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A qualitative study exploring the impact of student nurses working part time as a health care assistant
Nurse Education Today 33 (2013) 873–879
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A qualitative study exploring the impact of student nurses working part time as a health care assistant☆,☆☆ Felicity Hasson a,⁎, Hugh P. McKenna b, Sinead Keeney c a b c
Institute of Nursing Research, University of Ulster, Shore Road, Newtownabbey, Co. Antrim BT370QB, Northern Ireland, United Kingdom Research and Innovation, University of Ulster, Northern Ireland, United Kingdom Institute of Nursing Research, University of Ulster, Northern Ireland, United Kingdom
a r t i c l e
i n f o
Article history: Accepted 18 September 2012 Keywords: Part-time employment Nursing students Health care assistant Socialisation Qualitative
s u m m a r y Background: National and international evidence indicates that university students engage in employment whilst studying. Research has suggested that nursing students either enter training with previous care experience or tend to work part time in a health related area whilst undertaking higher education. The impact of this on the socialisation process remains unclear. Objectives: Based on the symbolic interactionist framework, this paper reports on a theme from a large mixed methods study — the extent and implications of student nurses' work experience on learning and training. Design: One qualitative stage from a sequential exploratory mixed methods design. Settings: One higher education institution in the United Kingdom. Participants: Forty-five pre-registration nursing students. Methods: Thirty-two students took part in four focus groups and 13 took part in individual interviews. Results: Findings revealed that 27 (60%) of students were in paid nursing related employment. This was reported to be advantageous by most participants with regards to enhancing confidence, skills and time spent in the clinical setting. However, it was also perceived by a small number of participants as being detrimental to subsequent learning resulting in role confusion, influencing placement behaviour, and preferences for future nursing practice. Student participants with no prior work experience believed this placed them at a disadvantage, negatively influencing their learning, ability to fit in, and adjustment on placement. Findings have suggested that student participants desire more recognition of the experience and skills they have gained from their employment. Conclusions: Whilst care experience among the student nursing population is advocated, the results of this study show that it is perceived to impinged on their learning and educational journey. Policy makers, educationalists and health service providers need to be aware of the students who operate within the dual roles of student and health care worker so as to provide guidance and appropriate direction. © 2012 Elsevier Ltd. All rights reserved.
Introduction National and international research has indicated that many undergraduate health care students are engaging in part-time employment, whilst studying full time. Estimates have suggested that between 50 and 60% of all full-time university students in Western nations engage in part time work (Australian Bureau of Statistics, 2002; Trade Union Congress/National Union of Students, 2006; American Council on Education, 2006). It would appear that financial necessity requires most students to work part time (Royal College of
☆ Role of the funding source: Acknowledgement is made to the Burdett Trust for Nursing who provided funding for part of this large scale study. The funder has no such involvement in the conduct of the research or preparation of this article. ☆☆ Conflict of interest: None exists. ⁎ Corresponding author. Tel.: +44 28 90 36 6895; fax: +44 28 90 36 8202. E-mail address: [email protected] (F. Hasson). 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.09.014
Nursing (RCN), 2008; Philips et al., 2011). However, practical experience and the possibility of future employment at the completion of their studies may also be a contributing factor (Gallagher, 2003). Given this, it is unsurprising that nursing students predominantly work part-time in health related settings as care assistants (Lee et al., 1999; Salamonson and Andrew, 2006; Royal College of Nursing, 2008; Rochford et al., 2009; Philips et al., 2011). This entails working between 10 and 16 h per week during term time in an array of clinical settings. Although there is a great deal of literature exploring the factors which influence the socialisation of student nurses (Olesen and Whittaker, 1968; Melia, 1987; Ousey, 2009; Condon and Sharts-Hopko, 2010), little attention has been given to examining the consequence of work experience on a nursing student's professional development. This is despite the fact that full-time university nursing students are being encouraged to engage in part-time work as care assistants (Australian National Nursing Education Review, 2002; Mallik and Aylott, 2005; Gulland, 2009). There have been calls for work experience to be used
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as a prerequisite for acceptance into nursing programmes (Wilson et al., 2010). At a policy level, in the United Kingdom (UK), neither the RCN nor the National Health Service (NHS) has rules to prevent student nurses working as support workers whilst undertaking nursing degree programmes. Although some universities have issued guidance for nursing students operating within the dual role of student and employee (The Robert Gordon University, 2004), these are not common. Using the symbolic interactionist framework, a large three-phased mixed methods study was undertaken that explored the role of health care assistants (HCA) in student nurses' clinical learning. This paper reports on the initial qualitative stage which explored student nurses experiences. It addresses one theme focusing on pre-registration nursing students' term-time employment commitments as health care assistants and the implications of this on their learning experience and views of nurse training. Background/Literature From a review of the existing literature on nursing students' part-time employment several key themes emerged. First, Salamonson and Andrew (2006) in an Australian survey of 267 nursing students found that more than three quarters held a part time job during their studies working on average for 13 h per week in nursing related jobs. Research from the UK and Ireland highlighted similar finding. For example, an online survey by the Royal College of Nursing (2008) revealed that 83% of nursing students worked more than 10 h per week as a health care support worker. Some had this position before entering nurse training whilst others gained employment whilst undertaking pre-registration programmes. More recently, Rochford et al. (2009) found that from a sample of 79 Irish degree students, 95% were in paid term-time employment, working an average of 16 h per week as a health care assistant. Secondly, literature on this topic has mainly focused on the implications of work experience. The majority of studies have explored the effect on nursing students' academic performance (Paton-Saltzberg and Lindsay, 1993; Ferguson and Cerinus, 1996; Lee et al., 1999; Salamonson and Andrew, 2006; Rochford et al., 2009), which suggested a detrimental impact. In Australia Salamonson and Andrew (2006) found that students who were not in paid employment had the highest academic achievements. In contrast, those working over 16 h in part-time employment had poorer academic performance. In nursing and other educational domains there is emerging evidence that term-time employment can also impact negatively on student attendance (Tangney, 2002), attrition (Callender, 1999); stress (Howard, 2001; Lo, 2002); fatigue and stress (Curtis and Shani, 2002; Salamonson et al., 2011). Work experience has also been found to influence practice choice. Biordi and Oermann (1993) found that it has a positive effect on students attitudes towards the disabled whilst Happell (2002) showed that part-time employment in nursing homes resulted in a lack of desire to work with older people following graduation. On the other hand, part-time employment in nursing-related occupations has been reported to be beneficial for a number of reasons. As well as meeting financial needs it has also been viewed as an opportunity to assist in nursing skill consolidation, broader clinical experience, development of confidence (Lee et al., 1999; Scott, 2007) greater independence and lower stress levels (Chesser-Smyth, 2005). Moreover, research suggested that many students enter training with an idealised view of nursing, not understanding what it entails (Grainger and Bolan, 2006). In such cases work experience exposes students to the reality of nursing practice (Macleod Clark et al., 1996; Godfrey, 2000; Rhodes and Bouic, 2005). Given this, it could therefore be argued that students with Health Care Assistant (HCA) experience are better prepared for a nursing role. Henry et al. (2000) carried out a small survey study with 66 American sophomore-level nursing students measuring self reported actions and decisions related to a range of patient care scenarios. They found no difference between workers and non-workers on clinical performance. The
researcher, whilst acknowledging the limitations of the survey approach, called for more research to be undertaken on this area. Having HCA work experience may be less beneficial than believed, as research suggested that it can influence learning requirements, cause stress, have conflicting student and HCA roles (Nicholl and Timmins, 2005; Royal College of Nursing, 2008; Tremayne, 2011) and has the potential to lead to dissonance. In the UK HCAs can be seconded from their work to undertake a nursing degree. Research focusing on such HCAs found that due to their previous experience they considered their learning needs to be different to other students. They also stated that the first year of nursing replicated what they already knew from working as a HCA and felt that they required less clinical skills teaching (Francis and Humphreys, 2000; Last and Fulbrook, 2003; Roberts, 2006). Moreover, research exploring the transition of seconded HCA to nursing students indicated that this is stressful process (Brennan and McSherry, 2007). Whilst seconded HCAs are a unique group, research does highlight the impact of work experience on their socialisation into nurse training. More recent international research has focused on the impact of prior life and work experiences on student nurses transition into education (Olson et al., 2001; Nelson et al., 2004; Scott, 2007; Lyons et al., 2010; Philips et al., 2011). In a small study, Scott (2007) used focus groups to explore the experiences of nine New Zealand nursing students who worked as HCAs. She found that whilst work experience enhanced learning, confidence, assertiveness skills and experimental learning opportunities, students reported their frustration at not being able to use their skills as a student nurse in their role as HCAs, leading most to experience role confusion. As part of a larger study exploring the impact on prior education, Lyons et al. (2010) explored how work experience affected the transition of 135 students into nurse education. They found that the majority (n= 132) had previous clinical experience in a health care setting; however this proved problematic for some, highlighting the difficulty of adapting to the novice role and accepting their low-ranking status as a student in both the classroom and clinical placement setting. Recently Philips et al. (2011) used focus groups with 75 newly qualified Australian nurses ‘to explore the influence of part time employment on practice choice and transition into their nursing role’. Findings revealed that over 90% of participants had part time jobs whilst studying, mainly in nursing related areas; they believed this helped their transition to registered nurse status and practice. Whilst the generalisablity to the UK context of each of these studies is questionable, it does highlight the influence work experience can have on students. Regardless of the benefits of prior work experience, some academics have voiced concerns about students operating within dual roles. For example, whilst Watson (2006), acknowledged that although he has no empirical evidence, he believes that working in unqualified positions is detrimental to nursing students; this is based on the premise that unqualified nursing work is different from the work of registered nurse. As Cockayne et al. (2007) stated “HCAs and pre-registration nursing students share the same patient groups, but their training, education and skills assessment are fundamentally different” (p46). Whilst dated, Holland's (1999) work also raised a number of concerns about this issue that can apply equally to seconded students and to the traditional entry students who are working as HCA during term time today. Firstly, if students are undertaking both roles simultaneously, when and how do they learn to internalise their future professional occupational role culture and its associated accountability? Secondly, who is teaching them the skills required of a registered nurse in relation to essential care-giving? If a student works as an HCA in one role, are they deemed competent to be undertaking those same skills as a student nurse? Such uncertainty has been exemplified by reports where a student working as a HCA was expected to perform as a third year student during a cardiac arrest on the same unit (Garrity, 1997). Some have been asked to work autonomously to deliver care as a HCA with no re-appraisal in relation to their new student role (Wood, 2006).
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In summary, whilst there is a scarcity of research exploring the student nurses' experience and impact of working as a HCA whilst studying, the results have suggested that previous experience has an influence on their academic and professional development. Employing a symbolic interactionist framework, this paper explores the perceived impact of work experience on student nurses' learning and training. This framework, a major sociological perspective, developed by Mead (1934) helps to provide an understanding of the processes by which interactions and experience modifies attitudes and behaviour. It is based on three premises, firstly that meanings are derived from social interactions; secondly, meanings we develop influence our behaviour and attitudes, and finally our meanings are not static but are modified through an interpretative process (Blumer, 1969). Within this framework, past behaviour such as work experience could be viewed as an intergenerational influence (IG) (Mead, 1934) within which the “…transmission of information, beliefs and recourses.... occurs” (Moore et al., 2002, p17). Based on this argument, HCA work experience would influence future attitudes and interactions with others. Using this framework allowed for the exploration of perspectives and meanings related to work experience and to the participants socialisation process. Methods The findings of this paper stem from a large sequential exploratory mixed methods project which explored how the interactions of HCAs with adult student nurses relate to and impact on the latter's clinical learning experience. The research was conducted in three phases and was guided by the symbolic interactionist framework (Mead, 1934; Blumer, 1969). This paper reports on phase one, interviews and focus groups undertaken with 45 pre-registration nursing students. Qualitative data are concerned with understanding how people give meaning and interpret their experiences (Fraenkel and Wallen, 1996; Pitney and Parker, 2001). Since this study seeks to understand the influence of work experience of student nurses, a qualitative approach was ideally suited. Participants The study was conducted at a major university in the United Kingdom where preregistration students must complete a three-year full time undergraduate degree. If they are successful, this leads to registration with the Nursing and Midwifery Council (NMC). At the time of the study, approximately 780 nursing students were enrolled. The inclusion criteria stipulated that they had to have clinical placement experience, be on a pre-registration nursing degree programme and provide informed consent. Following, web, email, poster and verbal presentations, to recruit, a total of 45 students agreed to participate in this phase. A much larger cohort participated in the following quantitative phase. Data Collection Data for the study were collected during 2006. In total, 32 students took part in four focus groups and 13 took part in individual interviews. These two qualitative methods were employed due to practical difficulties in accessing students and in response to requests to take part in one to one interviews. Combining these methods allowed for greater depth and breadth of data (Crabtree et al., 1993; Lambert and Loiselle, 2008) and for data to be validated and for clarification and illustration of the meaning of the findings to be explored (King, 1994). Nevertheless, it is acknowledged that focus groups can produce less data and more critical comments than interviews (Watts and Ebbutt, 1987). Therefore whilst complementary, it is likely that the data produced from focus group discussions will be different than that produced from interviews. A semi-structured interview schedule based on the theoretical framework, a review of the literature and aims of the study was devised. It included questions on students' perceptions of the HCA role
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and the opportunity to provide open comments about issues which impacted on their training and learning experience. The focus group and interviews ranged in time from 40 to 90 min. Ethical Considerations Approval to conduct the study was granted by the Nursing Ethics Filter Research Committee of the university in which the study took place. Informed consent was obtained from all participants and confidentiality was assured. Data Analysis All interviews and focus groups were audio-taped and transcribed verbatim. Data were subject to content analysis using Miles and Huberman's (1994) guidelines, which involved three stages. Firstly, the transcripts were reduced into themes guided by the aims and the theoretical framework. The second element, termed, data display, involved the formatting of the themes into diagrams or in text format, which enabled the identification of systematic patterns and interrelationships. The final element of analysis, conclusion drawing and verification involved condensing the analysed data to assess the implications and revisiting the data to verify the emergent themes. Data/Results Participant Demographics A total of 45 students participated in this phase of the larger study; the majority were female (n = 38) of these 19 represented third year, 16 in second year and 10 were in first year. Twenty seven of the respondents had experience of working as a HCA before and during their nurse education programme. Participants with HCA work experience reported that they had worked in a variety of clinical settings including nursing homes, and surgical, maternity and accident and emergency departments. Findings From the content analysis, two key themes emerged, comprising of 6 subthemes. These were related to the positive and negative effects of having HCA work experience on student learning (see Table 1). Confidence and Experience Students with experience of working as a HCA believed that they had greater confidence than those students without such experience. Familiarity with care settings not only helped to reduce anxiety but many believed that this put them at an advantage when entering placements. It ensured that they were familiar with ward routines and were confident interacting with patients and with members of the multidisciplinary team. Additionally, they felt they did not have to wait to be told what to do by ward staff, which they saw as
Table 1 Themes arising from the student nurses transcripts. Key Theme
Subtheme
Pros
Confidence and experience Prepared for the reality of nursing practice Treatment on wards Questioning the value of placement Role confusion
Cons
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advantageous to becoming accepted into the ward team. Indeed, just knowing what had to be done and getting on with it made them feel good: I have to admit that having had the experience …while others were learning…I felt that I had excelled a wee bit better in the first year, I definitely felt it gave me good grounding.3rd Year Par. No. 36 (HCA experience)
Yeah, I think you are more aware of the patient and confidentiality issues… you know what to expect and maybe you know how to approach a patient with regards to their empowerment3rd Year Focus Group Par. No. 38(HCA experience) In contrast, those students who had no previous care experience described the fear of the unknown when entering clinical placement and reported a high level of anxiety. Not having an HCA background was believed to be a disadvantage for some: … you would not have felt so stupid. You know, you would have known more about working in hospitals… I think if you worked in a hospital before you would have known what you have been letting yourself in for.1st Year Interview Par. No. 2
I thought it was a disadvantage; when I first went into the nursing home I didn't know what I was expected to do. I was kind of waiting on something or somebody to say: if I had worked in a nursing home before, I would have known, well the laundry had to be done.1st Year Interview Par. No. 6
Prepared for the Reality of Nursing Practice Students' with experience of working as a HCA stated that they were aware of the reality of nursing practice and an understanding of roles of both the role of the HCA and student nurse. For example, many were aware of staff shortages onwards, the division of labour and the hierarchy of clinical roles. They perceived that patient care was the often responsibility of the HCA, not the nurse. In contrast, those students with no pre-existing HCA experience spoke of the shock they experienced when they encountered the realities of being on a ward, the shortage of staff and particularly the lack of contact the nurse had with patients. Many of these students acknowledged that they entered nursing with an idealised view, thinking that nurses would have had time to talk to patients and provide ‘hands on’ care. However they found to their frustration, that this was not borne out in reality. “.. like I have gone into nursing with a dream….of being a nurse, like you know the way you dream of Florence nightingale and them kind of things right. But until I went into my placement I wish I had a been working as an assistant cause you get familiar with the routine …like they all know…. it was a disadvantage”1st Year Focus Group Par. No. 4 Students with experience of working as a HCA felt that they could empathise with both the role of the student nurse and that of the HCA. This provided them with a level of comfort that counterbalanced some of the negative effects of not feeling part of the main nursing team. They also recognised the potential for role conflict to exist between student nurses and the HCAs. Having experience of both roles was perceived to help students fit in much quicker and develop relationships. I felt empathy with the nursing auxiliaries in first and second year; you know I felt that I could closely identify with them more than I could the nursing staff….. I am glad I worked as a nursing auxiliary…as it gave
me the opportunity to look at and to weigh up both sides.3rd Year Interview Res. No. 31(HCA experience)
Treatment on the Wards Although previous HCA experience was viewed as an advantage, it was also reported to thwart learning opportunities. This was because there was a danger that student nurses with such familiarity would be treated by registered nurses as a knowledgeable HCA rather than as a learner. Some suggested that if ward staff found out they had worked as a HCA, they would be provided with less supervision and guidance. Because they were undertaking the basic care skills and routine tasks of a HCA, they were missing out on other clinical learning opportunities, leading some to feel frustrated with clinical placements. However, positive discrimination also occurred with mature second and third year students stating that if ward staff knew they had experience of working as an HCA they were viewed as having the necessary basic skills and were actively encouraged to participate in more advanced care. Some students who worked part time as HCAs during their training had clinical placements in their same area of employment. They reported that this caused confusion amongst clinical staff regarding what they could delegate. It also created frustration among students in what they could and could not undertake. Many felt that nursing staff could not differentiate between their student nurse's role and their HCA role and this resulted in the student resorting to the HCA role whilst on clinical placement. “But then you go into places and they find out what age you are and have you been married and have you worked before and then they totally change to you, their attitude, like I was in loads of places like that.”2nd Year Interview Par. No.23
Questioning the Value of Placement Some students with experience of working as a HCA believed they were competent in independently undertaking many basic care tasks without supervision. They argued that since they had already acquired basic nursing skills as a HCA, some clinical placements did not adequately meet their learning needs. For example, those who had previous experience of working in nursing homes felt they had adequate experience of caring for the older person and therefore considered such placements ineffective and not adding much to their skill base: I worked for a seven years as a nursing auxiliary so I don't think I gained out of that placement because I was doing what I had done in my own work just in a different building with different people. But it was the same role.1st Year Interview Res. No. 1(HCA experience)
Well the first placement in first year I don't see any difference because in this placement I learnt absolutely nothing that I didn't already know because I was a nursing assistant in a home for eleven years. So I gained absolutely nothing, there was no difference at all.2nd Year Focus Group Res. No. 20 (HCA experience)
Role Confusion Students with experience of working as a HCA had already developed a firm identity with that role and found it difficult to alter and move away to embrace a student nurse mindset. Some students reported that when they entered clinical placement they found themselves automatically “slipping into the role” of the HCA. Many reported that familiarity with
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the HCA role was a comforting experience as it acted as a safety net to get them through a placement. In contrast, others felt a frustration at being “pulled and pushed away” from the role with which they were familiar: Personally I find it hard to differentiate whenever you are within the ward, you know I think I have this perception you know that I am an auxiliary and I am getting to do extra bits. It's kind of the way that I look at it myself…but I don't think that was the point of being a nursing student.1st Year Interview Res. No. 1(HCA experience)
I still complete HCA roles/jobs and sometimes forget I'm a student nurse and need to be gathering nursing experience and knowledge.2nd Year Respondent 47 (HCA experience)
I felt that the nursing staff were pulling me away from the [HCA] role and I didn't want that…..I think it was just through ignorance of my own, I was still doing the tasks of the nursing auxiliary [HCA] and I didn't understand ….. what I needed to be doing as a nursing student.3rd Year Interview Res No. 31(HCA experience) In order to reaffirm the student nurse ideals, some students reported that their link lecturer, mentor and/or ward manager had taken them aside to remind them that they were training to be a nurse and not an HCA. As illustrated: In one of my first placements my mentor… took up aside and said to me you know that's not your job, you don't do that anymore you're here now to learn, you know your not here… to do the nursing auxiliaries' work. You know so I had to mentally take myself out of the HCA role and tell myself I was a student nurse.3rd Year Interview Res. No. 27(HCA experience) As students with experience of working as HCA progressed through their clinical placements they felt they had to remind themselves that they were training to be a nurse. Although they gradually accepted this, the lack of role boundaries between the student nurses and HCAs resulted in some finding this dichotomy frustrating and confusing. This was particularly the case with first and second year students. Nevertheless, by final year, student nurses had entered management placements and most reported they had a much clearer concept of what being a nurse involved and had moved away from their HCA task based approach.
5. Dicsussion Findings indicate that three-fifths of participants worked part time whilst studying. All were employed as health care assistants and from this employment had gained exposure to an array of clinical sites. This finding reflects previous national and international research results showing that nursing students are engaging in part time employment in nursing related positions (Salamonson and Andrew, 2006; Scott, 2007; Royal College of Nursing, 2008; Rochford et al., 2009; Philips et al., 2011). Whilst student nurses are being encouraged to participate in nursing related work prior to (Wilson et al., 2010) and during nurse training programmes (Australian National Nursing Education Review, 2002), the debate about the pros and cons continues. Findings of this study add to this discussion. For example, students who undertook paid HCA employment identified a number of benefits such as confidence building, opportunity to develop skills, and exposure to the reality of nursing roles and practice. Moreover it also increased the level of clinical experience, above university placement hours. Several authors (Macleod Clark et al., 1996; Olson et al., 2001; Rhodes and Bouic, 2005; Nelson et al., 2004; Scott, 2007: Philips et al., 2011) have reported similar advantages of
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HCA experience, viewing it as an aid in the transition process from student to registered professional. Having experience of being a HCA may assist in the transition to registered nurse. However, these findings indicate that it can also negatively encroach on the socialisation and educational experience of the nursing students, particularly on the development of identity, role transition and the acquisition of values, behaviour and attitudes. Although it may be a given that people who have work experience will adapt more readily than traditional nursing recruits, findings of this study suggest that role transition was a challenge. It led to confusion and inhibited the development of the professional mindset. Students found it difficult to walk away from the HCA role and some deliberately reverted back into it whilst on placement, reflective of Brennan and McSherry (2007) research on seconded HCAs. The challenge of students in this study was to try to disengage from the expectations and self-perceptions associated of the HCA role, whilst at the same time creating and adapting to socialising into the role of a student nurse. As echoed by Garrity (1997) and Wood (2006), dual roles also resulted in confusion amongst staff and this impacted in how students were treated at times to the detriment of learning and patient safety. HCA work experience was also found to influence values, attitudes and behaviour. Reflective of research undertaken on seconded HCAs (Roberts, 2006), students reported that their learning needs differed from other students. Moreover, confirming the concerns raised by Watson (2006), students in this study assumed that parts of the clinical placement experience and/or curriculum were superfluous to their training. Not only did they believe they were competent in undertaking basic care tasks without supervision but also they openly questioned the value of nursing home placements for students. This echoes the findings of Last and Fulbrook's (2003) who reported that participants with prior experience saw nursing home placements as not adequately meeting their learning needs. From a symbolic interactionist perspective, past experience plays a role in the interaction and interpretation of meanings. Blumer (1969) suggested that this inclines people to certain types of responses, resulting in some tension. This finding confirms those of Brennan and McSherry (2007), Wood (2006), Holland (1999) and Randle (2003) who have all reported the problems created by simultaneously having the dual roles of a student and an assistant. Accepting this, Watson (2006), Gould et al. (2006) and Holland (1999) maintained that this questions the value that the HCA experience may bring to nurse training. It is interesting that the third year student had moved away from HCA type of tasks and began to undertake activities more in line with those of registered nurses. This suggests that the first two years of a student nurse's learning is concerned with basic hands on care relating to feeding, grooming and general activities of living. Third year learning tends to focus more on ward management and supervision and includes medication rounds and medical rounds. Student nurses appeared glad that they had at last moved away from the HCA type tasks and routines. One could however interpret this as transferring from direct patient contact to more clinical hands off management practices. The implications for this are serious and fit with the ‘too posh to wash’ image of newly qualified nurses held by some members of the profession and the public (Fleming, 2009). Limitations Several limitations need to be considered when evaluating the findings, including the relatively small sample size, with no consideration of the influence of APEL programmes, the use of only one research site, the subjective nature of the research methods employed and potential self-report bias which may all affect the transferability of the findings. Clearly there is a need for further research to be conducted in this area, involving a larger sample size and using different data collection methods such as survey and observations. Nevertheless, these findings
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do reflect those in the extant international literature and point to the need to further examine the implications of HCA work experience on student nurses socialisation and educational experience. Conclusions This research identifies that nursing students are involved in term time HCA employment. This trend is also apparent in countries outside of the UK. There are advantages and disadvantages to part time employment impacting on the totality of the students' learning and clinical experience. However findings indicate that balancing the dual roles of being a student nurse whilst working as a HCA is not straightforward and has the potential to impact upon the socialisation experience of the student nurse. The findings of this study indicate the need for educationalists, policy makers and health service providers to be aware of the impact of HCA work experience on student nurses' development to enable them to be more effectively prepared for the challenges they are likely to encounter in clinical learning. For example, higher educational institutions should consider specific educational guidance be issued to students on managing the dual roles. It is recommended that further research be undertaken to explore the patterns, benefits and consequences of part time HCA work on student nurses' socialisation and training experience. Acknowledgements We acknowledge and thank the nursing students who participated in this survey. References American Council on Education, 2006. Working their way through college: student employment and its impact on the college experience. Issue Brief. ACE, United States . (Retrieved 15th June 2012, http://www.acenet.edu/AM/Template.cfm?template=/ CM/ContentDisplay.cfm&ContentFileID=1618). Australian Bureau of Statistics, 2002. Year Book Australia 2002: Education and Training Special Article — Combining Work and Study. ABS, Canberra. Australian National Nursing Education Review, 2002. National Review of Nursing Education 2002: Our Duty of Care. Department of Education, Science and Training, Canberra. Biordi, B., Oermann, M.H., 1993. The effect of prior experience in a rehabilitation setting on students' attitudes toward the disabled. Rehabilitative Nursing 8 (2), 95–98. Blumer, H., 1969. Symbolic Interactionism: Perspective and Method. University of California Press, Berkeley. Brennan, G., McSherry, R., 2007. Exploring the transition and professional socialisation from health care assistant to student nurse. Nurse Education in Practice 7 (4), 206–214. Callender, C., 1999. The Hardship of Learning: Students' Income and Expenditure and their Impact on Participation in Further Education. Further Education Funding Council, Coventry. Chesser-Smyth, P., 2005. The lived experiences of general student nurses on their first clinical placement: a phenomenological study. Nurse Education in Practice 5 (6), 320–327. Cockayne, D., Davis, G., Kenyon, L., 2007. Two levels of practice: meeting professional or workforce needs. Nursing Standard 21 (27), 44–47. Condon, E., Sharts-Hopko, N., 2010. Socialisation of Japanese nursing students. Nursing Education Perspectives 31 (3), 167–170. Crabtree, B.F., Yanoshik, M.K., Miller, W.L., O'Connor, P.J., 1993. Selecting individual or group interviews. In: Morgan, D.L. (Ed.), Successful Focus Groups: Advancing the State of the Art. Sage, Thousand Oaks, CA. Curtis, S., Shani, N., 2002. The effect of taking paid employment during term-time on students' academic studies. Journal of Further and Higher Education 26 (2), 129–138. Ferguson, C., Cerinus, M., 1996. Students in employment working and learning. Nurse Education Today 16 (5), 373–375. Fleming, G., 2009. Are student nurses too posh to wash? Nursing Times 6 November. Retrieved 10th June 2012 http://www.nursingtimes.net/whats-new-in-nursing/ beyond-the-bedpan/beyond-the-bedpan/are-student-nurses-too-posh-to-wash/ 5008269.article. Fraenkel, J.R., Wallen, N.E., 1996. How to Design and Evaluation Research in Education, 3rd ed. McGraw-Hill, New York. Francis, B., Humphreys, J., 2000. Professional education as a structural barrier to lifelong learning in the NHS. Journal of Education Policy 15 (3), 281–292. Gallagher, P., 2003. Re-thinking the theory–practice relationship in nursing: an alternative perspective. Contemporary Nurse 14 (2), 205–209. Garrity, M., 1997. Comment made at National Association of Further and Higher Education Conference. Nursing Times 5, 8. Godfrey, K., 2000. Don't believe the hype. Nursing Times 96 (28), 28–29.
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Sage Publications, California. Moore, E.S., Wilkie, W.L., Lutz, R.J., 2002. Passing the torch: intergenerational influences as a source of brand equity. Journal of Marketing 66 (2), 17–37. Nelson, D., Godfrey, L., Purdy, J., 2004. Using a mentorship program to recruit and retain student nurses. The Journal of Nursing Administration 34 (12), 551–553. Nicholl, H., Timmins, F., 2005. Programme-related stressors among part-time undergraduate nursing students. Journal of Advanced Nursing 50 (1), 93–100. Olesen, V.L., Whittaker, E.W., 1968. The Silent Dialogue: A Study in the Social Psychology of Professional Socialization Jossey-Bass, San Francisco. Olson, R.K., Nelson, M., Stuart, C., Young, L., Kleinsasser, A., Schroedermeier, R., Newstrom, P., 2001. Nursing student residency program: a model for a seamless transition from nursing student to RN. The Journal of Nursing Administration 31 (1), 40–48. Ousey, K., 2009. Socialization of student nurses — the role of the mentor. Learning in Health and Social Care 8 (3), 175–184. Paton-Saltzberg, R., Lindsay, R., 1993. The effects of paid employment on the academic performance of full-time students in a British ‘New’ University. A Report of a Study Commissioned by the Academic Standards Committee of the Oxford Brookes University, Oxford. Philips, C., Kenny, A., Smith, C., Esterman, A., 2011. Pre-registration paid employment choice: the views of newly qualified nurses. Nurse Education Today 32, 10–14. Pitney, W.A., Parker, J., 2001. Qualitative inquiry in athletic training: principles, possibilities, and promises. Journal of Athletic Training 36 (2), 185–189. Randle, J., 2003. Bullying in the nursing profession. Journal of Advanced Nursing 43 (4), 395-301. Rhodes, S., Bouic, L., 2005. An evaluation of taster days to recruit untrained healthcare staff to pre-registration mental health nurse education within one UK university. Nurse Education Today 25 (7), 556–563. Roberts, D., 2006. Learning experiences of seconded pre-registration nursing students. Nursing Standard 20 (36), 41–45. Rochford, C., Connolly, M., Drennan, J., 2009. Paid part-time employment and academic performance of undergraduate nursing students. Nurse Education Today 29 (6), 601–606. Royal College of Nursing, 2008. Nursing our Future: An RCN Study into the Challenge: Facing Today's Nursing Students in the UK. RCN, London. Salamonson, Y., Andrew, S., 2006. Academic performance in nursing students; influence of part-time employment, age and ethnicity. Journal of Advanced Nursing 55 (3), 342–349. Salamonson, Y., Everett, B., Kock, J., Andrew, S., Davison, M.P., 2011. The impact of term-time paid work on academic performance in nursing students: a longitudinal study. International Journal of Nursing Studies 49 (5), 579–585. Scott, H. 2007. An exploration of the experiences of undergraduate student nurses working as health care assistants: a qualitative descriptive analysis. 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Nurse Education Today journal homepage: www.elsevier.com/nedt
A qualitative study exploring the impact of student nurses working part time as a health care assistant☆,☆☆ Felicity Hasson a,⁎, Hugh P. McKenna b, Sinead Keeney c a b c
Institute of Nursing Research, University of Ulster, Shore Road, Newtownabbey, Co. Antrim BT370QB, Northern Ireland, United Kingdom Research and Innovation, University of Ulster, Northern Ireland, United Kingdom Institute of Nursing Research, University of Ulster, Northern Ireland, United Kingdom
a r t i c l e
i n f o
Article history: Accepted 18 September 2012 Keywords: Part-time employment Nursing students Health care assistant Socialisation Qualitative
s u m m a r y Background: National and international evidence indicates that university students engage in employment whilst studying. Research has suggested that nursing students either enter training with previous care experience or tend to work part time in a health related area whilst undertaking higher education. The impact of this on the socialisation process remains unclear. Objectives: Based on the symbolic interactionist framework, this paper reports on a theme from a large mixed methods study — the extent and implications of student nurses' work experience on learning and training. Design: One qualitative stage from a sequential exploratory mixed methods design. Settings: One higher education institution in the United Kingdom. Participants: Forty-five pre-registration nursing students. Methods: Thirty-two students took part in four focus groups and 13 took part in individual interviews. Results: Findings revealed that 27 (60%) of students were in paid nursing related employment. This was reported to be advantageous by most participants with regards to enhancing confidence, skills and time spent in the clinical setting. However, it was also perceived by a small number of participants as being detrimental to subsequent learning resulting in role confusion, influencing placement behaviour, and preferences for future nursing practice. Student participants with no prior work experience believed this placed them at a disadvantage, negatively influencing their learning, ability to fit in, and adjustment on placement. Findings have suggested that student participants desire more recognition of the experience and skills they have gained from their employment. Conclusions: Whilst care experience among the student nursing population is advocated, the results of this study show that it is perceived to impinged on their learning and educational journey. Policy makers, educationalists and health service providers need to be aware of the students who operate within the dual roles of student and health care worker so as to provide guidance and appropriate direction. © 2012 Elsevier Ltd. All rights reserved.
Introduction National and international research has indicated that many undergraduate health care students are engaging in part-time employment, whilst studying full time. Estimates have suggested that between 50 and 60% of all full-time university students in Western nations engage in part time work (Australian Bureau of Statistics, 2002; Trade Union Congress/National Union of Students, 2006; American Council on Education, 2006). It would appear that financial necessity requires most students to work part time (Royal College of
☆ Role of the funding source: Acknowledgement is made to the Burdett Trust for Nursing who provided funding for part of this large scale study. The funder has no such involvement in the conduct of the research or preparation of this article. ☆☆ Conflict of interest: None exists. ⁎ Corresponding author. Tel.: +44 28 90 36 6895; fax: +44 28 90 36 8202. E-mail address: [email protected] (F. Hasson). 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.09.014
Nursing (RCN), 2008; Philips et al., 2011). However, practical experience and the possibility of future employment at the completion of their studies may also be a contributing factor (Gallagher, 2003). Given this, it is unsurprising that nursing students predominantly work part-time in health related settings as care assistants (Lee et al., 1999; Salamonson and Andrew, 2006; Royal College of Nursing, 2008; Rochford et al., 2009; Philips et al., 2011). This entails working between 10 and 16 h per week during term time in an array of clinical settings. Although there is a great deal of literature exploring the factors which influence the socialisation of student nurses (Olesen and Whittaker, 1968; Melia, 1987; Ousey, 2009; Condon and Sharts-Hopko, 2010), little attention has been given to examining the consequence of work experience on a nursing student's professional development. This is despite the fact that full-time university nursing students are being encouraged to engage in part-time work as care assistants (Australian National Nursing Education Review, 2002; Mallik and Aylott, 2005; Gulland, 2009). There have been calls for work experience to be used
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as a prerequisite for acceptance into nursing programmes (Wilson et al., 2010). At a policy level, in the United Kingdom (UK), neither the RCN nor the National Health Service (NHS) has rules to prevent student nurses working as support workers whilst undertaking nursing degree programmes. Although some universities have issued guidance for nursing students operating within the dual role of student and employee (The Robert Gordon University, 2004), these are not common. Using the symbolic interactionist framework, a large three-phased mixed methods study was undertaken that explored the role of health care assistants (HCA) in student nurses' clinical learning. This paper reports on the initial qualitative stage which explored student nurses experiences. It addresses one theme focusing on pre-registration nursing students' term-time employment commitments as health care assistants and the implications of this on their learning experience and views of nurse training. Background/Literature From a review of the existing literature on nursing students' part-time employment several key themes emerged. First, Salamonson and Andrew (2006) in an Australian survey of 267 nursing students found that more than three quarters held a part time job during their studies working on average for 13 h per week in nursing related jobs. Research from the UK and Ireland highlighted similar finding. For example, an online survey by the Royal College of Nursing (2008) revealed that 83% of nursing students worked more than 10 h per week as a health care support worker. Some had this position before entering nurse training whilst others gained employment whilst undertaking pre-registration programmes. More recently, Rochford et al. (2009) found that from a sample of 79 Irish degree students, 95% were in paid term-time employment, working an average of 16 h per week as a health care assistant. Secondly, literature on this topic has mainly focused on the implications of work experience. The majority of studies have explored the effect on nursing students' academic performance (Paton-Saltzberg and Lindsay, 1993; Ferguson and Cerinus, 1996; Lee et al., 1999; Salamonson and Andrew, 2006; Rochford et al., 2009), which suggested a detrimental impact. In Australia Salamonson and Andrew (2006) found that students who were not in paid employment had the highest academic achievements. In contrast, those working over 16 h in part-time employment had poorer academic performance. In nursing and other educational domains there is emerging evidence that term-time employment can also impact negatively on student attendance (Tangney, 2002), attrition (Callender, 1999); stress (Howard, 2001; Lo, 2002); fatigue and stress (Curtis and Shani, 2002; Salamonson et al., 2011). Work experience has also been found to influence practice choice. Biordi and Oermann (1993) found that it has a positive effect on students attitudes towards the disabled whilst Happell (2002) showed that part-time employment in nursing homes resulted in a lack of desire to work with older people following graduation. On the other hand, part-time employment in nursing-related occupations has been reported to be beneficial for a number of reasons. As well as meeting financial needs it has also been viewed as an opportunity to assist in nursing skill consolidation, broader clinical experience, development of confidence (Lee et al., 1999; Scott, 2007) greater independence and lower stress levels (Chesser-Smyth, 2005). Moreover, research suggested that many students enter training with an idealised view of nursing, not understanding what it entails (Grainger and Bolan, 2006). In such cases work experience exposes students to the reality of nursing practice (Macleod Clark et al., 1996; Godfrey, 2000; Rhodes and Bouic, 2005). Given this, it could therefore be argued that students with Health Care Assistant (HCA) experience are better prepared for a nursing role. Henry et al. (2000) carried out a small survey study with 66 American sophomore-level nursing students measuring self reported actions and decisions related to a range of patient care scenarios. They found no difference between workers and non-workers on clinical performance. The
researcher, whilst acknowledging the limitations of the survey approach, called for more research to be undertaken on this area. Having HCA work experience may be less beneficial than believed, as research suggested that it can influence learning requirements, cause stress, have conflicting student and HCA roles (Nicholl and Timmins, 2005; Royal College of Nursing, 2008; Tremayne, 2011) and has the potential to lead to dissonance. In the UK HCAs can be seconded from their work to undertake a nursing degree. Research focusing on such HCAs found that due to their previous experience they considered their learning needs to be different to other students. They also stated that the first year of nursing replicated what they already knew from working as a HCA and felt that they required less clinical skills teaching (Francis and Humphreys, 2000; Last and Fulbrook, 2003; Roberts, 2006). Moreover, research exploring the transition of seconded HCA to nursing students indicated that this is stressful process (Brennan and McSherry, 2007). Whilst seconded HCAs are a unique group, research does highlight the impact of work experience on their socialisation into nurse training. More recent international research has focused on the impact of prior life and work experiences on student nurses transition into education (Olson et al., 2001; Nelson et al., 2004; Scott, 2007; Lyons et al., 2010; Philips et al., 2011). In a small study, Scott (2007) used focus groups to explore the experiences of nine New Zealand nursing students who worked as HCAs. She found that whilst work experience enhanced learning, confidence, assertiveness skills and experimental learning opportunities, students reported their frustration at not being able to use their skills as a student nurse in their role as HCAs, leading most to experience role confusion. As part of a larger study exploring the impact on prior education, Lyons et al. (2010) explored how work experience affected the transition of 135 students into nurse education. They found that the majority (n= 132) had previous clinical experience in a health care setting; however this proved problematic for some, highlighting the difficulty of adapting to the novice role and accepting their low-ranking status as a student in both the classroom and clinical placement setting. Recently Philips et al. (2011) used focus groups with 75 newly qualified Australian nurses ‘to explore the influence of part time employment on practice choice and transition into their nursing role’. Findings revealed that over 90% of participants had part time jobs whilst studying, mainly in nursing related areas; they believed this helped their transition to registered nurse status and practice. Whilst the generalisablity to the UK context of each of these studies is questionable, it does highlight the influence work experience can have on students. Regardless of the benefits of prior work experience, some academics have voiced concerns about students operating within dual roles. For example, whilst Watson (2006), acknowledged that although he has no empirical evidence, he believes that working in unqualified positions is detrimental to nursing students; this is based on the premise that unqualified nursing work is different from the work of registered nurse. As Cockayne et al. (2007) stated “HCAs and pre-registration nursing students share the same patient groups, but their training, education and skills assessment are fundamentally different” (p46). Whilst dated, Holland's (1999) work also raised a number of concerns about this issue that can apply equally to seconded students and to the traditional entry students who are working as HCA during term time today. Firstly, if students are undertaking both roles simultaneously, when and how do they learn to internalise their future professional occupational role culture and its associated accountability? Secondly, who is teaching them the skills required of a registered nurse in relation to essential care-giving? If a student works as an HCA in one role, are they deemed competent to be undertaking those same skills as a student nurse? Such uncertainty has been exemplified by reports where a student working as a HCA was expected to perform as a third year student during a cardiac arrest on the same unit (Garrity, 1997). Some have been asked to work autonomously to deliver care as a HCA with no re-appraisal in relation to their new student role (Wood, 2006).
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In summary, whilst there is a scarcity of research exploring the student nurses' experience and impact of working as a HCA whilst studying, the results have suggested that previous experience has an influence on their academic and professional development. Employing a symbolic interactionist framework, this paper explores the perceived impact of work experience on student nurses' learning and training. This framework, a major sociological perspective, developed by Mead (1934) helps to provide an understanding of the processes by which interactions and experience modifies attitudes and behaviour. It is based on three premises, firstly that meanings are derived from social interactions; secondly, meanings we develop influence our behaviour and attitudes, and finally our meanings are not static but are modified through an interpretative process (Blumer, 1969). Within this framework, past behaviour such as work experience could be viewed as an intergenerational influence (IG) (Mead, 1934) within which the “…transmission of information, beliefs and recourses.... occurs” (Moore et al., 2002, p17). Based on this argument, HCA work experience would influence future attitudes and interactions with others. Using this framework allowed for the exploration of perspectives and meanings related to work experience and to the participants socialisation process. Methods The findings of this paper stem from a large sequential exploratory mixed methods project which explored how the interactions of HCAs with adult student nurses relate to and impact on the latter's clinical learning experience. The research was conducted in three phases and was guided by the symbolic interactionist framework (Mead, 1934; Blumer, 1969). This paper reports on phase one, interviews and focus groups undertaken with 45 pre-registration nursing students. Qualitative data are concerned with understanding how people give meaning and interpret their experiences (Fraenkel and Wallen, 1996; Pitney and Parker, 2001). Since this study seeks to understand the influence of work experience of student nurses, a qualitative approach was ideally suited. Participants The study was conducted at a major university in the United Kingdom where preregistration students must complete a three-year full time undergraduate degree. If they are successful, this leads to registration with the Nursing and Midwifery Council (NMC). At the time of the study, approximately 780 nursing students were enrolled. The inclusion criteria stipulated that they had to have clinical placement experience, be on a pre-registration nursing degree programme and provide informed consent. Following, web, email, poster and verbal presentations, to recruit, a total of 45 students agreed to participate in this phase. A much larger cohort participated in the following quantitative phase. Data Collection Data for the study were collected during 2006. In total, 32 students took part in four focus groups and 13 took part in individual interviews. These two qualitative methods were employed due to practical difficulties in accessing students and in response to requests to take part in one to one interviews. Combining these methods allowed for greater depth and breadth of data (Crabtree et al., 1993; Lambert and Loiselle, 2008) and for data to be validated and for clarification and illustration of the meaning of the findings to be explored (King, 1994). Nevertheless, it is acknowledged that focus groups can produce less data and more critical comments than interviews (Watts and Ebbutt, 1987). Therefore whilst complementary, it is likely that the data produced from focus group discussions will be different than that produced from interviews. A semi-structured interview schedule based on the theoretical framework, a review of the literature and aims of the study was devised. It included questions on students' perceptions of the HCA role
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and the opportunity to provide open comments about issues which impacted on their training and learning experience. The focus group and interviews ranged in time from 40 to 90 min. Ethical Considerations Approval to conduct the study was granted by the Nursing Ethics Filter Research Committee of the university in which the study took place. Informed consent was obtained from all participants and confidentiality was assured. Data Analysis All interviews and focus groups were audio-taped and transcribed verbatim. Data were subject to content analysis using Miles and Huberman's (1994) guidelines, which involved three stages. Firstly, the transcripts were reduced into themes guided by the aims and the theoretical framework. The second element, termed, data display, involved the formatting of the themes into diagrams or in text format, which enabled the identification of systematic patterns and interrelationships. The final element of analysis, conclusion drawing and verification involved condensing the analysed data to assess the implications and revisiting the data to verify the emergent themes. Data/Results Participant Demographics A total of 45 students participated in this phase of the larger study; the majority were female (n = 38) of these 19 represented third year, 16 in second year and 10 were in first year. Twenty seven of the respondents had experience of working as a HCA before and during their nurse education programme. Participants with HCA work experience reported that they had worked in a variety of clinical settings including nursing homes, and surgical, maternity and accident and emergency departments. Findings From the content analysis, two key themes emerged, comprising of 6 subthemes. These were related to the positive and negative effects of having HCA work experience on student learning (see Table 1). Confidence and Experience Students with experience of working as a HCA believed that they had greater confidence than those students without such experience. Familiarity with care settings not only helped to reduce anxiety but many believed that this put them at an advantage when entering placements. It ensured that they were familiar with ward routines and were confident interacting with patients and with members of the multidisciplinary team. Additionally, they felt they did not have to wait to be told what to do by ward staff, which they saw as
Table 1 Themes arising from the student nurses transcripts. Key Theme
Subtheme
Pros
Confidence and experience Prepared for the reality of nursing practice Treatment on wards Questioning the value of placement Role confusion
Cons
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advantageous to becoming accepted into the ward team. Indeed, just knowing what had to be done and getting on with it made them feel good: I have to admit that having had the experience …while others were learning…I felt that I had excelled a wee bit better in the first year, I definitely felt it gave me good grounding.3rd Year Par. No. 36 (HCA experience)
Yeah, I think you are more aware of the patient and confidentiality issues… you know what to expect and maybe you know how to approach a patient with regards to their empowerment3rd Year Focus Group Par. No. 38(HCA experience) In contrast, those students who had no previous care experience described the fear of the unknown when entering clinical placement and reported a high level of anxiety. Not having an HCA background was believed to be a disadvantage for some: … you would not have felt so stupid. You know, you would have known more about working in hospitals… I think if you worked in a hospital before you would have known what you have been letting yourself in for.1st Year Interview Par. No. 2
I thought it was a disadvantage; when I first went into the nursing home I didn't know what I was expected to do. I was kind of waiting on something or somebody to say: if I had worked in a nursing home before, I would have known, well the laundry had to be done.1st Year Interview Par. No. 6
Prepared for the Reality of Nursing Practice Students' with experience of working as a HCA stated that they were aware of the reality of nursing practice and an understanding of roles of both the role of the HCA and student nurse. For example, many were aware of staff shortages onwards, the division of labour and the hierarchy of clinical roles. They perceived that patient care was the often responsibility of the HCA, not the nurse. In contrast, those students with no pre-existing HCA experience spoke of the shock they experienced when they encountered the realities of being on a ward, the shortage of staff and particularly the lack of contact the nurse had with patients. Many of these students acknowledged that they entered nursing with an idealised view, thinking that nurses would have had time to talk to patients and provide ‘hands on’ care. However they found to their frustration, that this was not borne out in reality. “.. like I have gone into nursing with a dream….of being a nurse, like you know the way you dream of Florence nightingale and them kind of things right. But until I went into my placement I wish I had a been working as an assistant cause you get familiar with the routine …like they all know…. it was a disadvantage”1st Year Focus Group Par. No. 4 Students with experience of working as a HCA felt that they could empathise with both the role of the student nurse and that of the HCA. This provided them with a level of comfort that counterbalanced some of the negative effects of not feeling part of the main nursing team. They also recognised the potential for role conflict to exist between student nurses and the HCAs. Having experience of both roles was perceived to help students fit in much quicker and develop relationships. I felt empathy with the nursing auxiliaries in first and second year; you know I felt that I could closely identify with them more than I could the nursing staff….. I am glad I worked as a nursing auxiliary…as it gave
me the opportunity to look at and to weigh up both sides.3rd Year Interview Res. No. 31(HCA experience)
Treatment on the Wards Although previous HCA experience was viewed as an advantage, it was also reported to thwart learning opportunities. This was because there was a danger that student nurses with such familiarity would be treated by registered nurses as a knowledgeable HCA rather than as a learner. Some suggested that if ward staff found out they had worked as a HCA, they would be provided with less supervision and guidance. Because they were undertaking the basic care skills and routine tasks of a HCA, they were missing out on other clinical learning opportunities, leading some to feel frustrated with clinical placements. However, positive discrimination also occurred with mature second and third year students stating that if ward staff knew they had experience of working as an HCA they were viewed as having the necessary basic skills and were actively encouraged to participate in more advanced care. Some students who worked part time as HCAs during their training had clinical placements in their same area of employment. They reported that this caused confusion amongst clinical staff regarding what they could delegate. It also created frustration among students in what they could and could not undertake. Many felt that nursing staff could not differentiate between their student nurse's role and their HCA role and this resulted in the student resorting to the HCA role whilst on clinical placement. “But then you go into places and they find out what age you are and have you been married and have you worked before and then they totally change to you, their attitude, like I was in loads of places like that.”2nd Year Interview Par. No.23
Questioning the Value of Placement Some students with experience of working as a HCA believed they were competent in independently undertaking many basic care tasks without supervision. They argued that since they had already acquired basic nursing skills as a HCA, some clinical placements did not adequately meet their learning needs. For example, those who had previous experience of working in nursing homes felt they had adequate experience of caring for the older person and therefore considered such placements ineffective and not adding much to their skill base: I worked for a seven years as a nursing auxiliary so I don't think I gained out of that placement because I was doing what I had done in my own work just in a different building with different people. But it was the same role.1st Year Interview Res. No. 1(HCA experience)
Well the first placement in first year I don't see any difference because in this placement I learnt absolutely nothing that I didn't already know because I was a nursing assistant in a home for eleven years. So I gained absolutely nothing, there was no difference at all.2nd Year Focus Group Res. No. 20 (HCA experience)
Role Confusion Students with experience of working as a HCA had already developed a firm identity with that role and found it difficult to alter and move away to embrace a student nurse mindset. Some students reported that when they entered clinical placement they found themselves automatically “slipping into the role” of the HCA. Many reported that familiarity with
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the HCA role was a comforting experience as it acted as a safety net to get them through a placement. In contrast, others felt a frustration at being “pulled and pushed away” from the role with which they were familiar: Personally I find it hard to differentiate whenever you are within the ward, you know I think I have this perception you know that I am an auxiliary and I am getting to do extra bits. It's kind of the way that I look at it myself…but I don't think that was the point of being a nursing student.1st Year Interview Res. No. 1(HCA experience)
I still complete HCA roles/jobs and sometimes forget I'm a student nurse and need to be gathering nursing experience and knowledge.2nd Year Respondent 47 (HCA experience)
I felt that the nursing staff were pulling me away from the [HCA] role and I didn't want that…..I think it was just through ignorance of my own, I was still doing the tasks of the nursing auxiliary [HCA] and I didn't understand ….. what I needed to be doing as a nursing student.3rd Year Interview Res No. 31(HCA experience) In order to reaffirm the student nurse ideals, some students reported that their link lecturer, mentor and/or ward manager had taken them aside to remind them that they were training to be a nurse and not an HCA. As illustrated: In one of my first placements my mentor… took up aside and said to me you know that's not your job, you don't do that anymore you're here now to learn, you know your not here… to do the nursing auxiliaries' work. You know so I had to mentally take myself out of the HCA role and tell myself I was a student nurse.3rd Year Interview Res. No. 27(HCA experience) As students with experience of working as HCA progressed through their clinical placements they felt they had to remind themselves that they were training to be a nurse. Although they gradually accepted this, the lack of role boundaries between the student nurses and HCAs resulted in some finding this dichotomy frustrating and confusing. This was particularly the case with first and second year students. Nevertheless, by final year, student nurses had entered management placements and most reported they had a much clearer concept of what being a nurse involved and had moved away from their HCA task based approach.
5. Dicsussion Findings indicate that three-fifths of participants worked part time whilst studying. All were employed as health care assistants and from this employment had gained exposure to an array of clinical sites. This finding reflects previous national and international research results showing that nursing students are engaging in part time employment in nursing related positions (Salamonson and Andrew, 2006; Scott, 2007; Royal College of Nursing, 2008; Rochford et al., 2009; Philips et al., 2011). Whilst student nurses are being encouraged to participate in nursing related work prior to (Wilson et al., 2010) and during nurse training programmes (Australian National Nursing Education Review, 2002), the debate about the pros and cons continues. Findings of this study add to this discussion. For example, students who undertook paid HCA employment identified a number of benefits such as confidence building, opportunity to develop skills, and exposure to the reality of nursing roles and practice. Moreover it also increased the level of clinical experience, above university placement hours. Several authors (Macleod Clark et al., 1996; Olson et al., 2001; Rhodes and Bouic, 2005; Nelson et al., 2004; Scott, 2007: Philips et al., 2011) have reported similar advantages of
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HCA experience, viewing it as an aid in the transition process from student to registered professional. Having experience of being a HCA may assist in the transition to registered nurse. However, these findings indicate that it can also negatively encroach on the socialisation and educational experience of the nursing students, particularly on the development of identity, role transition and the acquisition of values, behaviour and attitudes. Although it may be a given that people who have work experience will adapt more readily than traditional nursing recruits, findings of this study suggest that role transition was a challenge. It led to confusion and inhibited the development of the professional mindset. Students found it difficult to walk away from the HCA role and some deliberately reverted back into it whilst on placement, reflective of Brennan and McSherry (2007) research on seconded HCAs. The challenge of students in this study was to try to disengage from the expectations and self-perceptions associated of the HCA role, whilst at the same time creating and adapting to socialising into the role of a student nurse. As echoed by Garrity (1997) and Wood (2006), dual roles also resulted in confusion amongst staff and this impacted in how students were treated at times to the detriment of learning and patient safety. HCA work experience was also found to influence values, attitudes and behaviour. Reflective of research undertaken on seconded HCAs (Roberts, 2006), students reported that their learning needs differed from other students. Moreover, confirming the concerns raised by Watson (2006), students in this study assumed that parts of the clinical placement experience and/or curriculum were superfluous to their training. Not only did they believe they were competent in undertaking basic care tasks without supervision but also they openly questioned the value of nursing home placements for students. This echoes the findings of Last and Fulbrook's (2003) who reported that participants with prior experience saw nursing home placements as not adequately meeting their learning needs. From a symbolic interactionist perspective, past experience plays a role in the interaction and interpretation of meanings. Blumer (1969) suggested that this inclines people to certain types of responses, resulting in some tension. This finding confirms those of Brennan and McSherry (2007), Wood (2006), Holland (1999) and Randle (2003) who have all reported the problems created by simultaneously having the dual roles of a student and an assistant. Accepting this, Watson (2006), Gould et al. (2006) and Holland (1999) maintained that this questions the value that the HCA experience may bring to nurse training. It is interesting that the third year student had moved away from HCA type of tasks and began to undertake activities more in line with those of registered nurses. This suggests that the first two years of a student nurse's learning is concerned with basic hands on care relating to feeding, grooming and general activities of living. Third year learning tends to focus more on ward management and supervision and includes medication rounds and medical rounds. Student nurses appeared glad that they had at last moved away from the HCA type tasks and routines. One could however interpret this as transferring from direct patient contact to more clinical hands off management practices. The implications for this are serious and fit with the ‘too posh to wash’ image of newly qualified nurses held by some members of the profession and the public (Fleming, 2009). Limitations Several limitations need to be considered when evaluating the findings, including the relatively small sample size, with no consideration of the influence of APEL programmes, the use of only one research site, the subjective nature of the research methods employed and potential self-report bias which may all affect the transferability of the findings. Clearly there is a need for further research to be conducted in this area, involving a larger sample size and using different data collection methods such as survey and observations. Nevertheless, these findings
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do reflect those in the extant international literature and point to the need to further examine the implications of HCA work experience on student nurses socialisation and educational experience. Conclusions This research identifies that nursing students are involved in term time HCA employment. This trend is also apparent in countries outside of the UK. There are advantages and disadvantages to part time employment impacting on the totality of the students' learning and clinical experience. However findings indicate that balancing the dual roles of being a student nurse whilst working as a HCA is not straightforward and has the potential to impact upon the socialisation experience of the student nurse. The findings of this study indicate the need for educationalists, policy makers and health service providers to be aware of the impact of HCA work experience on student nurses' development to enable them to be more effectively prepared for the challenges they are likely to encounter in clinical learning. For example, higher educational institutions should consider specific educational guidance be issued to students on managing the dual roles. It is recommended that further research be undertaken to explore the patterns, benefits and consequences of part time HCA work on student nurses' socialisation and training experience. Acknowledgements We acknowledge and thank the nursing students who participated in this survey. References American Council on Education, 2006. Working their way through college: student employment and its impact on the college experience. Issue Brief. ACE, United States . (Retrieved 15th June 2012, http://www.acenet.edu/AM/Template.cfm?template=/ CM/ContentDisplay.cfm&ContentFileID=1618). Australian Bureau of Statistics, 2002. Year Book Australia 2002: Education and Training Special Article — Combining Work and Study. ABS, Canberra. Australian National Nursing Education Review, 2002. National Review of Nursing Education 2002: Our Duty of Care. Department of Education, Science and Training, Canberra. Biordi, B., Oermann, M.H., 1993. The effect of prior experience in a rehabilitation setting on students' attitudes toward the disabled. Rehabilitative Nursing 8 (2), 95–98. Blumer, H., 1969. Symbolic Interactionism: Perspective and Method. University of California Press, Berkeley. Brennan, G., McSherry, R., 2007. Exploring the transition and professional socialisation from health care assistant to student nurse. Nurse Education in Practice 7 (4), 206–214. Callender, C., 1999. The Hardship of Learning: Students' Income and Expenditure and their Impact on Participation in Further Education. Further Education Funding Council, Coventry. Chesser-Smyth, P., 2005. The lived experiences of general student nurses on their first clinical placement: a phenomenological study. Nurse Education in Practice 5 (6), 320–327. Cockayne, D., Davis, G., Kenyon, L., 2007. Two levels of practice: meeting professional or workforce needs. Nursing Standard 21 (27), 44–47. Condon, E., Sharts-Hopko, N., 2010. Socialisation of Japanese nursing students. Nursing Education Perspectives 31 (3), 167–170. Crabtree, B.F., Yanoshik, M.K., Miller, W.L., O'Connor, P.J., 1993. Selecting individual or group interviews. In: Morgan, D.L. (Ed.), Successful Focus Groups: Advancing the State of the Art. Sage, Thousand Oaks, CA. Curtis, S., Shani, N., 2002. The effect of taking paid employment during term-time on students' academic studies. Journal of Further and Higher Education 26 (2), 129–138. Ferguson, C., Cerinus, M., 1996. Students in employment working and learning. Nurse Education Today 16 (5), 373–375. Fleming, G., 2009. Are student nurses too posh to wash? Nursing Times 6 November. Retrieved 10th June 2012 http://www.nursingtimes.net/whats-new-in-nursing/ beyond-the-bedpan/beyond-the-bedpan/are-student-nurses-too-posh-to-wash/ 5008269.article. Fraenkel, J.R., Wallen, N.E., 1996. How to Design and Evaluation Research in Education, 3rd ed. McGraw-Hill, New York. Francis, B., Humphreys, J., 2000. Professional education as a structural barrier to lifelong learning in the NHS. Journal of Education Policy 15 (3), 281–292. Gallagher, P., 2003. Re-thinking the theory–practice relationship in nursing: an alternative perspective. Contemporary Nurse 14 (2), 205–209. Garrity, M., 1997. Comment made at National Association of Further and Higher Education Conference. Nursing Times 5, 8. Godfrey, K., 2000. Don't believe the hype. Nursing Times 96 (28), 28–29.
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