Learning to care: a review of the literature

NURSE EDUCATION TODAY Q Longman Group Ltd 1985

(1985) 5, 178-182

Learning to care: a review of the literature Pam Smith

Hospital morale is taken as the starting point for exploring the relationship between learning nursing and the giving of patient care. Approaches to defining the quality of care are identified, including dependency studies, quality assurance instruments and the nursing process. Implications for learning nursing are discussed. Similarly, studies that have researched nurse learning but with implications for patient care are referred to. The Quality Patient Care Scale (Qualpacs) is described as one approach to examining the complex relationship between nurse learning and patient care. The nursing process and the practical assessments that learners undergo throughout training are compared and contrasted with Qualpacs. They are offered as comparable approaches not only to assessing the quality of learning and caring but also their relationship to each other.

The

references

for this literature

selected

from

bracing

a variety

ological tional be

an

extensive

of theoretical

approaches psychology

that

as

much

(Moores

of this review between

from industrial as

patient quality

care.

75

nursing

Implications

em-

and educa-

cent

is provided

& Moult

were

method-

Since

per

1979),

was to explore

learning

and

and sociology.

nursing care in Britain training

review

bibliography,

it may

of direct

for

of years.

hospitals distinct

Revans’

are complex characteristics

staff and patients, ly.

Hospitals

or negativeis high

have

their

are

Sickness

the

assessing

also

patients lower.

Wards

to have better

the

where

turnover length

FOR MORALE but little

(1964).

The

the

system within

recovery

and nurse stability,

and

each

group’s

from what the hospital

patients’ of

hospital

stresses and anxieties.

of each

re-

High morale

effectiveness

internal

are

are

than in those

of staff is high with

quickly.

learners

hospitals

atmosphere

reducing

in

Patient

said Revans, capacity

is the

to

are learn

has to offer. He goes on

to suggest that the patient and trainee nurse are often undergoing a similar learning process together:

P Smith MSc BNurs RNT, Senior Nurse (Research), The Middlesex Hospital, London Wl N BAA

these

of stay is longer.

associated

indicators

more

rates among in

ported average

point is the much quoted

discharged

and attrition

of

giving

data for his study were collected from a number of hospitals in the north of England over a

178

morale

the purpose

communication

acted upon work by R W Revans

which

of

by nurses in

also

The starting

either positively

in

with

that affect the morale

of all grades of nursing staff and

of care are also discussed.

STANDARDS

thesis goes as follows:

social organisations

lower turnover

the relationship

and

period

‘Both

are

tasks of adjustment, of life, the patient

faced

with

the student

considerable

nurse in a way

to the path of recovery.’

pression

PATIENT DEPENDENCY AND WORKLOAD

and

on medical feelings

were

allocated llbout

thr

rr.port.

studies

time

that were

dependency, (1967).

The

looking

at

process

define

workloads

prescribing xtudirs

\,irw

of nursing

have

with

at

dependency, levels.

criticised

is that

staff-patient

ratios

thp

and

nurses,

training

thr

subtleties

llnpredictability 1979

raised

icln to

these

the

point

that

issues

particularly

allocation in a way

iijr them.

He

workload

and

statt‘ may

aff‘ect

of that

the

IO learn.

mix

and

and

c,uample

where

in one

I)er of‘ learners More

recently,

Reid

out

what

nurses

is not

any

that

a simple

numbers

one

have

hospital

level

but

each

the

types

occupational important will only

stress.

The

since

riot take

lrarnc~r

wards

(1983) student satis-

to learners of contact

on they

process

allect to

1979

Parkrs’

findings

in

first

experienced

adequate

the

of

higher

also showed

levels

stress the care that

months of anxiety

of

extent

inti,r

and

that

to xi\.cl (‘arc’ ih

1,~ the

SC’S 01 thcil

of t’hc ~\;trd.

(1975)

learning.

they

only the

that

the

patirnts.

brtwrrn

the

Government

arr

tutors

more

limcls

that

improvement

in

thr

will improve

the quality

made

assumptions

it

similar

necrssary

is

climates

and

are ‘good

to

the

and

ot

traininK

of (‘arc‘. Orton

qualit\

: 1981

and

a

w.ud

characteri>tic,s

‘l(.ss good’.

ha\.?

high

level

and

patients

trnd

(Birch female

these

‘good’

wards.

‘good’

ward

climates

and

climates

must

ing hcttrr MrGhee

training

the

and

rc.laticm

de-

Mard

the

and

ward

their

Orton

sister to the

c-motional

She

patirnts’

cannot patient.

that b)c

who

OII

Lrxsociatr(l ti)r both

c,onsidrred atlitudcs

subscqurtlt

of

nrcds

10 l)f, met

Ihrrcli)rc

as ben&ci:rl

( 1961 ) asserted

ah and

sixtc.1 is aware

patients.

affect

thal

rJf‘ those

of. teamwork

of lrarncrs

the

thar

learning

‘l’hohc, 4r~ drfinrs

and

and

learners

m:tintained

rsamiric,

phvsical

learner’s

ward

a request with a hollow I-in? in t ht ing, economic climate of the 1980s. Shr considerrd

The

not

of‘ patient ;I(‘( ountable for that tt1c inlet tlilrsr traiu-

stafl‘ needs.

if the

two

Hendall

;Ind

consultation

is

i:rl1t.

tcnc-h in the

classroom,

puts

of

writtc,n

for their

introduction

nursr

than

their

20 per

nurses

111~ nurse

md

ol)srrvation

and

carrd

about

so that

cart’,

her

of agrrrmrnt

was

asstunrd

car-r

in the wards

of how

amount

of patirnt

discussed

working

accounts

t,1981

Orton

of

learning will

Brndall

learners The

and quality

on

stress

(if at all)

nursing six

of that

In turn, but

ability students

subject

effectively

stress.

learning give

workloads

it is recognised

place

is under

and

and

thr specialt)

recommended

the issue of the effects

of

results

~)f’ allocation

in training

to learn

ti)r

!OU, I~~vrls 01

srqurncc

to students

between

‘good’

i 1980) raised

Parkes

Brndall

allocation

c.arin,q tbr patients. different

and

to some and

is

in one

to

the

pattern

and ‘I‘hest,

wards.

higher

I hr!- rcportcd

although

pressure

in all

ability-

versions

num-

of having

during

of work

both

.\nGety

QUALITY LEARNING AND CARING

rather

colleagues

c+he amount other

br critical

their

is critical staff

may

variability

ward

matter

the

an extreme

to it increased and

that

of

trainee

a great

of trained

shift,

with

be sense

to 17.

point4 Iilctory

the

to untrained the

levels xupport

were

tirst.

were

wards,

l‘hrze

trainers

ward

satisfaction

high

influenced

if

surgical

in male

staff

link

in relat-

quoting

allocated

three

the

the

what

mix,

nor

should

that

AMoores found

numbers

the

learning

of trained

how

itI staff

wevk from

also

into

of

makes

trainees

also work

patients

Moores

He

makes

suggested

take

need,

workload.

of nurses.

oraanised

,tblr

not

a

satisfaction

wards.

recom-

experiences

the

training

static

of Morl\

on surgical

levels

The

do

but

students

levels

than

compounded

to

studrnts’

under-

staffing

of patient

of

and

the

care.

mended

to

for their

adequate

ac~caunt

in

However,

care;

nursing

in

way

attempting

patient

patient

‘good’

work

some

staffing

been and

look

Barr’s went

of care,

and

I)ing- assumption tA(Iuatr

his

to

studies

optimum

these

published

including

patient Oxford

the

Revans undertaken

lower

wards

thca that

to

t‘rco\.(‘r)

gf.tt-

rates.

thf, importance

01‘

rrtmphasised

it1

01

jlltlyrs

ht.r t)v thr

NURSE

180

EDUCATION

atmosphere Revans

of her (1964),

and ward of

care

and

ward.

Orton

suggested

atmosphere, and

measure

TODAY

staff

or climate,

learning

but

in a quantiliable

technical

(1981),

that

affect

are

way

patient,

staff

communication

implications.

quality

less

than

like

attitudes easy

observed to

rated

are

asked

as trained

tions.

skills.

and

observers ments

knowledge

Each

ASSESSING QUALITY

ned

to fit the

nurses Although

instruments

have

been

two

things

have

been

developed, about

and

nurses

such

have

America

against

health

warned

instruments

majority

care,

us

are

is complex

interaction

recording: patient

an

care only care

bed

dimensional

concept &

approach ship

State

in

may

the

rate

a

physical

University

The

the

caring. the

in the early College

scale

is

complex

and from

patients observed

of

centred

are randomly for a two

trained

data

patients’

hand-over

from charts

reports.

one

nursing

expected

that

raters

ings

and

1974).

hold

consistently

The

agree

criteria

used

scale

judge in

the nurse-

conceptions staff

(Wandelt

to judge

are ‘safe, adequate,

and sett-

& Ager

a first

the nursing

of

nurse’,

in diflferent

occasions

in meeting

the patient

similar level

in

as their

of the to

displayed

of a first

on many

involved

extent

authors

care

interactions

care

care

level

needs

therapeutic

of and

Slater

Nurse

we already

quality

Nursing

ners

undergo

tools

provide

(Slater groups

is spent

nursing

or by listening

of

a unit and by nurses

hour

notes,

of nursing psychosocial

the

1970s at Wayne

in that

Information

at

process

A further case

COMPARABLE APPROACHES TO ASSESSING QUALITY In Britain

instru-

re-

to nurses’

is also collected

about staffing levels and patient dependency, to put the selected patients (up to five) into a ward context. The scale covers 68 items and six dimensions to the physical and

patient

not

relationThe

selected from hour period

to use the scale.

collecting cords,

is patient

of

level North

is the

(Qualpacs)

1967). Qualpacs

competent

staff nurse

and

of care

Scale

1974).

developed Scale

The

that

stan-

supportive’.

of quality

learning

Competency

lost

counterparts.

claim

The

since

to the same

‘nurses

in a form

of a first

nurse,

British quality

on acceptable

review.

are

the

tries to get at the multi-

to examining

was

be

the gentleness

Care

Ager

between

ment

that

Patient

(Wandelt

be

by the patient.

instrument

Quality

to

as receiving

and fail to capture

experienced

One

not

observer

bathed

of

nursing into so essential in

may

‘objective’

being

colleagues

and

underestimated. By transforming items and scores, the subjectivity nurse-patient

supernumer-

development

nurses

of

in which

is that

student care

concepts

patients)

and

staff

judg-

observa-

by cues which

to agree

with

expected

patient

clinical their

context

and

The

cues may be redesig-

particular

qualified)

American direct

The

are

scale.

underlying

discussion

of care

(newly

a concern

and that

dard

satisfaction,

item.

(preferabIy group

their

to rate

is accompanied

are working

standards of peer

the

as consumer

in training

of care

remembering

date,

Giovannetti

Secondly,

(1984)

To

in North

as well

where

ary.

them.

of private

profits

quality

it is worth

developed

a background with

to assess

to use

as to the

for each

professional

interactions

on a live point nurses

item

give guidance quality

and

All nurse-patient

care, relating needs of the

and

possess

of nursing

the practical

giving of patient care. Each tool will be taken content

and

trasted

with

method

observation practice

that

briefly of

part

in

turn

of

the the their

and

con-

Firstly,

the

nursing

of the Qualpacs

and and

compared

learthese

exploring

nursing

Qualpacs.

component forms

Both

for

learning

nursing that

training.

opportunities between

for looking

~ the

assessments

throughout

relationships

tools

care

process assessment.

Items referring to the nursing process appear in the dimensions of care relating to Communication, such as: ‘Well-developed nursing care plans are established and incorporated into nursing

assignments’

(item

57).

They

also

ap-

EDI~C:A’I’IoN

NCKSE

pt*ar

in

the

Professional

dimensions

of caring

Implications.

Items

stat?

respectively:

plans

reflect

nursing

care’

(11’ the

patient’s

LVandelt

and

of

nurse

learning

take

condition

of care

has

take

to

should

care

informed

discussed

will

such

no

the

(Young

to indiv-

learners

improvement things

will

process

liar recording

and

&luating

learners

care

received

traded

hy


Barnett’s

patient

instructions the

supervision (‘are,

of learners

‘technical

staff

because in giving

being

similarities

with

c.omprise

the

1972)

and

ilic- nursing

skills

(viz.

administration,

total and

nursing

may

skills

continuous

Nursing

Board’s

four

or

1976,

Young

being

consideration underlying

assessed

their

stage with

criterion {Young

underpins

it. All three

nursing with

respect is being

1982).

lear-

about

some

Donabedian

assessments

standard

without

drug

sourcrs

ward

quate

of the divided

There

is,

(McBride the nursby learners

is taken

into

quality.

The

‘safe’ or ‘unsafe’ the

guide

components

to Ir~k

the

adequate

i the training

process

learning

and nor

strategy

structureorhrr.

But

material

re-

InclLtdrs

ade-

tar le;irnrrs.

will be of the rrquirrd

thr

1Y8Ol. ‘l‘hc

cac,h and

outcome

will

it1

usirlg as

a

iKcn to

that

iy talked

r’valu,ttion

which

support

ward 1975

l‘irlall) muc,h

human

the

and

as Bendall

and

structure;,

above, at caring

tutorial

suggestrd

related

ttr

which

mentioned

approach arr

a:,

neither

IIt‘ <.aring

and

qualit\.

References

assessment

given

Indeed,

tools

setting

( 1966)

is only trained

the

National

1982).

to

Specific learner’s into

nurs(L

framework

literature.

process-outcome

of spec-

variation assessment,

is that

conceptual

suggested, a realistic teaching also improve patient care. assurancr

tool

individual

to bring

care,

01

hand,

ot’ c’ar-r rrc,eivctl

asst‘ssmcnt

as the

as the

assessment

of training

any valid

and

technique,

lxr-

indi\-idual

in developing,

ward-based

however, room for local 1983 Unlike a Qualpacs and

and

use it and

(King’s

be

quality than

together

Council’s/English part

1Exton-Smith

III summary, reliable

report

part

overall

learning

that

of

drlivery

on rht. othrr

staff

have

judgment

assessment

the collecti1.r

rather

i.\

under

nursr

Qualpacs.

the

patients

assessor

on individual

and

patient

form

than

thr

of inadequate

communication).

assessment

(ieneral

rather

to patients.

tent,

setting

‘objective’

a discrepancy

The

aseptic

less

for nurses

training

additional

management

practice

un-

occupied

progress

has

the

the

Moreo\rer,

opportunities

assessments

Qualpacs.

ward

and

concentrates

quality

throughout

that

and

offer

‘basic’

fully

the practical

undergo

ing care

written

activity

procedures’.

Srcondly,

l’und

which

to monitor nursing

frequently

often

in

likely

emphasises

df

is illus-

study,

and

assessments,

it is more

1982).

judgments

competence.

the sup&vision

plans

was

opportunity

by patients

actual

two,

trained

ners

care

There

Iletwren

offers

(1982)

against

dertaken.

care

clinical

the content learner

nurse

re-

in the method>

With

the

‘the

rather

assessments

to be trained to rate

that

1972’.

lcarnrr

to use their

with

formance

enable

Fund

and

strrsscs

as a ItLarner

observed.

observation

nurses

by

nursing

and

nurses

however,

the skills which

responsibility

and

as trained

familiar

happens be

prescribed

the impliby Bendall

(King’s

the assessors

of the care

reports

be assessed

Qualpacs

improving

individual

for what

are given

at the

progress

a nurse’

Both quire

whereabouts’

for

than

of

very little.’

That

only

and

by patients,

‘Until

there

thrm alter

and

been

responsibility thry

ward

trainee

of results

allocation

stated:

,rnd until

care

tool is looking

received

1dua1 patients,

writing

1974).

patient

She

and

staff keep

the Qualpacs

,xtions 1975

in

evaluation

‘Assigned

6t Ager

Although quality

‘Changes

continuous

to 68

relating 64

I81

l’OD.\\

to to

Barr 4 1967 Measurement of nursing ~WY’ Operational Research Unit Report No. 9 Barnett D E 1982 Planning patient cart’. ntr. -1. Nursine Times 78 (Suppl 13): 26 L Bendall E 1975 So you passed, Nursr. Kcrl, London Birch J 1979 The anxious learners. Nursing ;Ilirror 148 6.: 17.-22 Donahedian A 1966 Evaluating the quality of medical care. Milbank Memorial Fund Quarterly44: I66 206 Exton-Smith J 1976 Management of ward-bawd assrssmrms. Nursing Times 7219 1’ 349~ ‘iSO

182

NURSE

EDUCATION

TODAY

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