- Email: [email protected]
Developing clinical placements in times of scarcity
Nurse Education Today (2006) 26, 627–633
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Developing clinical placements in times of scarcity Wendy A. Hall
*
University of British Columbia, School of Nursing, T. 201 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5 Accepted 19 July 2006
KEYWORDS
Summary This article takes the position that the current shortage of clinical placements may be creating problems, but it can also be seen as an opportunity to reconsider the design of students’ clinical experiences and the goals to be attained. It begins with a description of paradoxes in professional education. The following sections examine some of the considerations which need to be incorporated in the development of clinical placements and the way they are incorporated into health care courses. The considerations germane to clinical placement development include social participation in clinical settings, communities of learning, and consumer-centred inter-professional collaboration. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 627–633 and Nurse Education in Practice Vol. 6, No. 6, pp. 319–325.
Clinical teaching; Scarcity; Communities of learning; Inter-professional
Introduction In preparing students for their career, professional education for health care providers is faced with a continuing tension between fulfilling desirable goals in education and health care and preparing students to cope with acute care problems. Mcilfatrick (2004) has ably described some of the paradoxes which spring from this tension. She points out that there is an increasing call for nurses to engage in health promotion and prevention at the same time as there is an emphasis on cure and palliation, with resources concentrated in the acute * Corresponding author. Tel.: +1 604 822 7447; fax: +1 604 822 7466. E-mail address: [email protected].
care settings. For example, community nurses spend a considerable proportion of their time with maternity early discharge patients and have little opportunity for community development, while there are increasing resources dedicated to technological approaches to childbirth. And, in the hospital setting, health promotion and prevention activities are difficult to incorporate into a schedule dominated by caring for sick and dying patients who have short stays in acute care areas. Such conditions create a demand for inter-professional collaboration with shared resources and technology in clinical placements (Mcilfatrick, 2004). A second paradox identified by Mcilfatrick (2004) derives from rival sources of authority in making health care decisions. Professional expertise gives health care providers special knowledge, but
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
628 actions based on this expertise may conflict with public expectations for a full partnership with health professionals in decision-making. In the same way, teaching students that health care professionals should act as facilitators and partners with patients and the public may conflict with their actual experience of clinical placements, where traditional models of hierarchical authority are often the foundation of care. This paradox requires a shift towards health care professionals acting as facilitators and partners in health care, rather than as expert authorities. Another source of tension is the conflict between technical competence and the human quality of caring (Mcilfatrick, 2004). Finding time to talk with and listen to patients is difficult in fastpaced clinical areas where patient contact time is limited. This is a concern for all health care professionals, but it is particularly so for students who may feel that their prime goal is to have adequate time in clinical settings to gain technical competence. Students need time to listen to patients and understand their problems if they are to care for them properly (Ironside et al., 2005). An immediate response to the resolution of these paradoxes might simply be to ask for more resources both for health care and for the education of health care professionals. But, as Mcilfatrick (2004) argues, the problem is as much one of approach as of a lack of resources. It is for this reason that consideration of the design of the clinical placement components of health care students’ education is critical.
Clinical placements Practical nursing experience in clinical settings has long been a key element of nursing education, but the question of changing the design of these clinical components is complicated by the scarcity of clinical placements. Higher patient acuity levels in clinical settings, shorter lengths of stay for patients, staff shortages, a large casual workforce, and increasing work hours for nurses, all complicate the efforts by practicing nurses to support student learning (McKenna and Wellard, 2004). Constant technological and administrative change creates further disincentives for accepting student placements. The scarcity of clinical placements has been exacerbated by the recent growth in the enrolment of student nurses, midwives, physicians, and allied health care workers. In addition, increasing patient acuity and the rapid pace of technological change are generating pressures to earmark clinical set-
W.A. Hall tings for new specialist courses, displacing basic students. Such a situation generates competition among academic institutions for access to health care facilities and compounds the pressure on practice nurses and clinical educators (often sessional employees) (McKenna and Wellard, 2004), which in turn may produce a less welcoming and supportive learning environment for students. It is not suggested that all these problems can be dealt with simply by redesigning the experience of students in clinical placements. The argument is that the current concern with the scarcity of clinical placements for health care students should be seen as an opportunity to reflect on the development of clinical experiences for students. The following sections look at some of the considerations which need to be incorporated in any development of clinical placements and the way they are incorporated into health care courses.
Social participation and clinical placements For learning to make sense to students, it must be situated in real life contexts where they are allowed to participate legitimately as learners (Field, 2004); this has been a key justification for clinical placements. Field (2004) describes this as a social participation framework for learners. If students’ learning is viewed through the lens of social participation, knowledge is developed continuously through learners’ cognitive activity and participation in the group to which they belong; learners acquire social and cultural manners through interactions in clinical settings that constitute a community culture (Choi, 2006). For example, students in clinical settings soon become aware of the rapidly changing patient populations and health care providers’ rapid adaptation to understanding conditions and providing appropriate care for a range of patients. In applied disciplines, students learn culturally situated ‘practical knowledge’. Experience in the ‘culture’ is necessary to deal with complexity. Clinical settings provide the physical and conceptual structure of a problem in addition to the purpose of the activity and the social milieu (Rogoff and Lave, 1984). Students acquire practical knowledge about situations and how they reason about actions; contexts have their own peculiarities and understandings that are as important to successful action as conceptual knowledge (McCormick, 1999). In hospital and community settings, students who are social participants can incorporate speci-
Developing clinical placements in times of scarcity
629
ficities into successful action based on conceptual knowledge which is linked to procedural knowledge (McCormick, 1999). Clinical placements based on a social participation model offer opportunities to operationalise concepts, such as expected competencies for knowledge, skills, attitudes, behaviours, and judgements. They provide opportunities for creative nursing practice (Mcilfatrick, 2004). Learners, in clinical placements that take a social participation approach, have opportunities for dialogue with clinical instructors and nurse mentors who have strong theoretical knowledge (Field, 2004). In addition to developing such settings, educational design requires examining the fit between the placements and students’ skill levels. Otherwise, application of theory to practice would be impaired by inappropriate demands for learners’ skills. In times of clinical placement scarcity, such considerations are often difficult or overlooked. Using a social participation model requires energy to be directed to assisting preceptors to structure practical learning, assisting with research cultures in clinical areas, and incorporating practice educators whose clinical expertise is at least equivalent to the expertise of those in the clinical setting (Field, 2004). Curricular design must take those elements into consideration to support their development. For example, skilled instructors or nurse mentors who are using evidence-based approaches to care can support learners’ theoretical understandings gained from classrooms rather than having students question theoretical understandings when exposed to non-evidence based practice in clinical settings. Social participation in learning would be facilitated by developing placements that exemplify communities of learning.
achieves authentic learning about the complexities of real practice. That interaction enables learners to move toward full participation in the socio-cultural practices of their community; they become part of a community of practice (Lave and Wenger, 1991). Clinical placements with the characteristics of a learning community incorporate learners that run the gamut from novices to masters (Cox, 2005). When all members of the community are defined as learners, placements offer opportunities for support and openness to new ideas and collaborations. For example, in clinical settings where students are incorporated at various skill levels and care providers are exposed to students occupying positions along a trajectory toward mastery their participation at different levels is legitimised. Pearcy and Elliott (2004) indicated that students can learn from positive or negative cultures; students viewed clinical areas where there was practice development and an emphasis on research and teaching as positive learning communities. Clinical placements in the form of communities of learning can support a collaborative educational strategy that will help professionals and educational institutions deal successfully with many social and professional problems (Duncan-Hewitt and Austin, 2005). Communities of learning can help to sustain practitioner expertise, lead to closer relationships among academics and practitioners in institutions and communities, ensure that students achieve educational outcomes, and alter faculty workloads to increase faculty satisfaction and retention (Duncan-Hewitt and Austin, 2005). Creating networks of communities of learning moves the focus from students as educational clients and consumers as practice sites that hire them to educational clients being practitioners ranging from the novice (student) to the expert and consumers being patients and society (Duncan-Hewitt and Austin, 2005). Networks of communities of learning would require increased integration between theoretical courses and practice. They have the potential to emphasise the resources and structural conditions that care providers require to achieve the best outcomes for patients with the most parsimonious use of resources. Engaging government departments associated with health care and education in developing visions of and resources for clinical settings would contribute to a shift in emphasis. To achieve networks of communities of learning, universities, hospitals, and community agencies would require a shared mission and objectives (Duncan-Hewitt and Austin, 2005). In clinical placements, members would operationalise processes and theoretical strategies that would make
Communities of learning and clinical placements Without sustained social participation in the practices of a community of learning, students will not develop problem-solving derived from being associated with the health care provider community, particularly those in their disciplines. Students can actively construct knowledge in clinical placements that are communities of learning (Field, 2004). As newcomers in communities of learning, they can regard learning as a continuous, active, engaged, situated, and identity-forming process (Lave and Wenger, 1991), as opposed to particular skills that must be mastered in that setting. Informal and situated social interaction
630 practice more effective. Such clinical placements would assist students to develop a practice-centred identity, where they appropriate the ways in which experts in the profession think, feel, and behave. This has the potential to increase professionalism (Duncan-Hewitt and Austin, 2005). Staff in clinical placements that are communities of learning would regard students as moving from being peripheral to practice to become more central to practice as they are entrusted with more complex tasks. This approach can shift perspectives from students being burdens by consuming resources and not contributing substantively to that of practitioners contributing at different levels on a trajectory to becoming expert practitioners (Austin and Duncan-Hewitt, 2005). Students can learn explicit knowledge (concepts, principles, and procedures) and implicit knowledge (storytelling, conversation, demonstration, and coaching) (Duncan-Hewitt and Austin, 2005). For example, a common philosophy about learning and practice in the area of the contribution of technology could lead to defining competencies broadly to include relational activities and skills. Members of a community of learning who learn and work together negotiate mutual understanding through participation and reification (Duncan-Hewitt and Austin, 2005). In clinical placements, participation occurs by working towards shared goals and having a common context for understanding. Reification occurs when implicit knowledge is made explicit, for example turning amorphous experiences into concepts, tools, procedures, databases, missions, plans, and contracts, through negotiation. Participation in clinical placements overcomes the problem of reification dominating, where classrooms provide a host of reified facts that have no meaning outside the student experience. Lave and Wenger (1991) refer to this as situated activity where, rather than receiving a body of knowledge about the world, participation is based on situated negotiation of meaning, which implies that experience and understanding are mutually constitutive. Reification overcomes the problem of participating in ‘routine’ activities in clinical placements, without a focus on deepening understanding of practice problems and improving outcomes (Duncan-Hewitt and Austin, 2005). For example, groups of students could develop projects that were based on needs assessment, implemented and evaluated. Such projects could be long-term where students would build on the work of previous groups. Materials developed from those projects could be shared with practice staff and profiled in agency newsletters, conferences, and local newspapers.
W.A. Hall Networks of communities of learning can disseminate best practices and explicit knowledge (Duncan-Hewitt and Austin, 2005). While students develop identities that are centred in their professions, in clinical placements defined as communities of learning, practitioners can actively collaborate and communicate shared best practice information. As well, institutions can harmonise organisational strategies with personal development and the identity of practitioners, integrate novices, and make the workplace more hospitable (Duncan-Hewitt and Austin, 2005). In communities of learning, skilful problem-solving is linked to scientific process; individuals’ strategic thinking skills are enhanced; and organisational learning, quality management, and participative leadership are reinforced. There is circulation of knowledge among peers and near-peers through engaging in practice; mastery resides in the organisation of the community of learning, of which masters are a part (Lave and Wenger, 1991). For example, developing competencies with all participants in communities of practice sensitises practitioners and leads to reflection and action. The competences can serve as guides to recruitment, hiring, succession planning, performance review, and unit development. Communities of learning are engaged in the generative process of producing their own future (Lave and Wenger, 1991). By developing competencies which incorporate standards from regulatory bodies and leveling the competencies from novice to master, clinical placements can shape their sites of practice and their outcomes. Clinical placements that are developed as communities of learning lend themselves to administrative structures where students, practitioners, and academics raise important questions about practice and find answers for them (Duncan-Hewitt and Austin, 2005). Such activities would lead to less distinct boundaries between practice and academia, with academics participating in practice and practitioners getting access to educational resources. Those activities would reduce the solitudes that exist between scientists, clinicians, and educators (Duncan-Hewitt and Austin, 2005). For example, academics could develop programs of research associated with questions raised by practice communities, which would facilitate the conduct of research in setting where gaining ethical approval and achieving recruitment is often difficult. These activities would lead to preceptors and clinicians advancing their practice through faculty support; academics developing relevant and inter-professional research activities; and students building their confidence and competence in an en-
Developing clinical placements in times of scarcity
631
riched learning community (Austin and DuncanHewitt, 2005).
vided direction for placing the consumer or client at the centre of inter-professional activities. If professionals in health and social care are going to engage in collaborative practice, it is important to place the patient at the centre of the team (Cooper et al., 2001). In clinical placements that are structured as communities of learning, students and masters place the emphasis on the client through the assumptions they are using to guide inter-professional clinical experiences, such as, the client is the focus of care, the focus is improved client outcomes and cost-effective care, and the collaboration of team members promotes autonomy for professionals and clients (Burns et al., 2000). Developing clinical placements that incorporate an inter-professional clinical model, which places the client at the core of the model and incorporates health promotion, health maintenance, and illness care can cross acute care and community boundaries (Burns et al., 2000). Crossing those boundaries assists with managing the paradox where students are being asked to develop a knowledge base that incorporates health promotion and prevention, as well as cure and palliation. Developing clinical placements with inter-professional goals that include increasing inter-professional understanding and cooperation, promoting competent team work, making effective and efficient use of resources, and promoting high quality, comprehensive patient care (Cooper et al., 2001) can extend limited resources and promote sharing of technical and non-technical resources. Cooper and colleagues (2001) have pointed out that most of the evidence for the positive outcomes associated with interdisciplinary education is concentrated on quantitative studies, short-term evaluation, or anecdotal evidence. The largest effects of interdisciplinary educational activities have been on knowledge, attitudes, skills, beliefs, especially professional roles and team work; the smallest effects have been for transfer into practice and on learning environments (Glen, 2004). Clinical placements which incorporate client and inter-professional collaborative competencies in a community of learning enable long-term outcomes to be assessed, because learners include health care professionals who are staff and competencies are associated with recruitment, hiring, succession planning, performance review, and unit development, which shape clinical settings and their outcomes. Incorporating collaboration in learning communities legitimises peripheral participation and provides access to a nexus of connections otherwise not perceived as connected (Lave and Wenger, 1991). Cooper and colleagues (2001) recommended
Consumer and inter-professional collaboration and clinical placements Contemplating clinical placements that are developed as learning communities is intricately linked to consumer participation. The paradox introduced earlier in the paper indicated that, while members of the public rely on professional expertise, they also expect full partnership with health care professionals in decision-making around their care. Learning communities without clients at their centre would fail to accomplish the professional socialisation that these communities can provide. Glen (2004) has defined interdisciplinary (inter-professional) education as interactive educational activity that involves two or more professionals and improves collaboration focused on patient care. Thus, inter-professional collaboration has at its core high quality, comprehensive patient care (Cooper et al., 2001; Ruebling et al., 2000). It is difficult to find descriptions of inter-professional teams in the literature where the patient is included as an equal team member. There has been some evidence indicating that client stays in hospital are shorter and there is increased client satisfaction when inter-professional collaboration occurs; however, the effects seem to have been focused on acute rather than chronic care situations (Glen, 2004). Students who are unable to participate in clinical placements characterised by inter-professional teams with clients at their centre will engage in social participation learning which fails to prepare them for clients who want to be full partners in their care and inter-professional collaboration for care. For example, clinical placements that incorporate principles of communities of learning and consumer and inter-professional collaboration would be characterised by patients explicitly sharing power, having their knowledge and perceptions valued, and having opportunities to teach health care providers about their experiences. Objectives for learning would be altered to reflect the expectation that students will demonstrate behaviours to support such activities. When Duncan-Hewitt and Austin (2005) discussed clinical placements characterised as communities of learning, which moved the focus from consumers as practice sites that hire students to consumers being patients and society, they pro-
632 discussion between educators, practitioners, and students serve as a basis to determine a fundamental approach to inter-professional education. Such recommendations do not go far enough. To develop professional education to support communities of learning, discussions for inter-professional collaboration must incorporate patients and families from the beginning of developing competencies to shaping the clinical setting to achieve those competencies (Van Stolk, 2006). Designing inter-professional clinical education opportunities presents challenges around bringing students together, making curricular changes to make inter-professional education possible, and creating change in health and social care institutions to facilitate contact (Glen, 2004). In clinical placements with hands-on clinical inter-professional components, experts are required who model respect for other health professions, their values and their expertise (Ruebling et al., 2000). To build support for clinical placements that feature interprofessional clinical education, research must document improvements in health status and services (Glen, 2004). To facilitate such clinical activities, participatory action research strategies could be incorporated in clinical settings, with longitudinal designs and quantitative and qualitative components. Such designs would allow the ‘team’ to generate the research questions and short and long-term outcomes to be documented, as well as processes.
Conclusion The opening discussion of the tension between short and long-term goals of health care is increasingly mirrored in the conflicting pressures on educating health care professionals. The stress on professional expertise, the requirements of technical proficiency, and the inevitability of resource constraints all compete with considerations of long-term health promotion, consultation in decision-making, and providing a caring setting for patients. Clinical placements for health care students have traditionally served, not only to give students the experience of providing practical care, but also to help them to understand how short and long-term health care goals can be accommodated. This article argues that the current shortage of clinical placements may be creating problems but it can also be seen as an opportunity to reconsider the design of students’ clinical experience and the goals that are to be attained. Developing clinical
W.A. Hall placements that emphasise social participation, communities of learning, consumer participation, and inter-professional collaboration can assist with overcoming the paradoxes identified. Those elements, in and of themselves, will not be sufficient without re-designing professional curricula so that they can support and sustain clinical placements that offer opportunities to define students as contributing members of a larger community of learners that are working to achieve common goals.
Acknowledgement I would like to acknowledge my colleagues’ thoughtful and scholarly discussions during the NET/NEP International Conference, which contributed to the development of this paper.
References Austin, Z., Duncan-Hewitt, W., 2005. Faculty, student, and practitioner development within a community of practice. American Journal of Pharmaceutical Education 69 (3) (article 55). Burns, C.M., Smith, A.A., Jacobson, H., 2000. An interdisciplinary approach to training health professionals. Nursing and Health Care Perspectives 21 (2), 76–81. Choi, M., 2006. Communities of practice: an alternative learning model for knowledge creation. British Journal of Educational Technology 37 (1), 143–146. Cooper, H., Carlisle, C., Gibbs, T., Watkins, C., 2001. Developing an evidence-base for interdisciplinary learning: a systematic review. Journal of Advanced Nursing 35 (2), 228– 237. Cox, A., 2005. What are communities of practice? A comparative review of four seminal works. Journal of Information Science 31 (6), 527–540. Duncan-Hewitt, W., Austin, Z., 2005. Pharmacy schools as expert communities of practice? A proposal to radically restructure pharmacy education to optimize learning. American Journal of Pharmaceutical Education 69 (3) (article 54). Field, D.E., 2004. Moving from novice to expert – the value of learning in clinical practice: a literature review. Nurse Education Today 24 (7), 560–565. Glen, S., 2004. Interprofessional education: the evidence base influencing policy and policy makers. Nurse Education Today 24 (3), 157–159. Ironside, P., Diekelmann, N., Hirschmann, M., 2005. Learning the practices of knowing and connecting: the voices of students. Journal of Nursing Education 44 (4), 153–155. Lave, J., Wenger, E., 1991. Situated Learning: Legitimate Peripheral Participation. Cambridge University Press, Cambridge. McCormick, R., 1999. Practical knowledge: a view from the snooker table. In: McCormick, R., Paechter, C. (Eds.), Learning and Knowledge. Paul Chapman Ltd., London, England, pp. 112–135. Mcilfatrick, S., 2004. The future of nurse education: characterised by paradoxes. Nurse Education Today 24 (2), 79– 83.
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McKenna, L.G., Wellard, S.J., 2004. Discursive influences on clinical teaching in Australian undergraduate nursing programs. Nurse Education Today 24 (3), 229–235. Pearcy, P.A., Elliott, B.E., 2004. Student impressions of clinical nursing. Nurse Education Today 24 (5), 382–387. Rogoff, B., Lave, J. (Eds.), 1984. Everyday Cognition: Its Development in Social Context. Harvard University Press, Cambridge.
Ruebling, I., Lavin, M., Banks, R., Block, L., Counte, M., Furman, G., Miller, P., Reese, C., Viehmann, V., 2000. Facilitating factors for, barriers to, and outcomes of interdisciplinary education projects in the health sciences. Journal of Allied Health 29, 165–170. Van Stolk, D., 2006. Interprofessional competences. BC, Interprofessional Network of BC June Forum, Vancouver, BC.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Developing clinical placements in times of scarcity Wendy A. Hall
*
University of British Columbia, School of Nursing, T. 201 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5 Accepted 19 July 2006
KEYWORDS
Summary This article takes the position that the current shortage of clinical placements may be creating problems, but it can also be seen as an opportunity to reconsider the design of students’ clinical experiences and the goals to be attained. It begins with a description of paradoxes in professional education. The following sections examine some of the considerations which need to be incorporated in the development of clinical placements and the way they are incorporated into health care courses. The considerations germane to clinical placement development include social participation in clinical settings, communities of learning, and consumer-centred inter-professional collaboration. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 627–633 and Nurse Education in Practice Vol. 6, No. 6, pp. 319–325.
Clinical teaching; Scarcity; Communities of learning; Inter-professional
Introduction In preparing students for their career, professional education for health care providers is faced with a continuing tension between fulfilling desirable goals in education and health care and preparing students to cope with acute care problems. Mcilfatrick (2004) has ably described some of the paradoxes which spring from this tension. She points out that there is an increasing call for nurses to engage in health promotion and prevention at the same time as there is an emphasis on cure and palliation, with resources concentrated in the acute * Corresponding author. Tel.: +1 604 822 7447; fax: +1 604 822 7466. E-mail address: [email protected].
care settings. For example, community nurses spend a considerable proportion of their time with maternity early discharge patients and have little opportunity for community development, while there are increasing resources dedicated to technological approaches to childbirth. And, in the hospital setting, health promotion and prevention activities are difficult to incorporate into a schedule dominated by caring for sick and dying patients who have short stays in acute care areas. Such conditions create a demand for inter-professional collaboration with shared resources and technology in clinical placements (Mcilfatrick, 2004). A second paradox identified by Mcilfatrick (2004) derives from rival sources of authority in making health care decisions. Professional expertise gives health care providers special knowledge, but
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
628 actions based on this expertise may conflict with public expectations for a full partnership with health professionals in decision-making. In the same way, teaching students that health care professionals should act as facilitators and partners with patients and the public may conflict with their actual experience of clinical placements, where traditional models of hierarchical authority are often the foundation of care. This paradox requires a shift towards health care professionals acting as facilitators and partners in health care, rather than as expert authorities. Another source of tension is the conflict between technical competence and the human quality of caring (Mcilfatrick, 2004). Finding time to talk with and listen to patients is difficult in fastpaced clinical areas where patient contact time is limited. This is a concern for all health care professionals, but it is particularly so for students who may feel that their prime goal is to have adequate time in clinical settings to gain technical competence. Students need time to listen to patients and understand their problems if they are to care for them properly (Ironside et al., 2005). An immediate response to the resolution of these paradoxes might simply be to ask for more resources both for health care and for the education of health care professionals. But, as Mcilfatrick (2004) argues, the problem is as much one of approach as of a lack of resources. It is for this reason that consideration of the design of the clinical placement components of health care students’ education is critical.
Clinical placements Practical nursing experience in clinical settings has long been a key element of nursing education, but the question of changing the design of these clinical components is complicated by the scarcity of clinical placements. Higher patient acuity levels in clinical settings, shorter lengths of stay for patients, staff shortages, a large casual workforce, and increasing work hours for nurses, all complicate the efforts by practicing nurses to support student learning (McKenna and Wellard, 2004). Constant technological and administrative change creates further disincentives for accepting student placements. The scarcity of clinical placements has been exacerbated by the recent growth in the enrolment of student nurses, midwives, physicians, and allied health care workers. In addition, increasing patient acuity and the rapid pace of technological change are generating pressures to earmark clinical set-
W.A. Hall tings for new specialist courses, displacing basic students. Such a situation generates competition among academic institutions for access to health care facilities and compounds the pressure on practice nurses and clinical educators (often sessional employees) (McKenna and Wellard, 2004), which in turn may produce a less welcoming and supportive learning environment for students. It is not suggested that all these problems can be dealt with simply by redesigning the experience of students in clinical placements. The argument is that the current concern with the scarcity of clinical placements for health care students should be seen as an opportunity to reflect on the development of clinical experiences for students. The following sections look at some of the considerations which need to be incorporated in any development of clinical placements and the way they are incorporated into health care courses.
Social participation and clinical placements For learning to make sense to students, it must be situated in real life contexts where they are allowed to participate legitimately as learners (Field, 2004); this has been a key justification for clinical placements. Field (2004) describes this as a social participation framework for learners. If students’ learning is viewed through the lens of social participation, knowledge is developed continuously through learners’ cognitive activity and participation in the group to which they belong; learners acquire social and cultural manners through interactions in clinical settings that constitute a community culture (Choi, 2006). For example, students in clinical settings soon become aware of the rapidly changing patient populations and health care providers’ rapid adaptation to understanding conditions and providing appropriate care for a range of patients. In applied disciplines, students learn culturally situated ‘practical knowledge’. Experience in the ‘culture’ is necessary to deal with complexity. Clinical settings provide the physical and conceptual structure of a problem in addition to the purpose of the activity and the social milieu (Rogoff and Lave, 1984). Students acquire practical knowledge about situations and how they reason about actions; contexts have their own peculiarities and understandings that are as important to successful action as conceptual knowledge (McCormick, 1999). In hospital and community settings, students who are social participants can incorporate speci-
Developing clinical placements in times of scarcity
629
ficities into successful action based on conceptual knowledge which is linked to procedural knowledge (McCormick, 1999). Clinical placements based on a social participation model offer opportunities to operationalise concepts, such as expected competencies for knowledge, skills, attitudes, behaviours, and judgements. They provide opportunities for creative nursing practice (Mcilfatrick, 2004). Learners, in clinical placements that take a social participation approach, have opportunities for dialogue with clinical instructors and nurse mentors who have strong theoretical knowledge (Field, 2004). In addition to developing such settings, educational design requires examining the fit between the placements and students’ skill levels. Otherwise, application of theory to practice would be impaired by inappropriate demands for learners’ skills. In times of clinical placement scarcity, such considerations are often difficult or overlooked. Using a social participation model requires energy to be directed to assisting preceptors to structure practical learning, assisting with research cultures in clinical areas, and incorporating practice educators whose clinical expertise is at least equivalent to the expertise of those in the clinical setting (Field, 2004). Curricular design must take those elements into consideration to support their development. For example, skilled instructors or nurse mentors who are using evidence-based approaches to care can support learners’ theoretical understandings gained from classrooms rather than having students question theoretical understandings when exposed to non-evidence based practice in clinical settings. Social participation in learning would be facilitated by developing placements that exemplify communities of learning.
achieves authentic learning about the complexities of real practice. That interaction enables learners to move toward full participation in the socio-cultural practices of their community; they become part of a community of practice (Lave and Wenger, 1991). Clinical placements with the characteristics of a learning community incorporate learners that run the gamut from novices to masters (Cox, 2005). When all members of the community are defined as learners, placements offer opportunities for support and openness to new ideas and collaborations. For example, in clinical settings where students are incorporated at various skill levels and care providers are exposed to students occupying positions along a trajectory toward mastery their participation at different levels is legitimised. Pearcy and Elliott (2004) indicated that students can learn from positive or negative cultures; students viewed clinical areas where there was practice development and an emphasis on research and teaching as positive learning communities. Clinical placements in the form of communities of learning can support a collaborative educational strategy that will help professionals and educational institutions deal successfully with many social and professional problems (Duncan-Hewitt and Austin, 2005). Communities of learning can help to sustain practitioner expertise, lead to closer relationships among academics and practitioners in institutions and communities, ensure that students achieve educational outcomes, and alter faculty workloads to increase faculty satisfaction and retention (Duncan-Hewitt and Austin, 2005). Creating networks of communities of learning moves the focus from students as educational clients and consumers as practice sites that hire them to educational clients being practitioners ranging from the novice (student) to the expert and consumers being patients and society (Duncan-Hewitt and Austin, 2005). Networks of communities of learning would require increased integration between theoretical courses and practice. They have the potential to emphasise the resources and structural conditions that care providers require to achieve the best outcomes for patients with the most parsimonious use of resources. Engaging government departments associated with health care and education in developing visions of and resources for clinical settings would contribute to a shift in emphasis. To achieve networks of communities of learning, universities, hospitals, and community agencies would require a shared mission and objectives (Duncan-Hewitt and Austin, 2005). In clinical placements, members would operationalise processes and theoretical strategies that would make
Communities of learning and clinical placements Without sustained social participation in the practices of a community of learning, students will not develop problem-solving derived from being associated with the health care provider community, particularly those in their disciplines. Students can actively construct knowledge in clinical placements that are communities of learning (Field, 2004). As newcomers in communities of learning, they can regard learning as a continuous, active, engaged, situated, and identity-forming process (Lave and Wenger, 1991), as opposed to particular skills that must be mastered in that setting. Informal and situated social interaction
630 practice more effective. Such clinical placements would assist students to develop a practice-centred identity, where they appropriate the ways in which experts in the profession think, feel, and behave. This has the potential to increase professionalism (Duncan-Hewitt and Austin, 2005). Staff in clinical placements that are communities of learning would regard students as moving from being peripheral to practice to become more central to practice as they are entrusted with more complex tasks. This approach can shift perspectives from students being burdens by consuming resources and not contributing substantively to that of practitioners contributing at different levels on a trajectory to becoming expert practitioners (Austin and Duncan-Hewitt, 2005). Students can learn explicit knowledge (concepts, principles, and procedures) and implicit knowledge (storytelling, conversation, demonstration, and coaching) (Duncan-Hewitt and Austin, 2005). For example, a common philosophy about learning and practice in the area of the contribution of technology could lead to defining competencies broadly to include relational activities and skills. Members of a community of learning who learn and work together negotiate mutual understanding through participation and reification (Duncan-Hewitt and Austin, 2005). In clinical placements, participation occurs by working towards shared goals and having a common context for understanding. Reification occurs when implicit knowledge is made explicit, for example turning amorphous experiences into concepts, tools, procedures, databases, missions, plans, and contracts, through negotiation. Participation in clinical placements overcomes the problem of reification dominating, where classrooms provide a host of reified facts that have no meaning outside the student experience. Lave and Wenger (1991) refer to this as situated activity where, rather than receiving a body of knowledge about the world, participation is based on situated negotiation of meaning, which implies that experience and understanding are mutually constitutive. Reification overcomes the problem of participating in ‘routine’ activities in clinical placements, without a focus on deepening understanding of practice problems and improving outcomes (Duncan-Hewitt and Austin, 2005). For example, groups of students could develop projects that were based on needs assessment, implemented and evaluated. Such projects could be long-term where students would build on the work of previous groups. Materials developed from those projects could be shared with practice staff and profiled in agency newsletters, conferences, and local newspapers.
W.A. Hall Networks of communities of learning can disseminate best practices and explicit knowledge (Duncan-Hewitt and Austin, 2005). While students develop identities that are centred in their professions, in clinical placements defined as communities of learning, practitioners can actively collaborate and communicate shared best practice information. As well, institutions can harmonise organisational strategies with personal development and the identity of practitioners, integrate novices, and make the workplace more hospitable (Duncan-Hewitt and Austin, 2005). In communities of learning, skilful problem-solving is linked to scientific process; individuals’ strategic thinking skills are enhanced; and organisational learning, quality management, and participative leadership are reinforced. There is circulation of knowledge among peers and near-peers through engaging in practice; mastery resides in the organisation of the community of learning, of which masters are a part (Lave and Wenger, 1991). For example, developing competencies with all participants in communities of practice sensitises practitioners and leads to reflection and action. The competences can serve as guides to recruitment, hiring, succession planning, performance review, and unit development. Communities of learning are engaged in the generative process of producing their own future (Lave and Wenger, 1991). By developing competencies which incorporate standards from regulatory bodies and leveling the competencies from novice to master, clinical placements can shape their sites of practice and their outcomes. Clinical placements that are developed as communities of learning lend themselves to administrative structures where students, practitioners, and academics raise important questions about practice and find answers for them (Duncan-Hewitt and Austin, 2005). Such activities would lead to less distinct boundaries between practice and academia, with academics participating in practice and practitioners getting access to educational resources. Those activities would reduce the solitudes that exist between scientists, clinicians, and educators (Duncan-Hewitt and Austin, 2005). For example, academics could develop programs of research associated with questions raised by practice communities, which would facilitate the conduct of research in setting where gaining ethical approval and achieving recruitment is often difficult. These activities would lead to preceptors and clinicians advancing their practice through faculty support; academics developing relevant and inter-professional research activities; and students building their confidence and competence in an en-
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riched learning community (Austin and DuncanHewitt, 2005).
vided direction for placing the consumer or client at the centre of inter-professional activities. If professionals in health and social care are going to engage in collaborative practice, it is important to place the patient at the centre of the team (Cooper et al., 2001). In clinical placements that are structured as communities of learning, students and masters place the emphasis on the client through the assumptions they are using to guide inter-professional clinical experiences, such as, the client is the focus of care, the focus is improved client outcomes and cost-effective care, and the collaboration of team members promotes autonomy for professionals and clients (Burns et al., 2000). Developing clinical placements that incorporate an inter-professional clinical model, which places the client at the core of the model and incorporates health promotion, health maintenance, and illness care can cross acute care and community boundaries (Burns et al., 2000). Crossing those boundaries assists with managing the paradox where students are being asked to develop a knowledge base that incorporates health promotion and prevention, as well as cure and palliation. Developing clinical placements with inter-professional goals that include increasing inter-professional understanding and cooperation, promoting competent team work, making effective and efficient use of resources, and promoting high quality, comprehensive patient care (Cooper et al., 2001) can extend limited resources and promote sharing of technical and non-technical resources. Cooper and colleagues (2001) have pointed out that most of the evidence for the positive outcomes associated with interdisciplinary education is concentrated on quantitative studies, short-term evaluation, or anecdotal evidence. The largest effects of interdisciplinary educational activities have been on knowledge, attitudes, skills, beliefs, especially professional roles and team work; the smallest effects have been for transfer into practice and on learning environments (Glen, 2004). Clinical placements which incorporate client and inter-professional collaborative competencies in a community of learning enable long-term outcomes to be assessed, because learners include health care professionals who are staff and competencies are associated with recruitment, hiring, succession planning, performance review, and unit development, which shape clinical settings and their outcomes. Incorporating collaboration in learning communities legitimises peripheral participation and provides access to a nexus of connections otherwise not perceived as connected (Lave and Wenger, 1991). Cooper and colleagues (2001) recommended
Consumer and inter-professional collaboration and clinical placements Contemplating clinical placements that are developed as learning communities is intricately linked to consumer participation. The paradox introduced earlier in the paper indicated that, while members of the public rely on professional expertise, they also expect full partnership with health care professionals in decision-making around their care. Learning communities without clients at their centre would fail to accomplish the professional socialisation that these communities can provide. Glen (2004) has defined interdisciplinary (inter-professional) education as interactive educational activity that involves two or more professionals and improves collaboration focused on patient care. Thus, inter-professional collaboration has at its core high quality, comprehensive patient care (Cooper et al., 2001; Ruebling et al., 2000). It is difficult to find descriptions of inter-professional teams in the literature where the patient is included as an equal team member. There has been some evidence indicating that client stays in hospital are shorter and there is increased client satisfaction when inter-professional collaboration occurs; however, the effects seem to have been focused on acute rather than chronic care situations (Glen, 2004). Students who are unable to participate in clinical placements characterised by inter-professional teams with clients at their centre will engage in social participation learning which fails to prepare them for clients who want to be full partners in their care and inter-professional collaboration for care. For example, clinical placements that incorporate principles of communities of learning and consumer and inter-professional collaboration would be characterised by patients explicitly sharing power, having their knowledge and perceptions valued, and having opportunities to teach health care providers about their experiences. Objectives for learning would be altered to reflect the expectation that students will demonstrate behaviours to support such activities. When Duncan-Hewitt and Austin (2005) discussed clinical placements characterised as communities of learning, which moved the focus from consumers as practice sites that hire students to consumers being patients and society, they pro-
632 discussion between educators, practitioners, and students serve as a basis to determine a fundamental approach to inter-professional education. Such recommendations do not go far enough. To develop professional education to support communities of learning, discussions for inter-professional collaboration must incorporate patients and families from the beginning of developing competencies to shaping the clinical setting to achieve those competencies (Van Stolk, 2006). Designing inter-professional clinical education opportunities presents challenges around bringing students together, making curricular changes to make inter-professional education possible, and creating change in health and social care institutions to facilitate contact (Glen, 2004). In clinical placements with hands-on clinical inter-professional components, experts are required who model respect for other health professions, their values and their expertise (Ruebling et al., 2000). To build support for clinical placements that feature interprofessional clinical education, research must document improvements in health status and services (Glen, 2004). To facilitate such clinical activities, participatory action research strategies could be incorporated in clinical settings, with longitudinal designs and quantitative and qualitative components. Such designs would allow the ‘team’ to generate the research questions and short and long-term outcomes to be documented, as well as processes.
Conclusion The opening discussion of the tension between short and long-term goals of health care is increasingly mirrored in the conflicting pressures on educating health care professionals. The stress on professional expertise, the requirements of technical proficiency, and the inevitability of resource constraints all compete with considerations of long-term health promotion, consultation in decision-making, and providing a caring setting for patients. Clinical placements for health care students have traditionally served, not only to give students the experience of providing practical care, but also to help them to understand how short and long-term health care goals can be accommodated. This article argues that the current shortage of clinical placements may be creating problems but it can also be seen as an opportunity to reconsider the design of students’ clinical experience and the goals that are to be attained. Developing clinical
W.A. Hall placements that emphasise social participation, communities of learning, consumer participation, and inter-professional collaboration can assist with overcoming the paradoxes identified. Those elements, in and of themselves, will not be sufficient without re-designing professional curricula so that they can support and sustain clinical placements that offer opportunities to define students as contributing members of a larger community of learners that are working to achieve common goals.
Acknowledgement I would like to acknowledge my colleagues’ thoughtful and scholarly discussions during the NET/NEP International Conference, which contributed to the development of this paper.
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