- Email: [email protected]
Implementation of a key skills agenda within an undergraduate programme of midwifery studies
Nurse Education Today (2004) 24, 483–490
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Implementation of a key skills agenda within an undergraduate programme of midwifery studies Annie Dixon1, Pat Donovan* Department of Midwifery Studies, University of Central Lancashire, Preston PR1 2HE, UK Accepted 25 May 2004
KEYWORDS
Summary There are a multitude of external forces that impinge on curriculum planning. This paper reports on a DfEE funded development project, which looked at overtly assessing key skills within an undergraduate midwifery curriculum. The aims of the project were developed to fit within University agreed objectives and included:
Key skills; Midwifery; Transferable skills; Audit; Portfolio
• • • • •
Identification of the main stakeholders Assessment of the current situation Identification of how to develop a strategy for key skills within the department Implementation and evaluation of any changes Cascading information throughout the Faculty of Health on completion of the evaluation
Two undergraduate midwifery programmes of study leading to professional qualification were included in the project. All stakeholders were identified and their responsibility with regard to key skills was explored. Audit of all modules was undertaken highlighting both the embedded nature and some imbalance in the provision of key skills. Meetings were held with both academic and clinical staff to enable understanding, co-operation and implementation of any changes. Focus groups were undertaken to investigate student perceptions of key skills and the usability of documentation devised to assess key skills. A tool was designed by which undergraduate students assessed their key skill development. The outcomes from these meetings, student focus groups and module audit are reported briefly here. Recommendations for future research and development are also stated. c 2004 Elsevier Ltd. All rights reserved.
Background
* Corresponding author. Tel.: +44-1772-893-826; fax: +441772-892-914. E-mail address: [email protected] (P. Donovan). 1 Tel.: +44-1772-893-824; fax: +44-1772-892-914.
When providing higher education for professional registration with the Nursing and Midwifery Council (NMC), universities have to take into account not only issues surrounding provision of education but also issues surrounding the National Health Service
0260-6917/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2004.05.005
484 (NHS). At the beginning of the current century the main influences on education came from the Department of Health (government), the UKCC (professional body), the Quality Assurance Agency (QAA), Higher Education Funding Council (HFCE) and the National Health Service (Service providers). Some of the most pertinent issues have been clinical effectiveness, clinical governance (DOH, 1999) and continuing professional development (UKCC, 1999a). In addition, the UKCC placed great emphasis on accountability (UKCC, 1992a) and scope of practice (UKCC, 1992b). From an educational point of view key skills are prominent in the QAA Benchmarking exercise for Nursing and Midwifery that took place in 2001 (QAAAG, 2001). Employers seek graduates with highly specialised knowledge and skills but express concern about their general capabilities (UKCC, 1999b). Therefore, educators of future health care professionals have an important role in ensuring students develop skills that can be transferred to other contexts (Brown, 2000). The recommendations (Recommendations 17 and 21) made by the National Committee of Inquiry into Higher Education (NCIHE), Dearing Report (1997), must be complied with. Most employers are looking for an adaptable workforce that can be successful in a wide range of tasks and work effectively as a member of a team (NCIHE, 1997). Competence is also essential for any employee of the NHS. In addition, with its many recent and ongoing changes including technological advances, workforce skills also need to be adapted to meet new challenges in a timely and appropriate manner (National Advisory Group for Continuing Education and Lifelong Learning, NAGCELL, 1997). Consequently, learning can no longer be seen as a defined end product but rather a continual process, this explains the governments focus on lifelong learning and the learning schemes developed to encourage continuing professional development, these include the University for Industry, University of the NHS (NAGCELL, 1999) and individual learning accounts. Learning to learn is fundamental to the development of all other key skills, therefore, all institutions of higher education should aim for student achievement in key skills to be an outcome for all programmes (NCIHE, 1997). However, the specific development of key skills is seen as a contentious issue within Higher Education (Murphy and Otter, 1999). The teaching of key skills is seen as being of limited relevance to professional (nurse) education (Milligan, 1998) due to the perception that they are “an inevitable part of the effective education of competent nurses” (Milligan, 1998, p. 273–275). Although these skills may be developed implicitly within nurse/midwifery
A. Dixon, P. Donovan education it is a requirement of Higher Education Institutions to make them explicit for their students, especially when looking at the recommendations of the Making a Difference Document (DOH, 1999), which promotes students “stepping on and off” their programmes. An emphasis on key skills, preferably from the commencement of their course will equip such students with skills that would be useful for future employers that may well be outside the NHS. To enable universities to promote key skills the Department for Education and Employment (DfEE) funded projects throughout Higher Education to facilitate the development and implementation of a key skill strategy. The University of Central Lancashire (UCLAN) submitted a successful bid and several departments’ commenced small-scale projects to develop the most appropriate way to incorporate key skills across the curriculum in a variety of different academic disciplines. The Department of Midwifery Studies appointed a project worker (AD) to implement the key skill agenda. The Department offers pre-registration undergraduate midwifery education as well as a wide range of undergraduate post-registration courses in neonatal care, midwifery and sexual health and Masters programmes.
Introduction With a limited time scale and finite funding a decision was made to concentrate on the undergraduate pre-registration midwifery courses within the department. The two main midwifery courses that lead to registration as a midwife within the department are an 18-month short course for qualified nurses, and a four-year long course for those with no prior nursing qualifications. Both of these courses lead to a BA (Hons) and professional registration that allows successful graduates to practice as a midwife within the UK and the European Community (dependent on additional practice for short course students). Both courses are made up of 50% theory and 50% clinical experience and thus the key skill strategy was implemented across both the university setting and clinical placement areas. For the purposes of the project the key skills focussed on were: • • • • •
Communication Numeracy Information technology Learning to learn Working with others
Implementation of a key skills agenda in midwifery studies The project was accountable to the University Key Skills Steering Committee where the process and findings were disseminated. This ensured cross-faculty sharing of ideas and enabled problems that arose to be dealt with appropriately allowing other departments to learn from them.
Development plan A variety of personnel can be defined as stakeholders within education provision. These groups had to be taken into account to ensure they were kept informed of and were active participants in the student experience of key skill development. The main aim of the project reflected the university objectives. Specific objectives were also identified for the Department project, and these were: • Assessment of the current situation • Designing tools to measure the development of key skills • Implementation and evaluation of the tools developed • Ensuring the tools could be implemented across the Faculty of Health with ease on completion of the project. Overall the project used a variety of methods to elicit the required information to inform the key skill agenda. Ethical approval was not sought as the plan was seen as an educational development rather than empirical research.
Assessment of current situation Academics, clinical staff and students were key players in facilitating the development of a focus on key skills. For the purposes of this project clinical staff were divided into two groups: • Heads of Midwifery Service (HOMS) • Clinical assessors/mentors The current perception of stakeholders was required to ensure that any changes would be beneficial, appropriate and timely. In addition, by involving all stakeholders at this time it was envisaged that a sense of ownership would be fostered thus facilitating the successful implementation of any proposed changes. As stakeholders all have different perceptions of the purpose of education and the benefits of
485
courses (Rushford and Ireland, 1997) the relationship between them is a dynamic process, which meant that they could not be viewed in isolation. To address this the project incorporated all the stakeholders in the following ways. Academic staff As academic staff are pivotal to student experience and play a major role in planning the learning experiences of students via the curricula it was vital that meetings be held to elicit the following: • How key skills fitted into the courses run within the department • How best to support students in their development of key skills. Meetings with academic staff highlighted that as key skills were embedded and implicit within modules it was difficult to assess to what degree each individual skill was present. An audit was undertaken to further the key skill agenda. The audit document was adapted from one designed by the Department of Biological Sciences at UCLAN and all modules in each undergraduate midwifery course were audited by the module leader facilitated by the project worker (AD). Following the key skill audit further meetings were held to assess what, if any, changes needed to be made to ensure key skills were explicit or to incorporate key skills where any deficiencies had been highlighted. Students Students are important stakeholders and as such it was imperative their views were sought. It was decided that focus groups would be the most appropriate way to collect information from students, as this would generate dialogue and valuable data to inform the project (Polit et al., 2001). The main aim of the focus groups was to investigate student perceptions of key skills and their relevance within the course they were undertaking. Focus group methodology enables people to explore and clarify their views through interaction with others in the group (Kevern and Webb, 2001). A secondary aim was to explore whether these views changed over the course of one year and also to evaluate documentation. Participation was voluntary and students were able to withdraw their support at any time if they wished with no prejudice to themselves. The university guidelines on student involvement in such activity were followed. In 1999/2000 a total of 41 first-year undergraduate midwifery students (long course n ¼ 23, short
486 course n ¼ 18) participated in key skill focus groups at three time points during the academic year. These students gain their clinical experience in six NHS Trusts and each focus group consisted of students from two Trusts giving a total of six focus groups at each time point, three for each course. Students in each focus group were asked a series of trigger questions to encourage discussion and debate between the students within the group. The focus group facilitator (AD) only participated when asked a direct question or if the discussion petered out when the next trigger question would be put to the group. The groups were asked several open and closed questions in relation to key skills and each group were asked the same questions. Each group had an initial session that explored the current situation and elicited students’ views on: • • • •
Knowledge of key skills Awareness of key skills within their course How best to make key skills explicit for them How best to incorporate key skills within their learning documentation both within the department and clinical site experience.
Six months later intermediate focus groups took place following the use of key skill documentation where the following was explored: • Current views and opinions of key skills • Perception of draft key skill documentation • Perception of the role of their academic advisor in relation to key skills • Perception of input from clinical assessors and clinical site staff in relation to key skills Final focus groups took place at the end of the academic year and elicited the following: • Current views and opinions of key skills • Utilisation of key skill documentation • Usefulness of key skill development
Clinical site staff HOMS have overall responsibility within their Trust for Midwifery students undertaking the clinical component of their course and, in the case of the short course students these managers were also their employers. Given this, meetings were held with HOMS for two reasons. Firstly, HOMS needed to be aware of the key skills project and secondly, their contribution was invaluable as the students were their potential future employees. Clinical assessors/mentors have on-going responsibility within specified clinical areas for stu-
A. Dixon, P. Donovan dents’ development of clinical competence. As stated students undertake 50% of their course within the clinical area therefore key skills need to be developed within the practice setting supervised by clinical assessors. For that reason explanation and dissemination of the project to clinical assessors was imperative to facilitate ongoing development of key skills. Therefore meetings were held with clinical assessors to inform and ensure understanding of key skills within the clinical areas. The discussions with HOMS raised departmental awareness of NHS Trust requirements and expectations of graduate employees. Site liaison staff attended a key skill seminar where they were able to ask questions and clarify their responsibilities. Copies of all key skill documentation were sent to each clinical site representative for dissemination to all relevant clinical staff.
Project findings Key skill module audit Descriptive statistics were carried out on the audit results. A grid was devised showing the training, development and assessment of each key skill. The results of the key skill audit confirmed that the majority of key skills were embedded within the modules students undertake but the data also highlighted some imbalance between the skills. Some modules did not appear to incorporate numeracy or information technology very effectively.
Student focus groups All audiotapes were transcribed and each transcript then underwent content analysis. The project worker coded transcripts into themes and the project co-ordinator separately coded the transcripts to ensure inter-rater reliability.
Results Academic The initial response from meeting with academic staff was one of wariness. Staff felt that key skills were already embedded within the modules and clinical placements that students experienced and thus key skills were perceived as just another paper exercise, that would increase their workload. However, as key skills are implicit and thus not always visible their visibility needed promoting.
Implementation of a key skills agenda in midwifery studies Academic staff highlighted the success of the role of academic advisor within the department. There was general agreement that, as students see their academic advisor regularly as part of their learning, discussion on key skills could be included during these meetings. This would remove the need for separate meetings, maintain continuity of the learning experience and was unlikely to increase the workload of the academic staff.
Students The information gathered from students at the baseline focus groups informed the development of key skill documentation. The students were concerned that inclusion of key skills would entail an increased workload for them. The audit revealed that the majority of key skills are embedded and assessed as part of the course, it was felt that separate additional summative assessment of key skills would be unnecessary. Thus key skills were incorporated into the portfolio of learning, the completion of which is a course requirement. A new section was developed in the portfolio that included: • Explanations and instructions on how to complete the key skills documentation • Self-assessment document • Learning contract • Overall key skill development grid
Table 1
The self-assessment document was devised using the NVQ core curriculum theme documents (NCVQ, 1996a,b,c,d; NCVQ, 1999). In view of student concerns about time constraints this document was developed as a tick box exercise. This could be completed at the start of the course and then either on a yearly basis for the long course students, or at the beginning of each part of the course for the short course students. Each key skill was sub-divided into a number of elements and further sub-divided into descriptors to facilitate student ability. To see the different components that formed communication see Table 1. Levels of ability in each descriptor were linked to the levels used within the department for students in their clinical placements (Table 2). The learning contract was developed in response to student desire for external validation (i.e. they wanted some form of assessment other than selfassessment). Students, in collaboration with their academic advisor, decided which descriptors to develop at any given time. They could then devise an action plan for achieving development and provide evidence of achievement within their portfolio, mainly by cross-referencing to other sections. The ability to cross-reference minimised the workload associated with key skills and a sense of external validity was provided as the academic advisor countersigned the learning contract. The overall development grid was designed so that employers could immediately gauge a potential employees level of key skill achievement.
Example of elements and descriptors within the student self-assessment document
Key skill
Elements
Examples of descriptors
Communication
Reading and responding
Can you gather relevant information? Can you collate and summarise information? Can you recognise opinion as opposed to fact? Is your work well presented and legible? Have you used an appropriate format and style? Have you referenced your work correctly? Can you put together a coherent well-articulated argument? Can you answer questions appropriately? Are you comfortable with your interview technique?
Written work
Verbal communication
Table 2
487
Competency levels used in both key skill and clinical competency documentation
Level
Student self-assessed achievement
1 2 3 4
Has observed the skill and can participate in the skill but requires supervision and observation Can undertake the skill with minimal supervision Is competent to undertake the skill without supervision Is able to teach the skill to someone else
488 The intermediate focus groups raised minor issues in relation to the key skill documentation and appropriate changes were made. For example, there was no level available for students to tick in the self-assessment document if they had no prior experience of a particular descriptor. Thus level 0 was incorporated into the document with the description attached “no prior experience of the skill”. Students also found some of the descriptors difficult to interpret. To address this a website was developed explaining each descriptor and giving examples for students to see. Students that accessed this resource evaluated it well. The final focus groups found that some students had made no attempt to utilise the documentation. The main reason cited for this was lack of time. Over the course of the academic year several differences between the short and long course students became apparent. Short course students felt their course was “crammed” without the addition of having to complete the key skill documentation as well. In addition the students felt that as they were already qualified nurses they had no need to further develop their key skills, because they felt that they had already achieved the required level. Students on the four-year course appeared more willing to develop their key skills as they perceived learning as a continuum within the university and the clinical setting whereas the 18month students perceived the clinical setting as work rather than a learning environment. Students from both courses expressed the opinion that the documentation was “long winded” and wanted it incorporated into their clinical assessment documentation. It is worth noting that, whilst educators regularly extol the virtues of the portfolio in terms of learning experience and reflective practice (Harris et al., 2001; Jasper, 1999; Alsop, 1995), students do not appear to hold them in such high regard. In fact the data from the focus groups suggested that students have a very negative view of portfolios. This is reflected in some recent work (Dolan et al., 2004). Students found it difficult to see the benefit and instead perceived the portfolio to be of little use once completed as no one asked to see it or look at it again following completion of their course. The students therefore saw it as a paper exercise and thus a waste of their valuable time. Students from both courses requested provision of timetabled portfolio workshops with a facilitator to enable them to benefit optimally from their production. Feedback from the latter two focus groups suggested that despite the information being sent to clinical site representatives, dissemination had not
A. Dixon, P. Donovan taken place as expected as assessors were not aware of the key skill agenda.
Discussion Overall As with all new initiatives there was a certain amount of resistance to the development and recording of key skills. This was alleviated following the audit, which showed the extent to which key skills were already embedded within the curriculum. It is interesting to note that the appointment of a project worker had both advantages and disadvantages. One advantage was that the co-ordinator could act as a change agent ensuring that all the differing strands of the project maintained cohesion. The main disadvantage was that the departmental academic staff perceived their role in key skill development as minimal because of the work of the project worker. This was worthy of note as the role of the academic advisor was pivotal to the success of the student development of key skills. This highlighted a need to foster ownership of key skills by all the staff in the department.
Academic staff As mentioned earlier, the key skill audit showed that the modules did not offer the students opportunity to develop in the areas of information technology and numeracy as well as they did in all other key skills. Reasons for this may be varied but may include the fact that academic staff themselves are not always fully cognisant of (a) the need to develop these skills, (b) the full embedded nature of them and (c) their personal level of achievement in these skills. In areas where the opportunities for developing these skills could be improved they can be offered within modules with a little thought and lateral thinking. This would enhance the learning the students undertake and ensure that key skills were built upon successively throughout the course. By the end of the project the majority of staff had realised the requirement of their own input and began accessing the project worker for information and help in promoting key skills with their own students. It was also noted that more lateral thinking was occurring in terms of how numeracy and IT could be incorporated into student learning which was a positive outcome of the project. Finally all module handbooks and programme specifications were updated with specific refer-
Implementation of a key skills agenda in midwifery studies ence being made to the key skills covered within the module both in terms of content and the learning outcomes.
489
used to reach a decision as to the appropriate degree classification for that student.
Clinical staff Students There were distinct differences between the long and short course students. These differences had an impact on student opinion as to the relevance of key skills to them and their course. Short course students could not understand why they were being asked to develop skills they perceived they already had, being trained nurses, despite their being derisory about the communication skills they had observed from qualified midwives. This raised interesting questions surrounding the level of skill a trained nurse may think has been achieved and the actual level of the skill attained. As noted in the results the short course student perception was that long course students had much more time to undertake their learning. In terms of length of course, this may be true but the reality is that long course students often have to take up employment to supplement an inadequate bursary. This is in contrast to short course students who are contracted to undertake their course by an NHS Trust and so receive a full salary. Although student opinion recommended that the key skill documentation be incorporated within the clinical placement competency document this was not done for several reasons. Firstly, students may only see key skills in a midwifery frame of reference thus losing the transferability of the skills. Secondly, the specific detail of the self-assessment document would be lost and with it the opportunity for the students to develop the full variety of competencies within a key skill. Finally, student thinking may be narrowed thus minimising the benefit of learning achieved from activities undertaken outside the remit of the course. The development of a professional portfolio is a statutory requirement (UKCC, 1999a,b) and should be used in regular supervisory meetings to identify specific learning needs (Burden and Jones, 2001; Robb, 2000). Whilst the negative perception of portfolios as an instrument in gaining employment may be valid at local level, students still need to understand the full nature of portfolio development. Given the importance of portfolio development the department decided to include several more timetabled sessions on how to compile a portfolio. Whilst students portfolios are not assessed, they are a course requirement and thus if a students’ work is borderline the portfolio may be
The need for continued sharing and dissemination of information between the Department of Midwifery Studies and clinical site staff was highlighted. Therefore key skills will be included in regular assessor updates in order to increase knowledge and understanding of clinical staff with regard to key skills as an inherent part of the student learning experience. The key skill documentation is now in use throughout all modules and courses within the Department of Midwifery Studies and further key skill audits will be undertaken to evaluate the effect of changes within the modules and also to assess the need for further improvement. The main themes identified from the focus groups will be used to design a questionnaire to gather more information from students about their perception and development of key skills.
Limitations of the project There were limitations inherent in this development project not least due to the constraints of time and funding. There may have been inherent biases present within the student focus groups as students’ chose which focus group to join and this may have influenced the internal dynamics of the group. However, the facilitator encouraged participation by all members of each focus group. The focus group facilitator was the project worker and as such was not a lecturer that the students had had previous contact. This changed over the time of the project when the students did meet the project worker in a lecturing capacity which may have influenced the discussions by students. As the focus groups were not compulsory attendance dropped off over the course of the academic year. In the final focus groups there were two groups held with a minimum of two attendees. There are several reasons as to why students may have chosen not to attend the final focus groups. They may have felt they had nothing further to add or they may not have understood the importance of their input in terms of future student experience. Alternatively they may not have been engaging in the project development, as they perceived it to be a fait accompli. Finally, the students were car sharing and if the student with the car was not coming other students may have found it difficult
490 to attend. Whatever the reason, lack of attendance at two of the final focus groups could have influenced the findings of the focus groups.
Conclusion Overall this project has raised the profile of key skills within a professional course. Given the governments drive for lifelong learning (DOH, 1999) it is important for educationalists to encourage students to develop their key skills from school into the higher education sector and into their chosen career. The outcomes of this project have the potential to enable students to continue to develop their key transferable skills, by providing a framework that can be carried through their professional life. For key skills to be successfully incorporated into health care all academic and clinical staff have to promote the benefits of transferable skills not only in a professional sense but also from a personal perspective. As with many projects of this nature more questions have been raised than answered. Further work needs to be undertaken in many different areas. These include: • The need to evaluate the usefulness of portfolios to potential employers. • The dissemination and usefulness of information from University departments to clinical assessors in terms of the role that they play in producing the future professional. • The differing underpinning student philosophies found within short and long course midwifery, to discover whether their learning needs are disparate, which would have implications on future curricula development and strategies. • Evaluating the level of key skill achievement of academic staff and addressing any training issues that arise from this evaluation.
References Alsop, A., 1995. The professional portfolio purpose, process and practice. Part 1: portfolios and professional practice. British Journal of Occupational Therapy 58 (7), 299–302. Burden, B., Jones, T., 2001. Improvements to supervision are essential for best practice. British Journal of Midwifery 9 (4), 220–226.
A. Dixon, P. Donovan Brown, S.E., 2000. Does a multi-disciplinary health degree provide a satisfactory post-registration course for nurses? A follow-up survey of health science studies graduates. Nurse Education Today 20 (8), 613–619. Department of Health, 1999. Making a Difference. Department of Health, London. Dolan, G., Fairbairn, G., Harris, S., 2004. Is our student portfolio valued? Nurse Education Today 24 (1), 4–13. Harris, S., Dolan, G., Fairbairn, G., 2001. Reflecting on the use of student portfolios. Nurse Education Today 21 (4), 278–286. Jasper, M., 1999. Nurses’ perceptions of the value of written reflection. Nurse Education Today 19 (6), 452–463. Kevern, J., Webb, C., 2001. Focus groups as tool for critical social research in nurse education. Nurse Education Today 21 (4), 323–333. Milligan, F., 1998. Defining and assessing competence: the distraction of outcomes and the importance of educational process. Nurse Education Today 18, 273–280. Murphy, R., Otter, S., 1999. A Common sense issue. The Times Higher, August 6. National Advisory Group for Continuing Education and Lifelong Learning, 1997. Learning for the Twenty-First Century. DfEE, Nottingham. National Advisory Group for Continuing Education and Lifelong Learning, 1999. Creating Learning Cultures: Next Steps in Achieving the Learning Age. DfEE, Nottingham. National Committee of Inquiry into Higher Education, 1997. Higher Education in the Learning Society, Summary Report (Dearing Report). HMSO, Norwich. National Council for Vocational Qualifications, 1996a. Core Skills Communication. NCVQ, London. National Council for Vocational Qualifications, 1996b. Core Skills Application of Number. NCVQ, London. National Council for Vocational Qualifications, 1996c. Core Skills Improving own learning and performance. NCVQ, London. National Council for Vocational Qualifications, 1996d. Core Skills Working with others. NCVQ, London. National Council for Vocational Qualifications, 1999. Key skills Information Technology. QCA, London. Polit, D.F., Hungler, D.P., Beck, C.T., 2001. Essentials of Nursing Research: Methods, Appraisal, and Utilization, 5th ed. Lippincott, Philadelphia. Quality Assurance Agency Advisory Group, 2001. Academic and Practitioner Standards: Midwifery (Draft consultation paper). QAA, Gloucester. Robb, F., 2000. Supervision of midwives what makes it special? The Practising Midwife 3 (5), 30–31. Rushford, H., Ireland, L., 1997. Fit for whose purpose? The contextual forces underpinning the provision of nurse education in the UK. Nurse Education Today 17, 437– 441. United Kingdom Central Council, 1992a. Code of Professional Conduct. UKCC, London. United Kingdom Central Council, 1992b. The Scope of Professional Practice. UKCC, London. United Kingdom Central Council, 1999a. The Continuing Professional Development Standard. UKCC, London. United Kingdom Central Council, 1999b. Fitness for Practice. UKCC, London.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Implementation of a key skills agenda within an undergraduate programme of midwifery studies Annie Dixon1, Pat Donovan* Department of Midwifery Studies, University of Central Lancashire, Preston PR1 2HE, UK Accepted 25 May 2004
KEYWORDS
Summary There are a multitude of external forces that impinge on curriculum planning. This paper reports on a DfEE funded development project, which looked at overtly assessing key skills within an undergraduate midwifery curriculum. The aims of the project were developed to fit within University agreed objectives and included:
Key skills; Midwifery; Transferable skills; Audit; Portfolio
• • • • •
Identification of the main stakeholders Assessment of the current situation Identification of how to develop a strategy for key skills within the department Implementation and evaluation of any changes Cascading information throughout the Faculty of Health on completion of the evaluation
Two undergraduate midwifery programmes of study leading to professional qualification were included in the project. All stakeholders were identified and their responsibility with regard to key skills was explored. Audit of all modules was undertaken highlighting both the embedded nature and some imbalance in the provision of key skills. Meetings were held with both academic and clinical staff to enable understanding, co-operation and implementation of any changes. Focus groups were undertaken to investigate student perceptions of key skills and the usability of documentation devised to assess key skills. A tool was designed by which undergraduate students assessed their key skill development. The outcomes from these meetings, student focus groups and module audit are reported briefly here. Recommendations for future research and development are also stated. c 2004 Elsevier Ltd. All rights reserved.
Background
* Corresponding author. Tel.: +44-1772-893-826; fax: +441772-892-914. E-mail address: [email protected] (P. Donovan). 1 Tel.: +44-1772-893-824; fax: +44-1772-892-914.
When providing higher education for professional registration with the Nursing and Midwifery Council (NMC), universities have to take into account not only issues surrounding provision of education but also issues surrounding the National Health Service
0260-6917/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2004.05.005
484 (NHS). At the beginning of the current century the main influences on education came from the Department of Health (government), the UKCC (professional body), the Quality Assurance Agency (QAA), Higher Education Funding Council (HFCE) and the National Health Service (Service providers). Some of the most pertinent issues have been clinical effectiveness, clinical governance (DOH, 1999) and continuing professional development (UKCC, 1999a). In addition, the UKCC placed great emphasis on accountability (UKCC, 1992a) and scope of practice (UKCC, 1992b). From an educational point of view key skills are prominent in the QAA Benchmarking exercise for Nursing and Midwifery that took place in 2001 (QAAAG, 2001). Employers seek graduates with highly specialised knowledge and skills but express concern about their general capabilities (UKCC, 1999b). Therefore, educators of future health care professionals have an important role in ensuring students develop skills that can be transferred to other contexts (Brown, 2000). The recommendations (Recommendations 17 and 21) made by the National Committee of Inquiry into Higher Education (NCIHE), Dearing Report (1997), must be complied with. Most employers are looking for an adaptable workforce that can be successful in a wide range of tasks and work effectively as a member of a team (NCIHE, 1997). Competence is also essential for any employee of the NHS. In addition, with its many recent and ongoing changes including technological advances, workforce skills also need to be adapted to meet new challenges in a timely and appropriate manner (National Advisory Group for Continuing Education and Lifelong Learning, NAGCELL, 1997). Consequently, learning can no longer be seen as a defined end product but rather a continual process, this explains the governments focus on lifelong learning and the learning schemes developed to encourage continuing professional development, these include the University for Industry, University of the NHS (NAGCELL, 1999) and individual learning accounts. Learning to learn is fundamental to the development of all other key skills, therefore, all institutions of higher education should aim for student achievement in key skills to be an outcome for all programmes (NCIHE, 1997). However, the specific development of key skills is seen as a contentious issue within Higher Education (Murphy and Otter, 1999). The teaching of key skills is seen as being of limited relevance to professional (nurse) education (Milligan, 1998) due to the perception that they are “an inevitable part of the effective education of competent nurses” (Milligan, 1998, p. 273–275). Although these skills may be developed implicitly within nurse/midwifery
A. Dixon, P. Donovan education it is a requirement of Higher Education Institutions to make them explicit for their students, especially when looking at the recommendations of the Making a Difference Document (DOH, 1999), which promotes students “stepping on and off” their programmes. An emphasis on key skills, preferably from the commencement of their course will equip such students with skills that would be useful for future employers that may well be outside the NHS. To enable universities to promote key skills the Department for Education and Employment (DfEE) funded projects throughout Higher Education to facilitate the development and implementation of a key skill strategy. The University of Central Lancashire (UCLAN) submitted a successful bid and several departments’ commenced small-scale projects to develop the most appropriate way to incorporate key skills across the curriculum in a variety of different academic disciplines. The Department of Midwifery Studies appointed a project worker (AD) to implement the key skill agenda. The Department offers pre-registration undergraduate midwifery education as well as a wide range of undergraduate post-registration courses in neonatal care, midwifery and sexual health and Masters programmes.
Introduction With a limited time scale and finite funding a decision was made to concentrate on the undergraduate pre-registration midwifery courses within the department. The two main midwifery courses that lead to registration as a midwife within the department are an 18-month short course for qualified nurses, and a four-year long course for those with no prior nursing qualifications. Both of these courses lead to a BA (Hons) and professional registration that allows successful graduates to practice as a midwife within the UK and the European Community (dependent on additional practice for short course students). Both courses are made up of 50% theory and 50% clinical experience and thus the key skill strategy was implemented across both the university setting and clinical placement areas. For the purposes of the project the key skills focussed on were: • • • • •
Communication Numeracy Information technology Learning to learn Working with others
Implementation of a key skills agenda in midwifery studies The project was accountable to the University Key Skills Steering Committee where the process and findings were disseminated. This ensured cross-faculty sharing of ideas and enabled problems that arose to be dealt with appropriately allowing other departments to learn from them.
Development plan A variety of personnel can be defined as stakeholders within education provision. These groups had to be taken into account to ensure they were kept informed of and were active participants in the student experience of key skill development. The main aim of the project reflected the university objectives. Specific objectives were also identified for the Department project, and these were: • Assessment of the current situation • Designing tools to measure the development of key skills • Implementation and evaluation of the tools developed • Ensuring the tools could be implemented across the Faculty of Health with ease on completion of the project. Overall the project used a variety of methods to elicit the required information to inform the key skill agenda. Ethical approval was not sought as the plan was seen as an educational development rather than empirical research.
Assessment of current situation Academics, clinical staff and students were key players in facilitating the development of a focus on key skills. For the purposes of this project clinical staff were divided into two groups: • Heads of Midwifery Service (HOMS) • Clinical assessors/mentors The current perception of stakeholders was required to ensure that any changes would be beneficial, appropriate and timely. In addition, by involving all stakeholders at this time it was envisaged that a sense of ownership would be fostered thus facilitating the successful implementation of any proposed changes. As stakeholders all have different perceptions of the purpose of education and the benefits of
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courses (Rushford and Ireland, 1997) the relationship between them is a dynamic process, which meant that they could not be viewed in isolation. To address this the project incorporated all the stakeholders in the following ways. Academic staff As academic staff are pivotal to student experience and play a major role in planning the learning experiences of students via the curricula it was vital that meetings be held to elicit the following: • How key skills fitted into the courses run within the department • How best to support students in their development of key skills. Meetings with academic staff highlighted that as key skills were embedded and implicit within modules it was difficult to assess to what degree each individual skill was present. An audit was undertaken to further the key skill agenda. The audit document was adapted from one designed by the Department of Biological Sciences at UCLAN and all modules in each undergraduate midwifery course were audited by the module leader facilitated by the project worker (AD). Following the key skill audit further meetings were held to assess what, if any, changes needed to be made to ensure key skills were explicit or to incorporate key skills where any deficiencies had been highlighted. Students Students are important stakeholders and as such it was imperative their views were sought. It was decided that focus groups would be the most appropriate way to collect information from students, as this would generate dialogue and valuable data to inform the project (Polit et al., 2001). The main aim of the focus groups was to investigate student perceptions of key skills and their relevance within the course they were undertaking. Focus group methodology enables people to explore and clarify their views through interaction with others in the group (Kevern and Webb, 2001). A secondary aim was to explore whether these views changed over the course of one year and also to evaluate documentation. Participation was voluntary and students were able to withdraw their support at any time if they wished with no prejudice to themselves. The university guidelines on student involvement in such activity were followed. In 1999/2000 a total of 41 first-year undergraduate midwifery students (long course n ¼ 23, short
486 course n ¼ 18) participated in key skill focus groups at three time points during the academic year. These students gain their clinical experience in six NHS Trusts and each focus group consisted of students from two Trusts giving a total of six focus groups at each time point, three for each course. Students in each focus group were asked a series of trigger questions to encourage discussion and debate between the students within the group. The focus group facilitator (AD) only participated when asked a direct question or if the discussion petered out when the next trigger question would be put to the group. The groups were asked several open and closed questions in relation to key skills and each group were asked the same questions. Each group had an initial session that explored the current situation and elicited students’ views on: • • • •
Knowledge of key skills Awareness of key skills within their course How best to make key skills explicit for them How best to incorporate key skills within their learning documentation both within the department and clinical site experience.
Six months later intermediate focus groups took place following the use of key skill documentation where the following was explored: • Current views and opinions of key skills • Perception of draft key skill documentation • Perception of the role of their academic advisor in relation to key skills • Perception of input from clinical assessors and clinical site staff in relation to key skills Final focus groups took place at the end of the academic year and elicited the following: • Current views and opinions of key skills • Utilisation of key skill documentation • Usefulness of key skill development
Clinical site staff HOMS have overall responsibility within their Trust for Midwifery students undertaking the clinical component of their course and, in the case of the short course students these managers were also their employers. Given this, meetings were held with HOMS for two reasons. Firstly, HOMS needed to be aware of the key skills project and secondly, their contribution was invaluable as the students were their potential future employees. Clinical assessors/mentors have on-going responsibility within specified clinical areas for stu-
A. Dixon, P. Donovan dents’ development of clinical competence. As stated students undertake 50% of their course within the clinical area therefore key skills need to be developed within the practice setting supervised by clinical assessors. For that reason explanation and dissemination of the project to clinical assessors was imperative to facilitate ongoing development of key skills. Therefore meetings were held with clinical assessors to inform and ensure understanding of key skills within the clinical areas. The discussions with HOMS raised departmental awareness of NHS Trust requirements and expectations of graduate employees. Site liaison staff attended a key skill seminar where they were able to ask questions and clarify their responsibilities. Copies of all key skill documentation were sent to each clinical site representative for dissemination to all relevant clinical staff.
Project findings Key skill module audit Descriptive statistics were carried out on the audit results. A grid was devised showing the training, development and assessment of each key skill. The results of the key skill audit confirmed that the majority of key skills were embedded within the modules students undertake but the data also highlighted some imbalance between the skills. Some modules did not appear to incorporate numeracy or information technology very effectively.
Student focus groups All audiotapes were transcribed and each transcript then underwent content analysis. The project worker coded transcripts into themes and the project co-ordinator separately coded the transcripts to ensure inter-rater reliability.
Results Academic The initial response from meeting with academic staff was one of wariness. Staff felt that key skills were already embedded within the modules and clinical placements that students experienced and thus key skills were perceived as just another paper exercise, that would increase their workload. However, as key skills are implicit and thus not always visible their visibility needed promoting.
Implementation of a key skills agenda in midwifery studies Academic staff highlighted the success of the role of academic advisor within the department. There was general agreement that, as students see their academic advisor regularly as part of their learning, discussion on key skills could be included during these meetings. This would remove the need for separate meetings, maintain continuity of the learning experience and was unlikely to increase the workload of the academic staff.
Students The information gathered from students at the baseline focus groups informed the development of key skill documentation. The students were concerned that inclusion of key skills would entail an increased workload for them. The audit revealed that the majority of key skills are embedded and assessed as part of the course, it was felt that separate additional summative assessment of key skills would be unnecessary. Thus key skills were incorporated into the portfolio of learning, the completion of which is a course requirement. A new section was developed in the portfolio that included: • Explanations and instructions on how to complete the key skills documentation • Self-assessment document • Learning contract • Overall key skill development grid
Table 1
The self-assessment document was devised using the NVQ core curriculum theme documents (NCVQ, 1996a,b,c,d; NCVQ, 1999). In view of student concerns about time constraints this document was developed as a tick box exercise. This could be completed at the start of the course and then either on a yearly basis for the long course students, or at the beginning of each part of the course for the short course students. Each key skill was sub-divided into a number of elements and further sub-divided into descriptors to facilitate student ability. To see the different components that formed communication see Table 1. Levels of ability in each descriptor were linked to the levels used within the department for students in their clinical placements (Table 2). The learning contract was developed in response to student desire for external validation (i.e. they wanted some form of assessment other than selfassessment). Students, in collaboration with their academic advisor, decided which descriptors to develop at any given time. They could then devise an action plan for achieving development and provide evidence of achievement within their portfolio, mainly by cross-referencing to other sections. The ability to cross-reference minimised the workload associated with key skills and a sense of external validity was provided as the academic advisor countersigned the learning contract. The overall development grid was designed so that employers could immediately gauge a potential employees level of key skill achievement.
Example of elements and descriptors within the student self-assessment document
Key skill
Elements
Examples of descriptors
Communication
Reading and responding
Can you gather relevant information? Can you collate and summarise information? Can you recognise opinion as opposed to fact? Is your work well presented and legible? Have you used an appropriate format and style? Have you referenced your work correctly? Can you put together a coherent well-articulated argument? Can you answer questions appropriately? Are you comfortable with your interview technique?
Written work
Verbal communication
Table 2
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Competency levels used in both key skill and clinical competency documentation
Level
Student self-assessed achievement
1 2 3 4
Has observed the skill and can participate in the skill but requires supervision and observation Can undertake the skill with minimal supervision Is competent to undertake the skill without supervision Is able to teach the skill to someone else
488 The intermediate focus groups raised minor issues in relation to the key skill documentation and appropriate changes were made. For example, there was no level available for students to tick in the self-assessment document if they had no prior experience of a particular descriptor. Thus level 0 was incorporated into the document with the description attached “no prior experience of the skill”. Students also found some of the descriptors difficult to interpret. To address this a website was developed explaining each descriptor and giving examples for students to see. Students that accessed this resource evaluated it well. The final focus groups found that some students had made no attempt to utilise the documentation. The main reason cited for this was lack of time. Over the course of the academic year several differences between the short and long course students became apparent. Short course students felt their course was “crammed” without the addition of having to complete the key skill documentation as well. In addition the students felt that as they were already qualified nurses they had no need to further develop their key skills, because they felt that they had already achieved the required level. Students on the four-year course appeared more willing to develop their key skills as they perceived learning as a continuum within the university and the clinical setting whereas the 18month students perceived the clinical setting as work rather than a learning environment. Students from both courses expressed the opinion that the documentation was “long winded” and wanted it incorporated into their clinical assessment documentation. It is worth noting that, whilst educators regularly extol the virtues of the portfolio in terms of learning experience and reflective practice (Harris et al., 2001; Jasper, 1999; Alsop, 1995), students do not appear to hold them in such high regard. In fact the data from the focus groups suggested that students have a very negative view of portfolios. This is reflected in some recent work (Dolan et al., 2004). Students found it difficult to see the benefit and instead perceived the portfolio to be of little use once completed as no one asked to see it or look at it again following completion of their course. The students therefore saw it as a paper exercise and thus a waste of their valuable time. Students from both courses requested provision of timetabled portfolio workshops with a facilitator to enable them to benefit optimally from their production. Feedback from the latter two focus groups suggested that despite the information being sent to clinical site representatives, dissemination had not
A. Dixon, P. Donovan taken place as expected as assessors were not aware of the key skill agenda.
Discussion Overall As with all new initiatives there was a certain amount of resistance to the development and recording of key skills. This was alleviated following the audit, which showed the extent to which key skills were already embedded within the curriculum. It is interesting to note that the appointment of a project worker had both advantages and disadvantages. One advantage was that the co-ordinator could act as a change agent ensuring that all the differing strands of the project maintained cohesion. The main disadvantage was that the departmental academic staff perceived their role in key skill development as minimal because of the work of the project worker. This was worthy of note as the role of the academic advisor was pivotal to the success of the student development of key skills. This highlighted a need to foster ownership of key skills by all the staff in the department.
Academic staff As mentioned earlier, the key skill audit showed that the modules did not offer the students opportunity to develop in the areas of information technology and numeracy as well as they did in all other key skills. Reasons for this may be varied but may include the fact that academic staff themselves are not always fully cognisant of (a) the need to develop these skills, (b) the full embedded nature of them and (c) their personal level of achievement in these skills. In areas where the opportunities for developing these skills could be improved they can be offered within modules with a little thought and lateral thinking. This would enhance the learning the students undertake and ensure that key skills were built upon successively throughout the course. By the end of the project the majority of staff had realised the requirement of their own input and began accessing the project worker for information and help in promoting key skills with their own students. It was also noted that more lateral thinking was occurring in terms of how numeracy and IT could be incorporated into student learning which was a positive outcome of the project. Finally all module handbooks and programme specifications were updated with specific refer-
Implementation of a key skills agenda in midwifery studies ence being made to the key skills covered within the module both in terms of content and the learning outcomes.
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used to reach a decision as to the appropriate degree classification for that student.
Clinical staff Students There were distinct differences between the long and short course students. These differences had an impact on student opinion as to the relevance of key skills to them and their course. Short course students could not understand why they were being asked to develop skills they perceived they already had, being trained nurses, despite their being derisory about the communication skills they had observed from qualified midwives. This raised interesting questions surrounding the level of skill a trained nurse may think has been achieved and the actual level of the skill attained. As noted in the results the short course student perception was that long course students had much more time to undertake their learning. In terms of length of course, this may be true but the reality is that long course students often have to take up employment to supplement an inadequate bursary. This is in contrast to short course students who are contracted to undertake their course by an NHS Trust and so receive a full salary. Although student opinion recommended that the key skill documentation be incorporated within the clinical placement competency document this was not done for several reasons. Firstly, students may only see key skills in a midwifery frame of reference thus losing the transferability of the skills. Secondly, the specific detail of the self-assessment document would be lost and with it the opportunity for the students to develop the full variety of competencies within a key skill. Finally, student thinking may be narrowed thus minimising the benefit of learning achieved from activities undertaken outside the remit of the course. The development of a professional portfolio is a statutory requirement (UKCC, 1999a,b) and should be used in regular supervisory meetings to identify specific learning needs (Burden and Jones, 2001; Robb, 2000). Whilst the negative perception of portfolios as an instrument in gaining employment may be valid at local level, students still need to understand the full nature of portfolio development. Given the importance of portfolio development the department decided to include several more timetabled sessions on how to compile a portfolio. Whilst students portfolios are not assessed, they are a course requirement and thus if a students’ work is borderline the portfolio may be
The need for continued sharing and dissemination of information between the Department of Midwifery Studies and clinical site staff was highlighted. Therefore key skills will be included in regular assessor updates in order to increase knowledge and understanding of clinical staff with regard to key skills as an inherent part of the student learning experience. The key skill documentation is now in use throughout all modules and courses within the Department of Midwifery Studies and further key skill audits will be undertaken to evaluate the effect of changes within the modules and also to assess the need for further improvement. The main themes identified from the focus groups will be used to design a questionnaire to gather more information from students about their perception and development of key skills.
Limitations of the project There were limitations inherent in this development project not least due to the constraints of time and funding. There may have been inherent biases present within the student focus groups as students’ chose which focus group to join and this may have influenced the internal dynamics of the group. However, the facilitator encouraged participation by all members of each focus group. The focus group facilitator was the project worker and as such was not a lecturer that the students had had previous contact. This changed over the time of the project when the students did meet the project worker in a lecturing capacity which may have influenced the discussions by students. As the focus groups were not compulsory attendance dropped off over the course of the academic year. In the final focus groups there were two groups held with a minimum of two attendees. There are several reasons as to why students may have chosen not to attend the final focus groups. They may have felt they had nothing further to add or they may not have understood the importance of their input in terms of future student experience. Alternatively they may not have been engaging in the project development, as they perceived it to be a fait accompli. Finally, the students were car sharing and if the student with the car was not coming other students may have found it difficult
490 to attend. Whatever the reason, lack of attendance at two of the final focus groups could have influenced the findings of the focus groups.
Conclusion Overall this project has raised the profile of key skills within a professional course. Given the governments drive for lifelong learning (DOH, 1999) it is important for educationalists to encourage students to develop their key skills from school into the higher education sector and into their chosen career. The outcomes of this project have the potential to enable students to continue to develop their key transferable skills, by providing a framework that can be carried through their professional life. For key skills to be successfully incorporated into health care all academic and clinical staff have to promote the benefits of transferable skills not only in a professional sense but also from a personal perspective. As with many projects of this nature more questions have been raised than answered. Further work needs to be undertaken in many different areas. These include: • The need to evaluate the usefulness of portfolios to potential employers. • The dissemination and usefulness of information from University departments to clinical assessors in terms of the role that they play in producing the future professional. • The differing underpinning student philosophies found within short and long course midwifery, to discover whether their learning needs are disparate, which would have implications on future curricula development and strategies. • Evaluating the level of key skill achievement of academic staff and addressing any training issues that arise from this evaluation.
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