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An integrated educational model for graduate entry nursing cirriculum design
Nurse Education Today 34 (2014) 145–149
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Review
An integrated educational model for graduate entry nursing cirriculum design Gemma Stacey ⁎, Julie McGarry, Aimee Aubeeluck, Heather Bull, Chris Simpson, Fiona Sheppard, Sue Thompson University of Nottingham, Division of Nursing, United Kingdom
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Article history: Accepted 22 August 2012 Keywords: Pre-registration nurse education Graduatness Critical dialogue Graduate entry nursing
s u m m a r y The constraints influencing the development of nurse education are widely debated and discussed within the academic, professional and public arena. In order to challenge these constraints it is proposed that nurse education should promote every opportunity for students to engage in critical dialogue with a range of influential sources. This paper will report on an integrated educational model for graduate entry curriculum design. The model capitalises on the skills and attributes students bring to the course, which are collectively termed “graduateness,” by utilising a range of teaching and learning approaches which compliment and build upon each other to foster the characteristics of a capable practitioner. It is envisaged that this will better enable those graduating from this programme to respond to the changing context of healthcare. © 2012 Elsevier Ltd. All rights reserved.
Introduction The Division of Nursing at the University of Nottingham in the UK has recently commenced the delivery of a re-designed Graduate Entry Nursing (GEN) Programme. This programme enables students who have already obtained a degree to complete a post graduate certificate in nursing and achieve registration with the Nursing and Midwifery Council (NMC) in two years with accreditation for prior learning. A detailed account of the development of this programme, and its underpinning principles and philosophy is reported in McGarry et al. (2010). The NMC's recent review of pre-registration nurse education (Nursing and Midwifery Council, 2010) has prompted widespread debate in both the professional and public press regarding the future of pre-registration nurse education in England. These debates greatly influenced curriculum decision-making in the development of the GEN programme. As such, course development has attempted to address the criticism that current models of pre-registration education fail to adequately prepare nurses for the continually changing demands of healthcare services (Hegarty et al., 2009). Recent policy drivers outlining the qualities required of nurses to respond to the needs of patients and demands of healthcare in the future, emphasise the message that there is a need for change in the way nurses view their position within the professional hierarchy (DH, 2008). However, there remains underpinning cultural issues, which have restricted educational development in nursing throughout history. These include the image of nursing influenced by historical conceptualisations, media representations, gender associations, and anti-intellectualism, which exist within the professional itself (Hallam, ⁎ Corresponding author at: Division of Nursing, Royal Derby Hospital, Uttoxester Rd, DE22 3NE, United Kingdom. Tel.: +44 1332 7324949. E-mail address: [email protected] (G. Stacey). 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.08.014
2002; Meerabeau, 2001; Takase et al., 2001). It is important that teaching and learning practices continue to evolve in order to meet the shifting requirements of the work environment for which student nurses are being prepared. In order to address these constraints, the GEN curriculum development team has devised an integrated educational model of innovative teaching and learning approaches which compliment and build upon each other. The methodology helps students develop skills for engaging in critical dialogue in order to take them beyond competence, to capable and confident practitioners. In this way, it is proposed, graduates will be better equipped to respond to the changing face of nursing. Background Prior to 1989, 98% of nurse education in the UK took place within the National Health Service (NHS) (Robinson, 1991). Apprenticeship models of education were the accepted mode of preparation and nursing qualifications had no academic currency. However, significant questions and criticisms were launched at this approach. For example, the United Kingdom Central Council for Nursing (1986) recognised that there was often a need to make educational compromises to ensure the wards were staffed. The apprenticeship method of preparation was also deemed to represent a form of role learning that prevented opportunity for the development of critical thought in order to challenge accepted practice or exercise social control. Individuals were compelled to conform to the rules and norms of the profession. Apprenticeship models were seen to exist for the good of the system more than the enhancement of learner potential or development of independent thought (Holloway and Penson, 1987; Freshwater and Stickley, 2004; Orland-Barak and Wilhelem, 2005). The Project 2000 curriculum attempted to address these failings by relocating nurse education from the NHS to Higher Education
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Institutions (HEI) and raising the minimal level of entry of the professional to Diploma. Opinions towards this move were polarised. As such, it was viewed as both positive in aiming to achieve a social recognition of the complexity of the nursing role, whilst also criticised for focusing more on the progression of the profession as oppose to the quality of patient care (Bradshaw and Merriman, 2008; Robinson, 1991). These concerns continue to rumble within the nursing press and moreover, the media and have recently been reignited by the NMC's decision to move to an all-graduate profession. Commentary in these publications often differentiates knowledge and care, and comments such as “too clever to care” and “too posh to wash” have become integrated into an anti-intellectualism discourse. These statements are underpinned by arguments that assume decreased standards of care are linked directly to a higher focus on theoretical knowledge (Matheson and Bobay, 2007). Meerabeau (2001) considered the influence of the media on the perception of nurse education and its portrayal of being unnecessarily rarefied and highly academic. These reports implied nurses were overqualified as applied work is the provision of “basic” care. Contributing to this, Hallam (2000) drew on the post war era where the public image of nursing drew on feminine conventions. This emphasised the feminine service to medicine as the Nightingale legacy firmly placed nursing as inferior to medicine. Moreover, media representation of nurses at this time were often sexualised and nurses were portrayed as unintelligent. These factors have been viewed as highly significant in influencing the social positioning of nursing and remain a major obstacle to professional development (Bridges, 1990; Meerabeau, 2001). Nurses appear to have maintained this anti-intellectualism culture by furiously upholding a stereotype of the “basic” role of a nurse whilst denigrating the intelligence required to demonstrate these “basic” skills within the complex and demanding healthcare environment (Takase et al., 2001). Roberts (2000) explains this defensiveness as the profession responding to a culture that defines their role as inferior. The antiintellectualism discourse which has emerged, acts as a form of rebellion to counteract the oppressing view held by society by defending practical activity and denigrating the relevance and value of abstract thought. Furthermore nurses are often silent about their own contributions to patient care, and therefore diminish their own sense of value, as well as their ability to deliver good care (Roberts et al., 2009). This style of communication creates a negative cycle because it diminishes active involvement in the care of patients and positive expressions about nursing work that leads to further devaluing (Buresh and Gordon, 2006). Freire (1971) identifies that such defensive reaction allows the oppressor to further label the oppressed as unintelligent. Freire (1971) maintains that the basic reason for this behaviour is that dominated people feel devalued in a culture where the powerful promote their own attributes as the valued ones. The oppressed, therefore, develop distain for themselves and a belief in their own inferiority that leads to a lack of pride and feelings of low self-esteem. Freire (2007) sees critical dialogue as essential to free both parties from the ascribed myths. However, the hierarchy embedded in nursing often inhibits such dialogue. Roberts (2000) criticises current approaches to nurse education and sees it as preventing opportunities for nurses to recognise and examine the structural contexts of their struggles, due to the many ways in which the curriculum maintains social control. Drawing on these arguments, it appears that in order for nursing to address its limitations, higher order thinking skills are not only desirable but essential. Watson (2006) supports this view and identifies that the development of competence is inadequate for an occupation to become a profession. He proposes that it is the acquisition of self-consciousness that is the hallmark of a profession. This refers to the ability to not only master a skill but also to give an account of the underpinning rationale for its use and reflection on its application.
Capability is proposed by Watson as an alternative concept that encompasses competence and accountability. Stephenson (1998) maintains that competence can be observed when we see people with justified confidence in their ability to: take effective and appropriate action; explain what they are about; live and work effectively with others; continue to learn from experience as individuals and with others to adapt to diverse and changing society. Therefore capability can be viewed as a higher order achievement as it involves the ability to deal with the unfamiliar. It is therefore evident that programmes that encourage learning by replication of skills through pure observation and imitation will be inadequate in achieving capability. Walker (1998) claims a capable graduate is one who has sufficient knowledge and skills to enable him or her to act effectively, who is knowledgeable in the use of skills and skilful in the use of knowledge, and who is aware of the social, intellectual and moral implications of factions. Capability is not only a more inclusive concept than competence; it recognises that skilful behaviour does not result from a set of discrete performance skills. Graduate Entry Nursing (GEN) Research exploring GEN programmes internationally has consistently found that they are effective and attract candidates into the profession with diverse life, educational and professional experiences (Walker et al., 2008; Siler et al., 2008; Kohn and Truglio-Londrigan, 2007). This is seen as a particular strength associated with this student population as it is maintained that successful completion of a first degree demonstrates academic ability and also skills that can be transferred into the study of nursing. Furthermore according to Penprase and Koczara (2009) and Raines (2007) graduates have the capacity to learn quickly due to their previous educational and life experience. The combination of these attributes is collectively known as “Graduateness” which is defined as the possession of the following qualities: • The ability to research, analyse and present information coherently. • Breadth of vision – the ability to continue learning, the ability to relate to a wide range of subjects, a curiosity about other subjects and a breadth of knowledge. • Expertise in their chosen field, the ability to achieve a balanced view and an open and flexible mind. • Impetus to reach a goal, in a disciplined manner. (HEQC, 1996). It is suggested that by attracting this type of individual into the profession we are more likely to produce new registrants who are able to meet the demands of the developing role of the nurse, as they will be flexible, knowledgeable, motivated, and committed to the profession (Neill, 2011). Halkett and McLafferty (2006) however, identify that recruitment of these students into the profession is only part of the equation. Programmes of study need to be designed which build upon their strengths and offer good quality learning experiences in practice. From this perspective, traditional teacher-dependent methods are criticised as being inadequate. In particular, they are seen to fall short in terms of developing advanced thinking skills that can effectively incorporate theory into practice and trigger positive innovation (Oztuk et al., 2008). The GEN programme designed by the School of Nursing, Midwifery and Physiotherapy at the University of Nottingham has attempted address this requirement through an extensive collaborative process of curriculum development involving key stakeholders, practitioners and service users and carers (McGarry et al., 2010). The integrated educational model adopted in this programme will now be described and discussed to illustrate how a range of learning approaches can be brought together to produce a cohesive programme which focuses on the development of capability (Watson, 2006) and maximises the “graduateness” of students on the programme (Walker, 1998).
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An Integrated Educational Model for Graduate Entry Curriculum Design The model below represents the underpinning ideology of the GEN programme as it identifies our expectations of the students and how their qualities are taken into consideration when designing the range of teaching and learning approaches utilised (Fig. 1). The two way arrow represents the integrated process as graduate attributes are drawn out and built upon in each of the educational forums to strengthen and build upon the experience and skills the students possess. Each of the educational forums are facilitated in a way that promotes critical dialogue amongst local and international peers, academics, practitioners and students from other professions. This aims to offer students the opportunity to move beyond the competent practitioner to become the capable practitioner who has developed their graduate attributes and is able to apply them in a nursing context. Underpinning Philosophy The person centred philosophical underpinning of the programme is reinforced not only by the teaching and learning methods adopted, but also in the organisation and delivery of the course. The programme adopts a shared learning approach whereby students studying the child, mental health and adult fields of nursing learn together for the majority of the course. This enables students to develop knowledge and skills that allow them to respond to the whole person. It also aims to challenge professional role boundaries which attempt to compartmentalise people or neglect essential aspects which can highly influence their response to healthcare. Students in the penultimate module apply this philosophy to complex clinical care environments that are specific to their field. Enquiry Base Learning This shared approach to learning is achievable through enquiry based learning (EBL), which represents the majority of theoretical learning on this program. It is stimulated by exploring a succession of person-centred case studies that are supported by a small number of lectures and workshops and clinical skills sessions (McGarry et al., 2010). The case studies have been constructed to draw on five key learning areas or domains, namely, biological science, psycho/social aspects of care, clinical decision-making and skills, personal and professional development, and evidence-based practice. Each case progresses through three sections that are released to the students at separate tutor-facilitated meetings over a period of a week.
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The case studies are innovatively presented using computer technology. This has the advantage of enabling a greater sense of realism and being linked to practice than if a paper format alone was use, and is therefore arguably more stimulating for the students. Where possible and appropriate, the case study is delivered using scripted and filmed clinical scenes, authentic video narratives, original photographic material, fictitious patient records on authentic forms, and web-links to government and other official documents. Each case study is made available to student groups by timed-release through a virtual learning environment (VLE). Working collaboratively in groups of six to eight, the students draw on their current knowledge and experience to reflectively and critically discuss issues presented in the case studies. The issues within the case studies prompt the students learning and could include a wide range of topics such as a set of symptoms, treatment regime, a social issue, or clinical procedure. In this way the students broaden their perception of the topic area, identify knowledge gaps, and formulate group learning-goals for a period of self-directed study that follows. The group reconvenes to share, discuss and debate their learning and to generate new meaning. This is carried forward to the next stage where additional information on the case study is presented and the cycle is repeated a second and then third time until the case study is complete. In this manner, the students deepen their understanding of complex issues encountered in nursing practice and advance their skills in locating, assimilating and analysing information from a range of sources. This enables them to develop a transferable methodology for managing unfamiliar scenarios in practice. The diversity of viewpoints present in the group is seen to enrich dialogue and to help the students develop confidence in debating, conducting and promoting discussion, presenting perspectives and working as part of a team. EBL is based on the constructivist theory which claims that people generate knowledge and meaning by engaging with their experiences and analysing them. A further principle is that learning takes place when it builds on previous learning, and is particularly successful when it is placed in the context of problem-solving activities that are relevant to the student (Matt, 2000). In agreement with this, EBL uses contextualised scenarios that simulated real life challenges for learners to address. The case studies operate as triggers to draw on students' background experience (McGarry et al., 2010). This in turn provides a basis for laying down new levels of learning, which may or may not remodel learners' pre-existing perceptions. Of additional interest, EBL embodies a learning style that is suited to the adult. It is noted that adult students learn best by ‘doing’, and prefer to work in groups. They tend to be self-motivated and respond better
Fig. 1. An integrated educational model for graduate entry curriculum design.
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to student-centred methods that favour deep learning (Rogers and Horrocks, 2010). Furthermore, EBL exploits advanced learning skills that adults and graduates of other disciplines may bring to further education after a change in career focus. Of particular relevance to nursing, the scenario-based approach offers strategies to overcome long-standing challenges in nurse education, such as enabling students to integrate nursing theory into practice (Ehrenberg and Haggblom, 2007) through the acquisition of skills in critical and reflective thinking (Oztuk et al., 2008). This methodology presents a simple framework that can be reworked to encourage life-long learning beyond registration. In this way, EBL can nurture the development of self directed learning skills which can enable the students to critically appraise the evidence, account for their judgments of practice and respond with confidence to unfamiliar clinical scenarios. Internationalisation The process of EBL is extended to the international arena through the facilitation of a virtual student exchange project (VEP). This is underpinned by the recognition that internationalism and globalisation are now an integral part of both the planning and delivery of contemporary nursing curricula worldwide in order to facilitate the development of a future health care workforce that is responsive to global health needs (World Health Organisation, 2000; Allen and Ogilvie, 2004). The growing interest and relevance of internationalism and globalisation within the context of pre-registration nurse education rests in the recognition that nurses are increasingly expected to be culturally competent at a general level. Nurses will increasingly need to be compete successfully within an international arena in terms of job opportunities., Furthermore, centrally, nurses will need to understand the implications of globalisation in terms of the social determinants of health, patterns of disease and illness, health inequalities and the underlining political and social dimensions that influence health and social inequalities for individuals and particular communities (Allen and Ogilvie, 2004). With this in mind, GEN has successfully embedded internationalism and global perspectives through establishing e-learning links and the development of e-learning resources with two partner universities in Ireland and Scotland and the VEP which is a web-based learning and teaching application designed to bring ‘study-elsewhere’ experiences into the student's own setting. The structure of the VEP is such that it offers students from different universities, with different health systems the opportunity to explore an EBL case study and share a range of learning opportunities in order for them to debate and discuss different perspectives on health and social care priorities and environments of care. Moreover, the context of the learning environment and its similarities to virtual social networks also facilitate greater understanding through the exchange of friendly dialogue that is grounded in the ‘connect, aspire, enjoy and achieve’ approach towards study and learning (Todhunter and Hallawell, 2010). The first phase of this work has evaluated extremely positively with students and the members of staff involved in this project and is currently being expanded further to include additional partner organisations in the United States. Group Clinical Supervision The opportunity to engage in critical and reflective dialogue with peers is continued when the students are in clinical practice through the facilitation of group supervision. A number of studies have provided evidence that supervision during pre registration nurse training promotes students professional identity and personal growth (Lindstrom, 1985; Arvidsson et al., 2008), enhances the development of empathy and understanding of others (Holm and Severinsson, 1998) and that it is perceived as supportive and restorative (Lindgren et al., 2005). Several studies also seek to make clear the relationship
between group supervision and the integration of practical and theoretical knowledge in the student. The NHS executive (1993) describe supervision as a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex situations. Therefore the underpinning principles on which the GEN curriculum was developed led to the decision to include group supervision as a core component of the course. Within the GEN programme each student is randomly assigned to a small group of no more than eight participants facilitated by a lecturer who has a supervisory role. The groups meet once every two weeks during practice placements for two hours. To enable their own development in role, all supervisors attend peer support meetings after conducting group supervision with the students. The supervisors establish a shared vision of working, and endeavour to develop a supervisory alliance (Proctor and Inskipp, 2001) within their individual groups. This includes a written agreement that is used to outline the limits of confidentiality, meeting arrangements, commitment to the process and each other, and finally any other issue that the group considers important. Proctor's model of supervision (Procto, 1991; Proctor and Inskipp, 2001) is used to agree the domains in which supervisors operate and attempts are made to achieve a balance between reflective learning (formative function) professional accountability (normative function) and providing support (restorative function). Discussions focus on bringing issues from the student's practice experience to share and unpick in relation to theoretical, ethical, personal and, what Carper (1978) termed, asthetic perspectives. The aim is to progress the student's different ‘ways of knowing’ (Carper, 1978) through increasingly sophisticated reflection on the application of theory to practice. However, every attempt is made to provide a comfortable, safe learning environment where students feel free to share their feelings, thoughts and ideas and test out their understanding. It is evident therefore that group supervision offers students the opportunity to develop reflective learning skills and encourages them to question what is observed in practice rather than excepting it without excising critical thought.
Inter-professional Learning These skills are also applied when working with other professionals in a practice based interprofessional learning opportunity know as the shared family study (SFS). Barr (2005 p7) suggests that interprofessional learning encompasses situations where people from at least two professional backgrounds learn “with, from and about one another to improve collaboration and the quality of care.” Whilst the most appropriate time to introduce interprofessional learning into curricula is still a subject of debate (Leaviss, 2000; Barr and Ross, 2006), the SFS runs over the first year of both the University of Nottingham GEN programme and the Graduate Entry to Medicine (GEM) programme. The project aims to facilitate the development of the skills required for collaborative working and problem solving through offering opportunities for students to explore clinical situations from a variety of professional perspectives. The students are teamed into interprofessional groups of three know as learning sets. Each set is assigned to a family who meets specific selection criteria and who have given consent to involvement in the SFS initiative. The criteria requires that one member of the family has a chronic illness, a life threatening condition but with a reasonable prognosis, complex social problems, or multiple agencies supporting their care. The students then have contact with family members over a period of the year and may see them in the home, hospital or other organisational setting. Guidelines are provided for each student together with a diary in which to record their anonymised contacts and reflections.
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Students meet with academic staff at two facilitated seminars throughout the year to gauge process and discuss experiences with other groups. A conference is held at the end of the year for which students present posters on a particular aspect of health related to their assigned family. They also have the opportunity to deliver an oral presentation to an invited academic audience consisting of fellow students, academic and practice colleagues. The experience of working together enables the students to gain an in depth understanding of each other's roles. It is intended that this will enhance communication, dialogue and recognition of skills, respective roles and expertise (Sherwood and Drenkard, 2007). The hope is that this will ultimately promote and sustain collaborative interprofessional working within the practice setting alongside developing the confidence to question professional hierarchies where they exist to the detriment of effective patient care. Conclusion It is proposed that each of these learning methods will offer students the opportunity to develop existing skills, to respond confidently and enthusiastically to challenges and meet the demands of the changing healthcare arena as a capable practitioner. Each of the educational approaches complements and builds upon each other to provide an integrated and cohesive curriculum model which exploits the skills and attributes the students bring by virtue of their graduate status. The emphasis of each of the educational forums is on promoting critical dialogue with a range of influential individuals and groups. This enables students to question cultural norms which have restricted the progression of nursing as a profession and give them the tools and confidence to exercises this in clinical practice. Graduates of the GEN programme should be able to encounter unfamiliar nursing situations with the knowledge that what they don't know, they can find out with accuracy and assimilate and synthesise into their current roles. As such the GEN programme has the ability to produce nurses that provide essential care alongside innovative and current evidence based practice. The extent to which the intended outcomes have been achieved is currently being explored through a series of longitudinal research projects considering the students experiences of the programme and how they respond to practice from varying perspectives. Internal evaluation is providing valuable feedback on the teaching and learning approaches described and adaptations are continually being made to address the students learning needs. We suggest that this is also a key element of maximising graduateness as it respects students as adult learners who are best positioned to define their learning requirements. References Allen, M., Ogilvie, L., 2004. Internationalisation of higher education: potentials and pitfalls for nursing education. International Nursing Review 51, 73–80. Arvidsson, B., Skärsäter, I., Baigi, A., Svensson, M.-L., Fridlund, B., 2008. The development of a questionnaire for evaluating process-oriented group supervision during nursing education. Nurse Education in Practice 8, 88–93. Barr, H., 2005. Interprofessional Education, Today, Yesterday and Tomorrow A Review United Kingdom. Higher Education Academy, London. Barr, H., Ross, F., 2006. Mainstreaming Interprofessional Education :A Position Paper. Journal of Interprofessional Care 20 (2), 96–104. Bradshaw, A., Merriman, C., 2008. Nursing competence 10 years on: fit for practice and purpose yet? Journal of Clinical Nursing 17, 1263–1269. Bridges, J.M., 1990. Literature review on the images of the nurse and nursing in the media. Journal of Advance Nursing 15 (7), 759–864. Buresh, B., Gordon, S., 2006. From Silence to Voice, 2nd edn. Canadian Nurses Association, Cornell University Press, Ithaca, NY. Carper, B., 1978. Fundamental Patterns of knowing in nursing. Advances in Nursing Science 1, 13–23. Department of Health, 2008. High Quality Care For All: NHS next stage review final report. HMSO, London. Ehrenberg, A.C., Haggblom, M., 2007. Problem-based learning in clinical nursing education: integrating theory and practice. Nurse Education in Practice 7, 67–74. Freire, P., 1971. Pedagogy of the Oppressed. Continuu, New York. Freire, P., 2007. Pedagogy of the Oppressed. Continuum International Publishing Group, New York.
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Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Review
An integrated educational model for graduate entry nursing cirriculum design Gemma Stacey ⁎, Julie McGarry, Aimee Aubeeluck, Heather Bull, Chris Simpson, Fiona Sheppard, Sue Thompson University of Nottingham, Division of Nursing, United Kingdom
a r t i c l e
i n f o
Article history: Accepted 22 August 2012 Keywords: Pre-registration nurse education Graduatness Critical dialogue Graduate entry nursing
s u m m a r y The constraints influencing the development of nurse education are widely debated and discussed within the academic, professional and public arena. In order to challenge these constraints it is proposed that nurse education should promote every opportunity for students to engage in critical dialogue with a range of influential sources. This paper will report on an integrated educational model for graduate entry curriculum design. The model capitalises on the skills and attributes students bring to the course, which are collectively termed “graduateness,” by utilising a range of teaching and learning approaches which compliment and build upon each other to foster the characteristics of a capable practitioner. It is envisaged that this will better enable those graduating from this programme to respond to the changing context of healthcare. © 2012 Elsevier Ltd. All rights reserved.
Introduction The Division of Nursing at the University of Nottingham in the UK has recently commenced the delivery of a re-designed Graduate Entry Nursing (GEN) Programme. This programme enables students who have already obtained a degree to complete a post graduate certificate in nursing and achieve registration with the Nursing and Midwifery Council (NMC) in two years with accreditation for prior learning. A detailed account of the development of this programme, and its underpinning principles and philosophy is reported in McGarry et al. (2010). The NMC's recent review of pre-registration nurse education (Nursing and Midwifery Council, 2010) has prompted widespread debate in both the professional and public press regarding the future of pre-registration nurse education in England. These debates greatly influenced curriculum decision-making in the development of the GEN programme. As such, course development has attempted to address the criticism that current models of pre-registration education fail to adequately prepare nurses for the continually changing demands of healthcare services (Hegarty et al., 2009). Recent policy drivers outlining the qualities required of nurses to respond to the needs of patients and demands of healthcare in the future, emphasise the message that there is a need for change in the way nurses view their position within the professional hierarchy (DH, 2008). However, there remains underpinning cultural issues, which have restricted educational development in nursing throughout history. These include the image of nursing influenced by historical conceptualisations, media representations, gender associations, and anti-intellectualism, which exist within the professional itself (Hallam, ⁎ Corresponding author at: Division of Nursing, Royal Derby Hospital, Uttoxester Rd, DE22 3NE, United Kingdom. Tel.: +44 1332 7324949. E-mail address: [email protected] (G. Stacey). 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.08.014
2002; Meerabeau, 2001; Takase et al., 2001). It is important that teaching and learning practices continue to evolve in order to meet the shifting requirements of the work environment for which student nurses are being prepared. In order to address these constraints, the GEN curriculum development team has devised an integrated educational model of innovative teaching and learning approaches which compliment and build upon each other. The methodology helps students develop skills for engaging in critical dialogue in order to take them beyond competence, to capable and confident practitioners. In this way, it is proposed, graduates will be better equipped to respond to the changing face of nursing. Background Prior to 1989, 98% of nurse education in the UK took place within the National Health Service (NHS) (Robinson, 1991). Apprenticeship models of education were the accepted mode of preparation and nursing qualifications had no academic currency. However, significant questions and criticisms were launched at this approach. For example, the United Kingdom Central Council for Nursing (1986) recognised that there was often a need to make educational compromises to ensure the wards were staffed. The apprenticeship method of preparation was also deemed to represent a form of role learning that prevented opportunity for the development of critical thought in order to challenge accepted practice or exercise social control. Individuals were compelled to conform to the rules and norms of the profession. Apprenticeship models were seen to exist for the good of the system more than the enhancement of learner potential or development of independent thought (Holloway and Penson, 1987; Freshwater and Stickley, 2004; Orland-Barak and Wilhelem, 2005). The Project 2000 curriculum attempted to address these failings by relocating nurse education from the NHS to Higher Education
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Institutions (HEI) and raising the minimal level of entry of the professional to Diploma. Opinions towards this move were polarised. As such, it was viewed as both positive in aiming to achieve a social recognition of the complexity of the nursing role, whilst also criticised for focusing more on the progression of the profession as oppose to the quality of patient care (Bradshaw and Merriman, 2008; Robinson, 1991). These concerns continue to rumble within the nursing press and moreover, the media and have recently been reignited by the NMC's decision to move to an all-graduate profession. Commentary in these publications often differentiates knowledge and care, and comments such as “too clever to care” and “too posh to wash” have become integrated into an anti-intellectualism discourse. These statements are underpinned by arguments that assume decreased standards of care are linked directly to a higher focus on theoretical knowledge (Matheson and Bobay, 2007). Meerabeau (2001) considered the influence of the media on the perception of nurse education and its portrayal of being unnecessarily rarefied and highly academic. These reports implied nurses were overqualified as applied work is the provision of “basic” care. Contributing to this, Hallam (2000) drew on the post war era where the public image of nursing drew on feminine conventions. This emphasised the feminine service to medicine as the Nightingale legacy firmly placed nursing as inferior to medicine. Moreover, media representation of nurses at this time were often sexualised and nurses were portrayed as unintelligent. These factors have been viewed as highly significant in influencing the social positioning of nursing and remain a major obstacle to professional development (Bridges, 1990; Meerabeau, 2001). Nurses appear to have maintained this anti-intellectualism culture by furiously upholding a stereotype of the “basic” role of a nurse whilst denigrating the intelligence required to demonstrate these “basic” skills within the complex and demanding healthcare environment (Takase et al., 2001). Roberts (2000) explains this defensiveness as the profession responding to a culture that defines their role as inferior. The antiintellectualism discourse which has emerged, acts as a form of rebellion to counteract the oppressing view held by society by defending practical activity and denigrating the relevance and value of abstract thought. Furthermore nurses are often silent about their own contributions to patient care, and therefore diminish their own sense of value, as well as their ability to deliver good care (Roberts et al., 2009). This style of communication creates a negative cycle because it diminishes active involvement in the care of patients and positive expressions about nursing work that leads to further devaluing (Buresh and Gordon, 2006). Freire (1971) identifies that such defensive reaction allows the oppressor to further label the oppressed as unintelligent. Freire (1971) maintains that the basic reason for this behaviour is that dominated people feel devalued in a culture where the powerful promote their own attributes as the valued ones. The oppressed, therefore, develop distain for themselves and a belief in their own inferiority that leads to a lack of pride and feelings of low self-esteem. Freire (2007) sees critical dialogue as essential to free both parties from the ascribed myths. However, the hierarchy embedded in nursing often inhibits such dialogue. Roberts (2000) criticises current approaches to nurse education and sees it as preventing opportunities for nurses to recognise and examine the structural contexts of their struggles, due to the many ways in which the curriculum maintains social control. Drawing on these arguments, it appears that in order for nursing to address its limitations, higher order thinking skills are not only desirable but essential. Watson (2006) supports this view and identifies that the development of competence is inadequate for an occupation to become a profession. He proposes that it is the acquisition of self-consciousness that is the hallmark of a profession. This refers to the ability to not only master a skill but also to give an account of the underpinning rationale for its use and reflection on its application.
Capability is proposed by Watson as an alternative concept that encompasses competence and accountability. Stephenson (1998) maintains that competence can be observed when we see people with justified confidence in their ability to: take effective and appropriate action; explain what they are about; live and work effectively with others; continue to learn from experience as individuals and with others to adapt to diverse and changing society. Therefore capability can be viewed as a higher order achievement as it involves the ability to deal with the unfamiliar. It is therefore evident that programmes that encourage learning by replication of skills through pure observation and imitation will be inadequate in achieving capability. Walker (1998) claims a capable graduate is one who has sufficient knowledge and skills to enable him or her to act effectively, who is knowledgeable in the use of skills and skilful in the use of knowledge, and who is aware of the social, intellectual and moral implications of factions. Capability is not only a more inclusive concept than competence; it recognises that skilful behaviour does not result from a set of discrete performance skills. Graduate Entry Nursing (GEN) Research exploring GEN programmes internationally has consistently found that they are effective and attract candidates into the profession with diverse life, educational and professional experiences (Walker et al., 2008; Siler et al., 2008; Kohn and Truglio-Londrigan, 2007). This is seen as a particular strength associated with this student population as it is maintained that successful completion of a first degree demonstrates academic ability and also skills that can be transferred into the study of nursing. Furthermore according to Penprase and Koczara (2009) and Raines (2007) graduates have the capacity to learn quickly due to their previous educational and life experience. The combination of these attributes is collectively known as “Graduateness” which is defined as the possession of the following qualities: • The ability to research, analyse and present information coherently. • Breadth of vision – the ability to continue learning, the ability to relate to a wide range of subjects, a curiosity about other subjects and a breadth of knowledge. • Expertise in their chosen field, the ability to achieve a balanced view and an open and flexible mind. • Impetus to reach a goal, in a disciplined manner. (HEQC, 1996). It is suggested that by attracting this type of individual into the profession we are more likely to produce new registrants who are able to meet the demands of the developing role of the nurse, as they will be flexible, knowledgeable, motivated, and committed to the profession (Neill, 2011). Halkett and McLafferty (2006) however, identify that recruitment of these students into the profession is only part of the equation. Programmes of study need to be designed which build upon their strengths and offer good quality learning experiences in practice. From this perspective, traditional teacher-dependent methods are criticised as being inadequate. In particular, they are seen to fall short in terms of developing advanced thinking skills that can effectively incorporate theory into practice and trigger positive innovation (Oztuk et al., 2008). The GEN programme designed by the School of Nursing, Midwifery and Physiotherapy at the University of Nottingham has attempted address this requirement through an extensive collaborative process of curriculum development involving key stakeholders, practitioners and service users and carers (McGarry et al., 2010). The integrated educational model adopted in this programme will now be described and discussed to illustrate how a range of learning approaches can be brought together to produce a cohesive programme which focuses on the development of capability (Watson, 2006) and maximises the “graduateness” of students on the programme (Walker, 1998).
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An Integrated Educational Model for Graduate Entry Curriculum Design The model below represents the underpinning ideology of the GEN programme as it identifies our expectations of the students and how their qualities are taken into consideration when designing the range of teaching and learning approaches utilised (Fig. 1). The two way arrow represents the integrated process as graduate attributes are drawn out and built upon in each of the educational forums to strengthen and build upon the experience and skills the students possess. Each of the educational forums are facilitated in a way that promotes critical dialogue amongst local and international peers, academics, practitioners and students from other professions. This aims to offer students the opportunity to move beyond the competent practitioner to become the capable practitioner who has developed their graduate attributes and is able to apply them in a nursing context. Underpinning Philosophy The person centred philosophical underpinning of the programme is reinforced not only by the teaching and learning methods adopted, but also in the organisation and delivery of the course. The programme adopts a shared learning approach whereby students studying the child, mental health and adult fields of nursing learn together for the majority of the course. This enables students to develop knowledge and skills that allow them to respond to the whole person. It also aims to challenge professional role boundaries which attempt to compartmentalise people or neglect essential aspects which can highly influence their response to healthcare. Students in the penultimate module apply this philosophy to complex clinical care environments that are specific to their field. Enquiry Base Learning This shared approach to learning is achievable through enquiry based learning (EBL), which represents the majority of theoretical learning on this program. It is stimulated by exploring a succession of person-centred case studies that are supported by a small number of lectures and workshops and clinical skills sessions (McGarry et al., 2010). The case studies have been constructed to draw on five key learning areas or domains, namely, biological science, psycho/social aspects of care, clinical decision-making and skills, personal and professional development, and evidence-based practice. Each case progresses through three sections that are released to the students at separate tutor-facilitated meetings over a period of a week.
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The case studies are innovatively presented using computer technology. This has the advantage of enabling a greater sense of realism and being linked to practice than if a paper format alone was use, and is therefore arguably more stimulating for the students. Where possible and appropriate, the case study is delivered using scripted and filmed clinical scenes, authentic video narratives, original photographic material, fictitious patient records on authentic forms, and web-links to government and other official documents. Each case study is made available to student groups by timed-release through a virtual learning environment (VLE). Working collaboratively in groups of six to eight, the students draw on their current knowledge and experience to reflectively and critically discuss issues presented in the case studies. The issues within the case studies prompt the students learning and could include a wide range of topics such as a set of symptoms, treatment regime, a social issue, or clinical procedure. In this way the students broaden their perception of the topic area, identify knowledge gaps, and formulate group learning-goals for a period of self-directed study that follows. The group reconvenes to share, discuss and debate their learning and to generate new meaning. This is carried forward to the next stage where additional information on the case study is presented and the cycle is repeated a second and then third time until the case study is complete. In this manner, the students deepen their understanding of complex issues encountered in nursing practice and advance their skills in locating, assimilating and analysing information from a range of sources. This enables them to develop a transferable methodology for managing unfamiliar scenarios in practice. The diversity of viewpoints present in the group is seen to enrich dialogue and to help the students develop confidence in debating, conducting and promoting discussion, presenting perspectives and working as part of a team. EBL is based on the constructivist theory which claims that people generate knowledge and meaning by engaging with their experiences and analysing them. A further principle is that learning takes place when it builds on previous learning, and is particularly successful when it is placed in the context of problem-solving activities that are relevant to the student (Matt, 2000). In agreement with this, EBL uses contextualised scenarios that simulated real life challenges for learners to address. The case studies operate as triggers to draw on students' background experience (McGarry et al., 2010). This in turn provides a basis for laying down new levels of learning, which may or may not remodel learners' pre-existing perceptions. Of additional interest, EBL embodies a learning style that is suited to the adult. It is noted that adult students learn best by ‘doing’, and prefer to work in groups. They tend to be self-motivated and respond better
Fig. 1. An integrated educational model for graduate entry curriculum design.
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to student-centred methods that favour deep learning (Rogers and Horrocks, 2010). Furthermore, EBL exploits advanced learning skills that adults and graduates of other disciplines may bring to further education after a change in career focus. Of particular relevance to nursing, the scenario-based approach offers strategies to overcome long-standing challenges in nurse education, such as enabling students to integrate nursing theory into practice (Ehrenberg and Haggblom, 2007) through the acquisition of skills in critical and reflective thinking (Oztuk et al., 2008). This methodology presents a simple framework that can be reworked to encourage life-long learning beyond registration. In this way, EBL can nurture the development of self directed learning skills which can enable the students to critically appraise the evidence, account for their judgments of practice and respond with confidence to unfamiliar clinical scenarios. Internationalisation The process of EBL is extended to the international arena through the facilitation of a virtual student exchange project (VEP). This is underpinned by the recognition that internationalism and globalisation are now an integral part of both the planning and delivery of contemporary nursing curricula worldwide in order to facilitate the development of a future health care workforce that is responsive to global health needs (World Health Organisation, 2000; Allen and Ogilvie, 2004). The growing interest and relevance of internationalism and globalisation within the context of pre-registration nurse education rests in the recognition that nurses are increasingly expected to be culturally competent at a general level. Nurses will increasingly need to be compete successfully within an international arena in terms of job opportunities., Furthermore, centrally, nurses will need to understand the implications of globalisation in terms of the social determinants of health, patterns of disease and illness, health inequalities and the underlining political and social dimensions that influence health and social inequalities for individuals and particular communities (Allen and Ogilvie, 2004). With this in mind, GEN has successfully embedded internationalism and global perspectives through establishing e-learning links and the development of e-learning resources with two partner universities in Ireland and Scotland and the VEP which is a web-based learning and teaching application designed to bring ‘study-elsewhere’ experiences into the student's own setting. The structure of the VEP is such that it offers students from different universities, with different health systems the opportunity to explore an EBL case study and share a range of learning opportunities in order for them to debate and discuss different perspectives on health and social care priorities and environments of care. Moreover, the context of the learning environment and its similarities to virtual social networks also facilitate greater understanding through the exchange of friendly dialogue that is grounded in the ‘connect, aspire, enjoy and achieve’ approach towards study and learning (Todhunter and Hallawell, 2010). The first phase of this work has evaluated extremely positively with students and the members of staff involved in this project and is currently being expanded further to include additional partner organisations in the United States. Group Clinical Supervision The opportunity to engage in critical and reflective dialogue with peers is continued when the students are in clinical practice through the facilitation of group supervision. A number of studies have provided evidence that supervision during pre registration nurse training promotes students professional identity and personal growth (Lindstrom, 1985; Arvidsson et al., 2008), enhances the development of empathy and understanding of others (Holm and Severinsson, 1998) and that it is perceived as supportive and restorative (Lindgren et al., 2005). Several studies also seek to make clear the relationship
between group supervision and the integration of practical and theoretical knowledge in the student. The NHS executive (1993) describe supervision as a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex situations. Therefore the underpinning principles on which the GEN curriculum was developed led to the decision to include group supervision as a core component of the course. Within the GEN programme each student is randomly assigned to a small group of no more than eight participants facilitated by a lecturer who has a supervisory role. The groups meet once every two weeks during practice placements for two hours. To enable their own development in role, all supervisors attend peer support meetings after conducting group supervision with the students. The supervisors establish a shared vision of working, and endeavour to develop a supervisory alliance (Proctor and Inskipp, 2001) within their individual groups. This includes a written agreement that is used to outline the limits of confidentiality, meeting arrangements, commitment to the process and each other, and finally any other issue that the group considers important. Proctor's model of supervision (Procto, 1991; Proctor and Inskipp, 2001) is used to agree the domains in which supervisors operate and attempts are made to achieve a balance between reflective learning (formative function) professional accountability (normative function) and providing support (restorative function). Discussions focus on bringing issues from the student's practice experience to share and unpick in relation to theoretical, ethical, personal and, what Carper (1978) termed, asthetic perspectives. The aim is to progress the student's different ‘ways of knowing’ (Carper, 1978) through increasingly sophisticated reflection on the application of theory to practice. However, every attempt is made to provide a comfortable, safe learning environment where students feel free to share their feelings, thoughts and ideas and test out their understanding. It is evident therefore that group supervision offers students the opportunity to develop reflective learning skills and encourages them to question what is observed in practice rather than excepting it without excising critical thought.
Inter-professional Learning These skills are also applied when working with other professionals in a practice based interprofessional learning opportunity know as the shared family study (SFS). Barr (2005 p7) suggests that interprofessional learning encompasses situations where people from at least two professional backgrounds learn “with, from and about one another to improve collaboration and the quality of care.” Whilst the most appropriate time to introduce interprofessional learning into curricula is still a subject of debate (Leaviss, 2000; Barr and Ross, 2006), the SFS runs over the first year of both the University of Nottingham GEN programme and the Graduate Entry to Medicine (GEM) programme. The project aims to facilitate the development of the skills required for collaborative working and problem solving through offering opportunities for students to explore clinical situations from a variety of professional perspectives. The students are teamed into interprofessional groups of three know as learning sets. Each set is assigned to a family who meets specific selection criteria and who have given consent to involvement in the SFS initiative. The criteria requires that one member of the family has a chronic illness, a life threatening condition but with a reasonable prognosis, complex social problems, or multiple agencies supporting their care. The students then have contact with family members over a period of the year and may see them in the home, hospital or other organisational setting. Guidelines are provided for each student together with a diary in which to record their anonymised contacts and reflections.
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Students meet with academic staff at two facilitated seminars throughout the year to gauge process and discuss experiences with other groups. A conference is held at the end of the year for which students present posters on a particular aspect of health related to their assigned family. They also have the opportunity to deliver an oral presentation to an invited academic audience consisting of fellow students, academic and practice colleagues. The experience of working together enables the students to gain an in depth understanding of each other's roles. It is intended that this will enhance communication, dialogue and recognition of skills, respective roles and expertise (Sherwood and Drenkard, 2007). The hope is that this will ultimately promote and sustain collaborative interprofessional working within the practice setting alongside developing the confidence to question professional hierarchies where they exist to the detriment of effective patient care. Conclusion It is proposed that each of these learning methods will offer students the opportunity to develop existing skills, to respond confidently and enthusiastically to challenges and meet the demands of the changing healthcare arena as a capable practitioner. Each of the educational approaches complements and builds upon each other to provide an integrated and cohesive curriculum model which exploits the skills and attributes the students bring by virtue of their graduate status. The emphasis of each of the educational forums is on promoting critical dialogue with a range of influential individuals and groups. This enables students to question cultural norms which have restricted the progression of nursing as a profession and give them the tools and confidence to exercises this in clinical practice. Graduates of the GEN programme should be able to encounter unfamiliar nursing situations with the knowledge that what they don't know, they can find out with accuracy and assimilate and synthesise into their current roles. As such the GEN programme has the ability to produce nurses that provide essential care alongside innovative and current evidence based practice. The extent to which the intended outcomes have been achieved is currently being explored through a series of longitudinal research projects considering the students experiences of the programme and how they respond to practice from varying perspectives. Internal evaluation is providing valuable feedback on the teaching and learning approaches described and adaptations are continually being made to address the students learning needs. We suggest that this is also a key element of maximising graduateness as it respects students as adult learners who are best positioned to define their learning requirements. References Allen, M., Ogilvie, L., 2004. Internationalisation of higher education: potentials and pitfalls for nursing education. International Nursing Review 51, 73–80. Arvidsson, B., Skärsäter, I., Baigi, A., Svensson, M.-L., Fridlund, B., 2008. The development of a questionnaire for evaluating process-oriented group supervision during nursing education. Nurse Education in Practice 8, 88–93. Barr, H., 2005. Interprofessional Education, Today, Yesterday and Tomorrow A Review United Kingdom. Higher Education Academy, London. Barr, H., Ross, F., 2006. Mainstreaming Interprofessional Education :A Position Paper. Journal of Interprofessional Care 20 (2), 96–104. Bradshaw, A., Merriman, C., 2008. Nursing competence 10 years on: fit for practice and purpose yet? Journal of Clinical Nursing 17, 1263–1269. Bridges, J.M., 1990. Literature review on the images of the nurse and nursing in the media. Journal of Advance Nursing 15 (7), 759–864. Buresh, B., Gordon, S., 2006. From Silence to Voice, 2nd edn. Canadian Nurses Association, Cornell University Press, Ithaca, NY. Carper, B., 1978. Fundamental Patterns of knowing in nursing. Advances in Nursing Science 1, 13–23. Department of Health, 2008. High Quality Care For All: NHS next stage review final report. HMSO, London. Ehrenberg, A.C., Haggblom, M., 2007. Problem-based learning in clinical nursing education: integrating theory and practice. Nurse Education in Practice 7, 67–74. Freire, P., 1971. Pedagogy of the Oppressed. Continuu, New York. Freire, P., 2007. Pedagogy of the Oppressed. Continuum International Publishing Group, New York.
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