of the nurse teacher: a review of the dispute. Journal of Advanced Nursing 23, 1127–1134. Mallik, M., Mc Gowan, B., 2007. Issues in practice based learning in nursing in the United Kingdom and the Republic of Ireland: results from a multi professional scoping exercise. Nurse Education Today 27, 52–59. Mannix, J., Faga, P., Beale, B., Jackson, D., 2006. Towards sustainable models for clinical education in nursing: an on-going conversation. Nurse Education in Practice 6, 3–11. Maslin-Prothero, S., Owen, S., 2001. Enhancing your links and credibility: the role of nurse lecturers and teachers in clinical practice. Nurse Education in Practice 1, 189–195.
195
Meskell, P., Murphy K., Shaw, D., 2009. The clinical role of lecturers in Nursing in Ireland: perceptions from key stakeholders groups in nurse education on the role. Nurse Education Today. doi:10.1016/j.nedt.2009.03.014. McArthur, G., Burns, I., 2008. An evaluation, at the 1-year stage, of a 3-year project to introduce practice education facilitators to NHS Tayside and Fife. Nurse Education in Practice 8, 149–155. Mc Carthy, B., Murphy, S., 2008. Assessing undergraduate nursing students in clinical practice: do preceptors use assessment strategies. Nurse Education Today 28, 301–313. Milner, F.M., Estabrooks, C.A., Humphrey, C., 2005. Clinical nurse educators as agents for change: increasing research utilization. International Journal of Nursing Studies 42, 899–914. Morgan, R., Keogh, B., 2005. Preceptorship in nursing: an Irish perspective. Clinical Excellence for Nurse practitioners 9 (4), 181–185. Morse, J.M., Field, P.A., 1996. Nursing Research: The Application of Qualitative Approaches, second ed. Stanley Thornes Publishers, Cheltenham. Murphy, P., 2000. Collaborating with practitioners in teaching and research: a model for developing the role of the nurse lecturer in practice areas. Journal of Advanced Nursing 31 (3), 704–714. Neary, M., 2000. Supporting student’s learning and professional development through the process of continuous assessment and mentorship. Nurse Education Today 20, 463–474. Nehls, R., Rather, M., Guyette, M., 1997. The preceptor model of clinical instruction: the lived experiences of students, preceptors, and faculty of record. Journal of Nursing Education 36 (5), 220–227. Norman, I., Watson, R., Murrells, T., Calman, L., Redfern, S., 2002. The validity and reliability of methods to assess competence to practice of pre registration nursing and midwifery students. International Journal of Nursing Studies 39, 133–145. Nursing and Midwifery Council, 2006. Standards to Support Learning and Assessment in Practice – NMC Standards for Mentors, Practice Teachers and Teachers. NMC, London. Pegram, A., Robinson, L., 2002. The experience of untaking faculty practice. Nurse Education in Practice 2, 30–34. Phillips, T., Schostak, J., Tyler, J., 2000. Practice and Assessment in Nursing and Midwifery: Doing it for Real The English National Board for Nursing. Midwifery and Health Visiting, London. Ramage, C., 2004. Negotiating multiple roles: link teachers in clinical nursing practice. Journal of Advanced Nursing 45 (3), 287–296. Spouse, J., 2001. Bridging theory and practice in the supervisory relationship: a sociocultural perspective. Journal of Advanced Nursing 33 (4), 512– 522. Streubert, H.J., Carpenter, D.R., 1995. Qualitative Research in Nursing Advancing the Human Perspective. Lippincott Company, Philadelphia. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1999. Fitness for Practice – The UKCC Commission for Nursing and Midwifery Education. UKCC, London. Williams, A., Taylor, C., 2008. An investigation of nurse educators perceptions and experiences of undertaking clinical practice. Nurse Education Today. doi:10.1016/j.nedt.2008.05.012.