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Learning in practice: But who learns from who?
Nurse Education in Practice (2006) 6, 1–2
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
EDITORIAL
Learning in practice: But who learns from who? I recently heard a conversation similar to the one below on an acute, general paediatric ward (all names are fictitious). It took place in a cubicle where Darren, an 18-month-old with a long-term chronic disorder and many complex care needs arising from this, was being cared for. He had been admitted two days earlier because of an episode of infective diarrhoea: Gerri Hi there, have you enjoyed your time off? Kim Oh great, yea, how about you? Gerri Fine thanks, it was good to get out for a while, enjoy the nice weather. Kim Good, IÕm just about to hook him up to his feed, now his diarrhoea is settling heÕs getting back to normal feeding. Gerri Oh right-I donÕt really know about his gastrostomy, IÕll have to find out about it . . . is this his pump? Kim Yea, the Kangaroo pump, thatÕs right, well why donÕt I tell you about it? I can show you how we dress the insertion site and emm . . . Toni joins in . . . how about his medication as well, giving them down his tube and how it needs flushing with water to keep it clear and that? Gerri Mmmm-I havenÕt actually done all that before, it would help me to learn more about it. Kim How about tomorrow, will you be in tomorrow? Cos IÕll be here in the morning. Gerri Yes IÕll be here in the morning as well. Kim Tomorrow then . . . IÕll show you everything; about the giving set and tubing and putting his medication down it and so on. Gerri Ok, fine, see you tomorrow then . . .
This is an interesting example of learning in practice that is a key focus of Nurse Education in Practice; indeed it is central to the Aims and Scope of the journal. Learning is of course an implicit part of health care practice at all times of day and night, in many contexts and involving different social relationships. Hearing this conversation prompted me 0962-4562/$ - see front matter Ó 2005 Published by Elsevier Ltd. doi:10.1016/j.nepr.2005.11.001
to reflect on the way learning in practice, in particular with regard to the care of chronically ill patients, has changed during my own nursing career. Chronic illnesses are on the increase for people of all ages, including children under 16 years who comprise 20% of the population of England and Wales (DoH, 2001; Judson, 2004; ONS, 2004). As the global, infant/child mortality rate is declining there is a concomitant increase in childhood chronic illness (Oduntan, 1995). It is predicted that by the year 2015, 623 million children worldwide under 5 years of age and 1.2 billion aged 5–14 years will have a significant chronic illness (Buckens and Boerma, 2001). At the same time, advances in health care are leading to improved life-expectancy for chronically ill children and a growing number survive into adulthood (MacDonald and Callery, 2004). However, nurses working with the chronically ill know something of the challenge this can be for families as they try to incorporate conditions and their consequences into daily life. Unlike professionals who: choose to learn about the management of conditions; work shifts; have days off and receive a salary, patients and families have little choice. The prevailing philosophy of family centred care and the drive, wherever possible, to nurse sick children in their own homes, means families often have to become proficient in a wide range of technical and clinical skills, some of which are unpleasant, invasive and distressing. These are often performed by family members with monotonous regularity at home, school, on holiday, while visiting friends, even when in hospital. The failure of families to become proficient can negatively influence the childÕs outcome. Nurses are very involved in teaching families, but they too learn a lot from families. So how is this two-way process of teaching and learning negotiated? Who (if anyone) decides who the teacher is, who the learner is and are these roles interchangeable? What social positions do you think Toni, Kim and Gerri hold? Some people
2 may be surprised to learn that Kim is DarrenÕs mother, Toni his father and Gerri a newly appointed staff nurse. Kim and Toni, both resident parents during DarrenÕs admission, had been home for a few hours rest while the ward-based nurses carried out DarrenÕs care. On their return, they resumed their roles as his main carers while the nurses monitored his condition. Gerri, a very competent staff nurse who had not previously cared for a child with such complex needs as Darren was starting a new shift after four days off-duty. Two ideas I found helpful when considering the questions provoked by this conversation are the concept of Communities of Practice (Wenger, 1998) and the Theory of Social Positioning (Harre and van-Langenhove, 1999). Through regular contact with a range of health-care professionals in hospital and community since DarrenÕs birth, Kim and Toni have been on a steep learning curve and have become experts in many aspects of his care. According to WengerÕs definition, they are on an inward trajectory in a Community of Practice (CoP). A CoP is a set of relations among people, their activity and their worlds over time and in relation with other tangential and overlapping Communities of Practice. The social structure of this practice and its power relationships define possibilities for learning and one of the key skills that Kim and Toni have learned is how to share their own knowledge with professionals in such a way that they will remain part of the CoP. In this way, they have Ôlearned about their learningÕ (meta-cognition) and demonstrated confidence in communicating with Gerri. By offering to provide learning opportunities for her, they have positioned themselves as powerful. Harre and van-Langenhove (1999) tell us that Social Positions are generally relational so that when one person is positioned as powerful (for example a nurse specialist teaching a child about the technical care of renal dialysis) then others may be positioned to feel powerless (for instance the child and parents). Although individuals may choose whether or not they wish to respond to being ÔpositionedÕ, in institutional settings choices may not exist for those subjected to positioning (for instance children and/or parents) by those who hold positions of authority (for instance professionals and/or parents). Whilst professionals regularly confirm the accuracy of familiesÕ knowledge in chronic illness care, some nurses might feel uncomfortable about exposing a deficit in their own knowledge base to parents. Child health care has undoubtedly changed dramatically since Sir James Spence (Spence, 1947) advocated a radical approach whereby children
Editorial and their mothers were admitted to the same room so care could continue and separation be avoided. Technical care was administered by trained nurses while Ôdaily careÕ continued to be provided by mothers. In todayÕs changing world of health care, however, by acknowledging the concept of Ôthe expert patientÕ (DoH, 2001) we are required to question some longstanding professional values. By exploring some contemporary aspects of learning in practice in relation to Social Positioning and Communities of Practice in Child Health, this brief discussion has probably raised more questions than answers. Perhaps the questions and possible answers may be different in other clinical settings, it would be interesting to explore those too.
Acknowledgement Thanks are due to Sister Karen Hudson and staff, Newcastle upon Tyne Hospitals NHS Trust for helpful comment on this editorial.
References Buckens, P., Boerma, J., 2001. Maternal and child health. In: Coop, C., Pearson, C., Schwarz, M. (Eds.), Critical Issues in Global Health. Jossey Bass, San Francisco, pp. 196–202. DoH, 2001. The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century. Department of Health, London. Harre, R., van-Langenhove, L., 1999. The dynamics of social episodes. In: Harre, R., van_Langenhove, L. (Eds.), Positioning Theory: Moral Contexts of Intentional Action. Blackwell, Oxford. Judson, L., 2004. Global childhood chronic illness. Nursing Administration Quarterly 28 (1), 60–66. MacDonald, H., Callery, P., 2004. Different meanings of respite: a study of parents, nurses and social workers caring for children with complex needs. Child Care Health and Development 30 (3), 279–288. Oduntan, S., 1995. Gender differences in childhood mortality and morbidity. In: Wallace, H., Giri, K., Serrano, C. (Eds.), Health Care of Women and Children in Developing Countries. Third Party Publishing Co, Oakland, CA, pp. 70–78. ONS, 2004. Mid-Year Population Statistics for the United Kingdom. Office of Population Statistics, London. Spence, J.C., 1947. The care of children in hospital. British Medical Journal 1 (4490), 125–130. Wenger, E., 1998. Communities of Practice: Learning, Meaning and Identity. Cambridge University Press, Cambridge.
Veronica Swallow Room Hoo9, Coach Lane Campus, Northumbria University, Newcastle Upon Tyne NE7 7XA, United Kingdom E-mail address: [email protected]
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
EDITORIAL
Learning in practice: But who learns from who? I recently heard a conversation similar to the one below on an acute, general paediatric ward (all names are fictitious). It took place in a cubicle where Darren, an 18-month-old with a long-term chronic disorder and many complex care needs arising from this, was being cared for. He had been admitted two days earlier because of an episode of infective diarrhoea: Gerri Hi there, have you enjoyed your time off? Kim Oh great, yea, how about you? Gerri Fine thanks, it was good to get out for a while, enjoy the nice weather. Kim Good, IÕm just about to hook him up to his feed, now his diarrhoea is settling heÕs getting back to normal feeding. Gerri Oh right-I donÕt really know about his gastrostomy, IÕll have to find out about it . . . is this his pump? Kim Yea, the Kangaroo pump, thatÕs right, well why donÕt I tell you about it? I can show you how we dress the insertion site and emm . . . Toni joins in . . . how about his medication as well, giving them down his tube and how it needs flushing with water to keep it clear and that? Gerri Mmmm-I havenÕt actually done all that before, it would help me to learn more about it. Kim How about tomorrow, will you be in tomorrow? Cos IÕll be here in the morning. Gerri Yes IÕll be here in the morning as well. Kim Tomorrow then . . . IÕll show you everything; about the giving set and tubing and putting his medication down it and so on. Gerri Ok, fine, see you tomorrow then . . .
This is an interesting example of learning in practice that is a key focus of Nurse Education in Practice; indeed it is central to the Aims and Scope of the journal. Learning is of course an implicit part of health care practice at all times of day and night, in many contexts and involving different social relationships. Hearing this conversation prompted me 0962-4562/$ - see front matter Ó 2005 Published by Elsevier Ltd. doi:10.1016/j.nepr.2005.11.001
to reflect on the way learning in practice, in particular with regard to the care of chronically ill patients, has changed during my own nursing career. Chronic illnesses are on the increase for people of all ages, including children under 16 years who comprise 20% of the population of England and Wales (DoH, 2001; Judson, 2004; ONS, 2004). As the global, infant/child mortality rate is declining there is a concomitant increase in childhood chronic illness (Oduntan, 1995). It is predicted that by the year 2015, 623 million children worldwide under 5 years of age and 1.2 billion aged 5–14 years will have a significant chronic illness (Buckens and Boerma, 2001). At the same time, advances in health care are leading to improved life-expectancy for chronically ill children and a growing number survive into adulthood (MacDonald and Callery, 2004). However, nurses working with the chronically ill know something of the challenge this can be for families as they try to incorporate conditions and their consequences into daily life. Unlike professionals who: choose to learn about the management of conditions; work shifts; have days off and receive a salary, patients and families have little choice. The prevailing philosophy of family centred care and the drive, wherever possible, to nurse sick children in their own homes, means families often have to become proficient in a wide range of technical and clinical skills, some of which are unpleasant, invasive and distressing. These are often performed by family members with monotonous regularity at home, school, on holiday, while visiting friends, even when in hospital. The failure of families to become proficient can negatively influence the childÕs outcome. Nurses are very involved in teaching families, but they too learn a lot from families. So how is this two-way process of teaching and learning negotiated? Who (if anyone) decides who the teacher is, who the learner is and are these roles interchangeable? What social positions do you think Toni, Kim and Gerri hold? Some people
2 may be surprised to learn that Kim is DarrenÕs mother, Toni his father and Gerri a newly appointed staff nurse. Kim and Toni, both resident parents during DarrenÕs admission, had been home for a few hours rest while the ward-based nurses carried out DarrenÕs care. On their return, they resumed their roles as his main carers while the nurses monitored his condition. Gerri, a very competent staff nurse who had not previously cared for a child with such complex needs as Darren was starting a new shift after four days off-duty. Two ideas I found helpful when considering the questions provoked by this conversation are the concept of Communities of Practice (Wenger, 1998) and the Theory of Social Positioning (Harre and van-Langenhove, 1999). Through regular contact with a range of health-care professionals in hospital and community since DarrenÕs birth, Kim and Toni have been on a steep learning curve and have become experts in many aspects of his care. According to WengerÕs definition, they are on an inward trajectory in a Community of Practice (CoP). A CoP is a set of relations among people, their activity and their worlds over time and in relation with other tangential and overlapping Communities of Practice. The social structure of this practice and its power relationships define possibilities for learning and one of the key skills that Kim and Toni have learned is how to share their own knowledge with professionals in such a way that they will remain part of the CoP. In this way, they have Ôlearned about their learningÕ (meta-cognition) and demonstrated confidence in communicating with Gerri. By offering to provide learning opportunities for her, they have positioned themselves as powerful. Harre and van-Langenhove (1999) tell us that Social Positions are generally relational so that when one person is positioned as powerful (for example a nurse specialist teaching a child about the technical care of renal dialysis) then others may be positioned to feel powerless (for instance the child and parents). Although individuals may choose whether or not they wish to respond to being ÔpositionedÕ, in institutional settings choices may not exist for those subjected to positioning (for instance children and/or parents) by those who hold positions of authority (for instance professionals and/or parents). Whilst professionals regularly confirm the accuracy of familiesÕ knowledge in chronic illness care, some nurses might feel uncomfortable about exposing a deficit in their own knowledge base to parents. Child health care has undoubtedly changed dramatically since Sir James Spence (Spence, 1947) advocated a radical approach whereby children
Editorial and their mothers were admitted to the same room so care could continue and separation be avoided. Technical care was administered by trained nurses while Ôdaily careÕ continued to be provided by mothers. In todayÕs changing world of health care, however, by acknowledging the concept of Ôthe expert patientÕ (DoH, 2001) we are required to question some longstanding professional values. By exploring some contemporary aspects of learning in practice in relation to Social Positioning and Communities of Practice in Child Health, this brief discussion has probably raised more questions than answers. Perhaps the questions and possible answers may be different in other clinical settings, it would be interesting to explore those too.
Acknowledgement Thanks are due to Sister Karen Hudson and staff, Newcastle upon Tyne Hospitals NHS Trust for helpful comment on this editorial.
References Buckens, P., Boerma, J., 2001. Maternal and child health. In: Coop, C., Pearson, C., Schwarz, M. (Eds.), Critical Issues in Global Health. Jossey Bass, San Francisco, pp. 196–202. DoH, 2001. The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century. Department of Health, London. Harre, R., van-Langenhove, L., 1999. The dynamics of social episodes. In: Harre, R., van_Langenhove, L. (Eds.), Positioning Theory: Moral Contexts of Intentional Action. Blackwell, Oxford. Judson, L., 2004. Global childhood chronic illness. Nursing Administration Quarterly 28 (1), 60–66. MacDonald, H., Callery, P., 2004. Different meanings of respite: a study of parents, nurses and social workers caring for children with complex needs. Child Care Health and Development 30 (3), 279–288. Oduntan, S., 1995. Gender differences in childhood mortality and morbidity. In: Wallace, H., Giri, K., Serrano, C. (Eds.), Health Care of Women and Children in Developing Countries. Third Party Publishing Co, Oakland, CA, pp. 70–78. ONS, 2004. Mid-Year Population Statistics for the United Kingdom. Office of Population Statistics, London. Spence, J.C., 1947. The care of children in hospital. British Medical Journal 1 (4490), 125–130. Wenger, E., 1998. Communities of Practice: Learning, Meaning and Identity. Cambridge University Press, Cambridge.
Veronica Swallow Room Hoo9, Coach Lane Campus, Northumbria University, Newcastle Upon Tyne NE7 7XA, United Kingdom E-mail address: [email protected]