- Email: [email protected]
Student nurse placements take a new direction
Nurse Education in Practice (2008) 8, 315–320
Nurse Education in Practice www.elsevier.com/nepr
Student nurse placements take a new direction Ann Purdie *, Louisa Sheward 1, Elaine Gifford
2
School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, United Kingdom Accepted 4 January 2008
KEYWORDS
Summary This article explores the experiences of the first ever student nurses in the United Kingdom to participate in an innovative two-week clinical placement with the charity ‘Across’. This charity takes seriously ill and disabled persons, referred to as VIPs, to Lourdes and back. The ethos of this partnership was the belief that senior students would benefit from refreshing or further developing their holistic caring skills. Six third year students were selected and were asked to keep a reflective diary and attend a focus group to discuss their experiences. The focus group was audiotaped, transcribed and analysed. Four key themes emerged: Perceptions of caring, interpersonal skills, spirituality and trust. These are essential aspects of holistic care. Delivering nursing care in this setting boosted the students’ confidence, developed their interpersonal skills, particularly listening, and personalised nursing care so that the student–VIP relationships were much more than simple interactions. In conclusion, the opportunities to enhance the student’s holistic caring skills exceeded expectations. Pre-registration programmes should consider such placements to further develop such skills. c 2008 Elsevier Ltd. All rights reserved.
Holistic caring skills; Student nurses; Innovative placement; Partnership
Introduction In 2004, the University of the West of Scotland (UWS) (formerly University of Paisley) School of Health, Nursing and Midwifery entered into partnership with the charity known as ‘Across’ (formerly Across Jumbulance) to develop an innovative clinical placement, the first of its kind in the United Kingdom for third year student nurses * Corresponding author. Tel.: +44 0141 849 4121. E-mail address: [email protected]. 1 Tel.: +44 0141 848 3823. 2 Tel.: +44 0141 849 4325.
(adult branch). There is a need for quality and diverse student placements to ensure student nurses are exposed to a variety of healthcare experiences (NHS Education for Scotland, 2002). According to the English National Board (ENB) and Department of Health (DoH) (2001), expansion of practice experience for student nurses is required due to the reduction in acute hospital patient numbers and the move towards increased care within the community (NHS Education for Scotland, 2002). Both ENB, DoH and NHS Education for Scotland purport working in partnership with voluntary/charitable organisations. With this in mind the UWS School of Health, Nursing and Midwifery approached the
1471-5953/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2008.01.001
316 ‘Across’ charity in order to develop a new learning environment. ‘Across’ is a charity which takes seriously ill and disabled persons, referred to as VIPs, to Lourdes and back on a purpose built coach (Across, 2006). The coach has ambulance status and is fitted with trolley beds, toilet, fitted kitchen, equipment, medical supplies and lift. Ten VIPs and 14 support staff travel together. The support staff consists of registered nurses, helpers, a doctor and a chaplain. During the placements student nurses replace two of the helpers and become part of the support team. Each trip and hence each placement for the student lasts 10 days with 8 days spent in an adapted hotel. The hotel has hospital beds, hoists and other equipment available. The programme for the students, during the placement, includes assisting VIPs and carrying out ‘care’ duties in relation to activities of living (Roper et al., 2000) all under the direction of a mentor. This article aims to describe the planning involved in developing this clinical placement with ‘Across’ and to report on the findings of the evaluation of students’ experiences. The article also contains practical advice for those wishing to develop a similar placement.
Background to the ‘Across’ placement Entering into a partnership with a charitable organisation in this unique setting was refreshing and challenging. It was anticipated that this placement had the potential to provide opportunities for student nurses to participate in holistic care unlike any within the National Health Service (NHS) environment, particularly in relation to developing interpersonal skills and spiritual care. Although nurses strive to provide holistic care, it is not always easy. Holistic care encompasses meeting physical, social, emotional and spiritual needs. Spiritual care, in particular, is difficult to provide for many reasons: the focus on physical needs, low nurse to patient ratios and acute patient illness (Wensley, 1995). Similar issues are raised by McDade, (2005, p. 287) who further expands on this by suggesting a number of other problems including: ‘ignorance, prejudices, misunderstandings and wrong assumptions’. Therefore to achieve holistic care requires the development of relationships based on a multitude of factors, such as trust, confidence and enthusiasm (Castledine, 2001). These are attributes all nurses aspire to but which, for the reasons highlighted above, are sometimes difficult to achieve. Likewise, these are essential elements required for spiritual care
A. Purdie et al. (McDade, 2005). McDade also recognises that the ‘patient role’ and the healthcare system can depersonalise individuals and even cause ‘dispiritedness’. Furthermore, he reports that the spiritual dimension of nursing is hard to define and even more difficult to put into practice. It is reported as much more than recognising religious beliefs, and varies from person to person. Hence, the ethos of this partnership with ‘Across’ was the belief that senior students would benefit from refreshing or further developing their skills in this unique 24hour placement. Nevertheless, it is important that students ‘maintain appropriate professional boundaries’ (Nursing and Midwifery Council (NMC), 2004, 2002) ‘‘to interact safely in a therapeutic relationship, which is based on meeting the client’s needs’’ (Taber, 2003, p. 360) and this was reinforced to students prior to departure. As this was the first time such a placement had been developed, a great deal of planning was initially required which took up to one year to complete. Much discussion took place between the project team, the ‘Across’ clinical and fundraising co-coordinators and with key members of the School of Health, Nursing and Midwifery (adult branch). It was agreed at the start of the planning process that it was good practice to carry out an in-depth evaluation of this innovative placement to assess its effectiveness (Robson, 2002). This project was designed to evaluate the experiences of these first students to have a placement with this charity. In order to do this, the project team felt it was important to use a ‘student focused’ approach. The findings would help to more fully understand if this type of placement was an effective and appropriate placement to develop students’ core holistic skills and, therefore, help further develop the pre-registration curriculum. It was also anticipated that students might find the student-focused evaluative approach empowering and confidence boosting. As part of the preparations for the placement, members of the ‘Across’ team came to the university to speak to look at the students. This included a chance to talk to some of the helpers, the co-ordinators and to the purpose built ambulance itself. Subsequently, a named liaison lecturer was appointed from the team and an educational audit carried out. It was essential to ensure that this was going to be a safe, appropriate, learning environment and that the correct policies and procedures were in place. Some examples of the information required were: expertise and experience of the registered nursing staff, other members of the multidisciplinary team who could act as a learning resource, philosophy of care, learning environment opportunities and professional documentation that
Student nurse placements take a new direction was in place to enhance learning, e.g. health and safety regulations and NMC guidelines. Supervision for the students whilst on placement was essential. Students were placed in teams where the support staff included a lead nurse who had attended a mentorship programme. The lead nurse also provided emotional and psychological support as it was recognised that this could be a stressful placement for the students as they were away from home and away from the support of the university. During their time on placement the students were expected to meet learning outcomes for a specialist placement within the School. These were in relation to professional conduct. Fundraising was also an important part of the role of the project team to help cover the fairly substantial costs of the placements. Social inclusion is at the heart of the UWS and for many students funding themselves for such a venture could be difficult. A number of strategies to fundraise were employed, many of these initiated by the students themselves. Early in 2005, the ‘Across’ placement was offered to all third year adult branch students in one of two campuses of the school of nursing. Students were asked to express their interest by writing a 300-word letter of application stating why they should be chosen, why they wanted to go on this placement and what they hoped to gain. Six places were available, although more students applied. These students travelled in pairs during the summer of 2005, providing support for each other. At the commencement of the project, because of indemnity reasons, it was stipulated to the students that their role would be that of helper and not student nurses. Students could not carry out any invasive nursing skills, such as administration of medication or urinary catheterisation. However, students were expected to be involved in delivering ‘essential’ nursing care to VIPs including personal cleansing and dressing, eating and drinking, and assisting with mobility. Initially, when students were introduced to the project, they expressed some concerns regarding their lack of development of technical skills experience on this placement. Discussion with the students facilitated their appreciation of the importance of revisiting and developing essential nursing skills.
Methods Ethical considerations Application for ethical approval to carry out an evaluative study of the experiences of students
317 whilst on the placement was submitted to the University Research Ethics Committee. The project was discussed and deemed to be audit. Approval was granted following amendments. All six students who had been selected and agreed to travel with ‘Across’, were informed as a group, both verbally and in writing, the aim of the evaluative project and the methods to be used to collect data. The students were informed of the need to ensure confidentiality of VIP and staff information at all times during the evaluative process. The project team were lecturers known to the students. It was essential to ensure students were aware that participation in the evaluation was entirely voluntary and that data would be reported anonymously. Distress can occur in all types of research (Parahoo, 2006). The facilitators anticipated that recalling and discussing the placement could bring back emotive experiences. It was therefore explained to the students that they could at any time choose to decline revealing sensitive information that may cause them anxiety. The students could discuss any anxieties on a one-to-one basis if required. All students agreed to participate in the evaluation. All students signed a consent form.
Data collection The six students were asked to keep a written diary of their experiences during the placement. They were encouraged to log relevant issues, incidents and activities carried out at regular intervals, whilst maintaining confidentiality at all times. Instructions on the completion of the diary were provided (Corti, 1993). The diary contained an insert on the definition of holistic care. This asked students to consider the physical, social, psychological and spiritual needs of an individual and to record activities/events in relation to each of these aspects of care. A diagram of the Roper, Logan and Tierney model of nursing care was also included as an overall framework to help students think about holistic care (Holland et al., 2003). In addition, a copy of Driscoll’s (1994) model of reflection was included and recommended as a framework for reflection. Students were asked to complete their diary at least twice a day. The diary remained private and was not read by the project team. The primary reason for the diary was that students could reread and refresh their memories prior to the focus group. It was also hoped the students would develop their reflective skills through doing so.
318 Following the placements, all six students were invited to a focus group in September 2005. A focus group was chosen because it was thought to be a supportive environment that would encourage discussion and sharing of their experiences, therefore providing a rich source of data (Goodman and Evans, 2006). This was facilitated by two members of the project team. Open questions were used, which encouraged the students to talk about their experiences. Issues of validity were addressed by preventing one participant dominating the discussion within the focus group and encouraging everyone to speak. The facilitators only intervened to clarify points made and to briefly summarize at the end to ensure validity. The focus group lasted approximately one hour and was audiotaped. Analysis followed Franz et al.’s (1996) five stages of analysis which involved listening to the audiotape several times, transcribing, familiarization with the data and selection and grouping of significant statements. To ensure reliability, all three members of the project team independently selected and grouped statements using colour coding. Subsequently these were discussed and common themes identified. Aspects of validity in relation to the analysis were addressed by concentrating on the relationship between the statements and the context of the discussion, and not concentrating simply on individual words or phrases (Franz et al., 1996).
Findings The focus group provided a rich insight into the student’s experience. Four key themes emerged from the transcript: the perceptions of caring, interpersonal skills, spirituality and trust. These are essential aspects of holistic care. The following is a selection of the students’ comments, with discussion, in relation to each theme.
Perceptions of caring ‘‘. . .being (in) a different setting and getting to know the VIP a bit better and seeing past the illness and seeing the person.’’ ‘‘It has definitely opened my eyes to being a 24 hour carer.’’ ‘‘It has made me open my eyes to know how important it actually is to help.’’ ‘‘In Lourdes it was pretty much one-to-one care so if somebody needed something there was no excuse. There wasn’t the same excuses or reasons for not being able to do something.’’
A. Purdie et al. ‘‘If you are on a ward you don’t have the same time to spend with the patients.’’ ‘‘It made me realise that it’s not just about giving injections.’’ These comments infer that the students appear to have developed insight into the nature of caring. This was particularly encouraging to the project team who identified with the work of McCance (2005, p. 34), who suggests that ‘‘Some nurses can be seen to be turning their backs on their raison d’e ˆtre. . ..’’ According to McCance (2005), becoming a caring nurse and developing caring skills requires the critical attributes of ‘‘respect for persons’’ and ‘‘amount of time’’.
Interpersonal skills ‘‘I didn’t realise how much I needed my own space.’’ ‘‘Tiring, exhausting, demanding.’’ ‘‘I don’t think you’ll ever get the opportunity like that ever again on a placement to develop communication skills.’’ ‘‘I think it was always on my mind to build up on our skills and the communication side of it. I think that side of it was quite challenging because you don’t have a senior standing over you telling you what you are doing next.’’ ‘‘I think I’m more relaxed in myself. Much more confident.’’ ‘‘I just learned so much just sitting listening. . .’’ Listening is another skill that is key to nursing practice in nurse–patient interaction (Shattell, 2004). Frequent statements were made not just in relation to listening to the VIPs, but also listening to advice from other support staff, particularly when the students felt tired and overwhelmed by the whole experience.
Spirituality ‘‘It was just so peaceful, so tranquil that you couldn’t explain it to anybody.’’ ‘‘The whole thing was just overwhelming.’’ ‘‘I have heard all about Lourdes and expected it to be people down on their knees praying all the time.’’ However, the students’ discussions suggested that the spiritual aspect was much more than this. ‘‘I learned something from everybody even if it wasn’t about nursing and I learned a lot about myself.’’
Student nurse placements take a new direction As previously discussed spirituality does not just address religious beliefs but can refer to the joining together of such concepts as ‘social, physical and emotional dimensions’ which are inherent in a persons’ individuality (Smith, 2002).
Trust Students, as expected, spent a lot of ‘quality’ time with VIPs. Discussion of such interactions was not superficial or task-orientated. Anecdotal evidence suggests this occurs in other settings. The interactions appeared to be profound and meaningful to the students and in which the VIPs became friends. The environment of this unique clinical placement shaped these interactions as the following suggests: ‘‘It was a brilliant honour and privilege to go and represent your University.’’ ‘‘. . .you don’t have a senior standing over you telling you what you are doing next.’’ ‘‘. . .. . . I think the patient needs to trust and know that you are there to look after them. Just sitting down and maybe talking about their family, you get more information out of them.’’ ‘‘I felt privileged being trusted with that person.’’ ‘‘I felt really humbled at one point with the VIP. . .. It was them thanking me for being there because she had laughed and she hadn’t laughed for weeks and I found that really humbling because I was only going about my business. . ..’’ This suggests that this student had felt the confidence to use humour and so ‘‘appeared more human, sensitive and trustworthy to patients’’ (Hyrkas, 2005, p. 221). It may be that such a placement enabled the student to have the confidence to be humourous and the intensity of such a placement facilitated this by creating a closer sense of rapport and deeper relationship than would normally have been possible. ‘‘. . .it’s just that bit different a relationship you have got with them because they are not patients they become friends.’’ As Downie and Calman (2003) suggest to become part of the patient’s life and to be told about his problems, is a privilege. These comments imply that the student is identifying with two of the key aspects of a therapeutic relationship: respect and trust (Chambers, 2005). The students emphasized the feeling that there was time to develop trusting and meaningful relationships. As indicated by Henderson et al., (2007) a close relationship in the acute care setting is limited due to ‘‘increased workloads and reduced staffing levels’’. It also
319 seemed that the students welcomed being trusted to provide one-to-one care and, in so doing developed more meaningful relationships. Being trusted seemed to boost their own confidence. To achieve holistic care requires developing meaningful interaction between individuals, ‘Across’ provided this in abundance. Rather than depersonalise, ‘Across’ personalised nursing care through its unique environment. This important issue was raised by the students who all described the positive ‘relationships’ which developed between themselves and the VIPs. As suggested by McDade (2005) from a spiritual perspective, these relationships were much more than simply interacting, but incorporated ‘sharing their time and themselves’. There is no doubt that caring is a central aspect of nursing (Kyle, 1995). Many definitions exist. These can be complex, but all have many key factors in common, e.g. establishing relationships based on trust and respect, and the importance of listening. Trust was discussed several times by students and was viewed as important to promote a therapeutic relationship as well as being trusted with the care of someone else. Likewise, interpersonal skills stood out as a central theme. An existing model of caring, from the perspective of student nurses, developed by Wilkes and Wallis (1997) located communication as the link between core actions of caring. These actions were: comfort, competence, commitment, confidence, courage and conscience, with compassion as the core. Wilkes and Wallis (1997) suggest that possible constraints within student learning environments, including lower nurse to patient ratios and lack of time, may affect these actions. However, the limited evidence from this evaluative suggests that the ‘Across’ environment encourages rather than hinders, the development of such caring attributes. More evidence is needed to support this and one suggestion would be to incorporate such a model in future research.
Conclusion In conclusion, ‘Across’ provided a clinical learning environment in which meaningful relationships could be developed. This was possible because of the increased carer to VIP ratios, the increased time available and the compassion shown by all involved in this charity. This environment promoted the development of student nurses understanding of holistic care and, in particular, the development of the perception of caring and some of the key aspects that this entails. It is the NMC’s (2006)
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intentions to increase the emphasis on caring and compassionate skills for pre-registration students. This placement seems to be one way of achieving this. In addition, delivering nursing care in this setting boosted the students’ confidence. On the basis of this evaluative study, similar innovative placements should be encouraged.
Acknowledgements We would like to give particular thanks to the students who participated in the study. In addition, special thanks are due to Margaret McElroy, Yvonne Pearson, Dr. Alan Green and all who helped facilitate the Across placements for student nurses. Special thanks are due also to colleagues, Library Staff from the UWS and all others who helped to raise funds and made these placements possible.
References Across, 2006. ACROSS.. Castledine, G., 2001. Is nursing losing its holistic focus?. British Journal of Nursing 10 (16) 1091. Chambers, M., 2005. A concept analysis of therapeutic relationships. In: Cutcliffe, J.R., McKenna, H.P. (Eds.), The Essential Concepts of Nursing: Building Blocks for Practice. Elsevier, Edinburgh, pp. 301–316. Corti, L., 1993. Using diaries in social research. Social Research Update. University of Surrey, Guildford. Downie, R.S., Calman, C., 2003. Healthy Respect: Ethics in Health Care, second ed. Oxford University Press, Oxford. Driscoll, J., 1994. Reflective practice for practise. Senior Nurse 13 (7), 47–50. ENB, DoH, 2001. Placements in focus. Guidance for education in practice for health care professions. ENB and DoH, London. Franz, J., Ferreira, H., Loh, H., Pendergast, D., Service, M., Stormont, D., Taylor, I., Thambiratnam, D., Williamson, B., 1996. Students’ and Lecturers’ conceptions of learning in context: an interdisciplinary study. Teaching in Higher Education 1 (3), 325–339. Goodman, C., Evans, C., 2006. Using focus groups. In: Gerrish, K., Lacey, A. (Eds.), The Research Process in Nursing. Blackwell Publishing, Oxford, pp. 353–366.
Henderson, A., Van Eps, M.A., Pearson, K., James, C., Henderson, P., Osborne, Y., 2007. ‘Caring for’ behaviours that indicate to patients that nurses ‘care about’ them. Journal of Advanced Nursing 60 (2), 146–153. Holland, K., Jenkins, J., Solomon, J., Whittam, S. (Eds.), 2003. Applying the Roper–Logan–Tierney Model in Practice. Churchill Livingstone, Edinburgh. Hyrkas, K., 2005. Taking ‘humour’ seriously – an analysis of the concept ‘humour’. In: Cutcliffe, J.R., McKenna, H.P. (Eds.), The Essential Concepts of Nursing: Building Blocks for Practice. Elsevier, Edinburgh, pp. 213–228. Kyle, T.V., 1995. The concept of caring: a review of the literature. The Journal of Advanced Nursing 21, 506–514. McCance, T., 2005. A concept analysis of comfort. In: Cutcliffe, J.R., McKenna, H.P. (Eds.), The Essential Concepts of Nursing: Building Blocks for Practice. Elsevier, Edinburgh, pp. 33–50. McDade, K.J., 2005. The Human Spirit in Health and Illness: A Handbook for Carers. APS Publishing, Salisbury. NHS Education for Scotland, 2002. The Development of Quality Standards for Practice Placements. Nursing and Midwifery Council, 2002. Practitioner–client relationships and the prevention of abuse. NMC, London. Nursing and Midwifery Council, 2004. The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. NMC, London. Nursing and Midwifery Council, 2006. Advance Information to Programme Providers Regarding the NMC’S Intention to Introduce Essential Skills Clusters for Pre-Registration Nursing Programmes. NMC Circular 35/2006. Parahoo, K., 2006. Nursing Research Principles, Process and Issues, second ed. Palgrave MacMillan Hampshire. Robson, C., 2002. Real World Research, second ed. Blackwell Publishers, Oxford. Roper, N., Logan, WW., Tierney, AJ., 2000. The Roper, Logan Tierney Model of Nursing. Churchill Livingstone, Edinburgh. Shattell, M., 2004. Nurse–patient interaction: a review of the literature. Journal of Clinical Nursing 13 (6), 714–722. Smith, M.E., 2002. Spiritual issues. In: Lugton, J., Kindlen, M. (Eds.), Palliative Care: The Nursing Role. Churchill Livingstone, Edinburgh, pp. 115–139. Taber, S.M., 2003. Managing risk in a Health Care Organization. In: Hinchliff, S., Norman, S., Schober, J. (Eds.), Nursing Practice and Health Care, fourth ed. Hodder Arnold, London, pp. 345–368. Wensley, M., 1995. Spirituality in nursing. St Vincent’s Nursing Monograph: Selected Works. Sydney: Nursing Monograph Series (Online). Wilkes, L.M., Wallis, M.C., 1997. A model of professional nurse caring: nursing students’ experience. Journal of Advanced Nursing 27, 582–589.
Available online at www.sciencedirect.com
Nurse Education in Practice www.elsevier.com/nepr
Student nurse placements take a new direction Ann Purdie *, Louisa Sheward 1, Elaine Gifford
2
School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, United Kingdom Accepted 4 January 2008
KEYWORDS
Summary This article explores the experiences of the first ever student nurses in the United Kingdom to participate in an innovative two-week clinical placement with the charity ‘Across’. This charity takes seriously ill and disabled persons, referred to as VIPs, to Lourdes and back. The ethos of this partnership was the belief that senior students would benefit from refreshing or further developing their holistic caring skills. Six third year students were selected and were asked to keep a reflective diary and attend a focus group to discuss their experiences. The focus group was audiotaped, transcribed and analysed. Four key themes emerged: Perceptions of caring, interpersonal skills, spirituality and trust. These are essential aspects of holistic care. Delivering nursing care in this setting boosted the students’ confidence, developed their interpersonal skills, particularly listening, and personalised nursing care so that the student–VIP relationships were much more than simple interactions. In conclusion, the opportunities to enhance the student’s holistic caring skills exceeded expectations. Pre-registration programmes should consider such placements to further develop such skills. c 2008 Elsevier Ltd. All rights reserved.
Holistic caring skills; Student nurses; Innovative placement; Partnership
Introduction In 2004, the University of the West of Scotland (UWS) (formerly University of Paisley) School of Health, Nursing and Midwifery entered into partnership with the charity known as ‘Across’ (formerly Across Jumbulance) to develop an innovative clinical placement, the first of its kind in the United Kingdom for third year student nurses * Corresponding author. Tel.: +44 0141 849 4121. E-mail address: [email protected]. 1 Tel.: +44 0141 848 3823. 2 Tel.: +44 0141 849 4325.
(adult branch). There is a need for quality and diverse student placements to ensure student nurses are exposed to a variety of healthcare experiences (NHS Education for Scotland, 2002). According to the English National Board (ENB) and Department of Health (DoH) (2001), expansion of practice experience for student nurses is required due to the reduction in acute hospital patient numbers and the move towards increased care within the community (NHS Education for Scotland, 2002). Both ENB, DoH and NHS Education for Scotland purport working in partnership with voluntary/charitable organisations. With this in mind the UWS School of Health, Nursing and Midwifery approached the
1471-5953/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2008.01.001
316 ‘Across’ charity in order to develop a new learning environment. ‘Across’ is a charity which takes seriously ill and disabled persons, referred to as VIPs, to Lourdes and back on a purpose built coach (Across, 2006). The coach has ambulance status and is fitted with trolley beds, toilet, fitted kitchen, equipment, medical supplies and lift. Ten VIPs and 14 support staff travel together. The support staff consists of registered nurses, helpers, a doctor and a chaplain. During the placements student nurses replace two of the helpers and become part of the support team. Each trip and hence each placement for the student lasts 10 days with 8 days spent in an adapted hotel. The hotel has hospital beds, hoists and other equipment available. The programme for the students, during the placement, includes assisting VIPs and carrying out ‘care’ duties in relation to activities of living (Roper et al., 2000) all under the direction of a mentor. This article aims to describe the planning involved in developing this clinical placement with ‘Across’ and to report on the findings of the evaluation of students’ experiences. The article also contains practical advice for those wishing to develop a similar placement.
Background to the ‘Across’ placement Entering into a partnership with a charitable organisation in this unique setting was refreshing and challenging. It was anticipated that this placement had the potential to provide opportunities for student nurses to participate in holistic care unlike any within the National Health Service (NHS) environment, particularly in relation to developing interpersonal skills and spiritual care. Although nurses strive to provide holistic care, it is not always easy. Holistic care encompasses meeting physical, social, emotional and spiritual needs. Spiritual care, in particular, is difficult to provide for many reasons: the focus on physical needs, low nurse to patient ratios and acute patient illness (Wensley, 1995). Similar issues are raised by McDade, (2005, p. 287) who further expands on this by suggesting a number of other problems including: ‘ignorance, prejudices, misunderstandings and wrong assumptions’. Therefore to achieve holistic care requires the development of relationships based on a multitude of factors, such as trust, confidence and enthusiasm (Castledine, 2001). These are attributes all nurses aspire to but which, for the reasons highlighted above, are sometimes difficult to achieve. Likewise, these are essential elements required for spiritual care
A. Purdie et al. (McDade, 2005). McDade also recognises that the ‘patient role’ and the healthcare system can depersonalise individuals and even cause ‘dispiritedness’. Furthermore, he reports that the spiritual dimension of nursing is hard to define and even more difficult to put into practice. It is reported as much more than recognising religious beliefs, and varies from person to person. Hence, the ethos of this partnership with ‘Across’ was the belief that senior students would benefit from refreshing or further developing their skills in this unique 24hour placement. Nevertheless, it is important that students ‘maintain appropriate professional boundaries’ (Nursing and Midwifery Council (NMC), 2004, 2002) ‘‘to interact safely in a therapeutic relationship, which is based on meeting the client’s needs’’ (Taber, 2003, p. 360) and this was reinforced to students prior to departure. As this was the first time such a placement had been developed, a great deal of planning was initially required which took up to one year to complete. Much discussion took place between the project team, the ‘Across’ clinical and fundraising co-coordinators and with key members of the School of Health, Nursing and Midwifery (adult branch). It was agreed at the start of the planning process that it was good practice to carry out an in-depth evaluation of this innovative placement to assess its effectiveness (Robson, 2002). This project was designed to evaluate the experiences of these first students to have a placement with this charity. In order to do this, the project team felt it was important to use a ‘student focused’ approach. The findings would help to more fully understand if this type of placement was an effective and appropriate placement to develop students’ core holistic skills and, therefore, help further develop the pre-registration curriculum. It was also anticipated that students might find the student-focused evaluative approach empowering and confidence boosting. As part of the preparations for the placement, members of the ‘Across’ team came to the university to speak to look at the students. This included a chance to talk to some of the helpers, the co-ordinators and to the purpose built ambulance itself. Subsequently, a named liaison lecturer was appointed from the team and an educational audit carried out. It was essential to ensure that this was going to be a safe, appropriate, learning environment and that the correct policies and procedures were in place. Some examples of the information required were: expertise and experience of the registered nursing staff, other members of the multidisciplinary team who could act as a learning resource, philosophy of care, learning environment opportunities and professional documentation that
Student nurse placements take a new direction was in place to enhance learning, e.g. health and safety regulations and NMC guidelines. Supervision for the students whilst on placement was essential. Students were placed in teams where the support staff included a lead nurse who had attended a mentorship programme. The lead nurse also provided emotional and psychological support as it was recognised that this could be a stressful placement for the students as they were away from home and away from the support of the university. During their time on placement the students were expected to meet learning outcomes for a specialist placement within the School. These were in relation to professional conduct. Fundraising was also an important part of the role of the project team to help cover the fairly substantial costs of the placements. Social inclusion is at the heart of the UWS and for many students funding themselves for such a venture could be difficult. A number of strategies to fundraise were employed, many of these initiated by the students themselves. Early in 2005, the ‘Across’ placement was offered to all third year adult branch students in one of two campuses of the school of nursing. Students were asked to express their interest by writing a 300-word letter of application stating why they should be chosen, why they wanted to go on this placement and what they hoped to gain. Six places were available, although more students applied. These students travelled in pairs during the summer of 2005, providing support for each other. At the commencement of the project, because of indemnity reasons, it was stipulated to the students that their role would be that of helper and not student nurses. Students could not carry out any invasive nursing skills, such as administration of medication or urinary catheterisation. However, students were expected to be involved in delivering ‘essential’ nursing care to VIPs including personal cleansing and dressing, eating and drinking, and assisting with mobility. Initially, when students were introduced to the project, they expressed some concerns regarding their lack of development of technical skills experience on this placement. Discussion with the students facilitated their appreciation of the importance of revisiting and developing essential nursing skills.
Methods Ethical considerations Application for ethical approval to carry out an evaluative study of the experiences of students
317 whilst on the placement was submitted to the University Research Ethics Committee. The project was discussed and deemed to be audit. Approval was granted following amendments. All six students who had been selected and agreed to travel with ‘Across’, were informed as a group, both verbally and in writing, the aim of the evaluative project and the methods to be used to collect data. The students were informed of the need to ensure confidentiality of VIP and staff information at all times during the evaluative process. The project team were lecturers known to the students. It was essential to ensure students were aware that participation in the evaluation was entirely voluntary and that data would be reported anonymously. Distress can occur in all types of research (Parahoo, 2006). The facilitators anticipated that recalling and discussing the placement could bring back emotive experiences. It was therefore explained to the students that they could at any time choose to decline revealing sensitive information that may cause them anxiety. The students could discuss any anxieties on a one-to-one basis if required. All students agreed to participate in the evaluation. All students signed a consent form.
Data collection The six students were asked to keep a written diary of their experiences during the placement. They were encouraged to log relevant issues, incidents and activities carried out at regular intervals, whilst maintaining confidentiality at all times. Instructions on the completion of the diary were provided (Corti, 1993). The diary contained an insert on the definition of holistic care. This asked students to consider the physical, social, psychological and spiritual needs of an individual and to record activities/events in relation to each of these aspects of care. A diagram of the Roper, Logan and Tierney model of nursing care was also included as an overall framework to help students think about holistic care (Holland et al., 2003). In addition, a copy of Driscoll’s (1994) model of reflection was included and recommended as a framework for reflection. Students were asked to complete their diary at least twice a day. The diary remained private and was not read by the project team. The primary reason for the diary was that students could reread and refresh their memories prior to the focus group. It was also hoped the students would develop their reflective skills through doing so.
318 Following the placements, all six students were invited to a focus group in September 2005. A focus group was chosen because it was thought to be a supportive environment that would encourage discussion and sharing of their experiences, therefore providing a rich source of data (Goodman and Evans, 2006). This was facilitated by two members of the project team. Open questions were used, which encouraged the students to talk about their experiences. Issues of validity were addressed by preventing one participant dominating the discussion within the focus group and encouraging everyone to speak. The facilitators only intervened to clarify points made and to briefly summarize at the end to ensure validity. The focus group lasted approximately one hour and was audiotaped. Analysis followed Franz et al.’s (1996) five stages of analysis which involved listening to the audiotape several times, transcribing, familiarization with the data and selection and grouping of significant statements. To ensure reliability, all three members of the project team independently selected and grouped statements using colour coding. Subsequently these were discussed and common themes identified. Aspects of validity in relation to the analysis were addressed by concentrating on the relationship between the statements and the context of the discussion, and not concentrating simply on individual words or phrases (Franz et al., 1996).
Findings The focus group provided a rich insight into the student’s experience. Four key themes emerged from the transcript: the perceptions of caring, interpersonal skills, spirituality and trust. These are essential aspects of holistic care. The following is a selection of the students’ comments, with discussion, in relation to each theme.
Perceptions of caring ‘‘. . .being (in) a different setting and getting to know the VIP a bit better and seeing past the illness and seeing the person.’’ ‘‘It has definitely opened my eyes to being a 24 hour carer.’’ ‘‘It has made me open my eyes to know how important it actually is to help.’’ ‘‘In Lourdes it was pretty much one-to-one care so if somebody needed something there was no excuse. There wasn’t the same excuses or reasons for not being able to do something.’’
A. Purdie et al. ‘‘If you are on a ward you don’t have the same time to spend with the patients.’’ ‘‘It made me realise that it’s not just about giving injections.’’ These comments infer that the students appear to have developed insight into the nature of caring. This was particularly encouraging to the project team who identified with the work of McCance (2005, p. 34), who suggests that ‘‘Some nurses can be seen to be turning their backs on their raison d’e ˆtre. . ..’’ According to McCance (2005), becoming a caring nurse and developing caring skills requires the critical attributes of ‘‘respect for persons’’ and ‘‘amount of time’’.
Interpersonal skills ‘‘I didn’t realise how much I needed my own space.’’ ‘‘Tiring, exhausting, demanding.’’ ‘‘I don’t think you’ll ever get the opportunity like that ever again on a placement to develop communication skills.’’ ‘‘I think it was always on my mind to build up on our skills and the communication side of it. I think that side of it was quite challenging because you don’t have a senior standing over you telling you what you are doing next.’’ ‘‘I think I’m more relaxed in myself. Much more confident.’’ ‘‘I just learned so much just sitting listening. . .’’ Listening is another skill that is key to nursing practice in nurse–patient interaction (Shattell, 2004). Frequent statements were made not just in relation to listening to the VIPs, but also listening to advice from other support staff, particularly when the students felt tired and overwhelmed by the whole experience.
Spirituality ‘‘It was just so peaceful, so tranquil that you couldn’t explain it to anybody.’’ ‘‘The whole thing was just overwhelming.’’ ‘‘I have heard all about Lourdes and expected it to be people down on their knees praying all the time.’’ However, the students’ discussions suggested that the spiritual aspect was much more than this. ‘‘I learned something from everybody even if it wasn’t about nursing and I learned a lot about myself.’’
Student nurse placements take a new direction As previously discussed spirituality does not just address religious beliefs but can refer to the joining together of such concepts as ‘social, physical and emotional dimensions’ which are inherent in a persons’ individuality (Smith, 2002).
Trust Students, as expected, spent a lot of ‘quality’ time with VIPs. Discussion of such interactions was not superficial or task-orientated. Anecdotal evidence suggests this occurs in other settings. The interactions appeared to be profound and meaningful to the students and in which the VIPs became friends. The environment of this unique clinical placement shaped these interactions as the following suggests: ‘‘It was a brilliant honour and privilege to go and represent your University.’’ ‘‘. . .you don’t have a senior standing over you telling you what you are doing next.’’ ‘‘. . .. . . I think the patient needs to trust and know that you are there to look after them. Just sitting down and maybe talking about their family, you get more information out of them.’’ ‘‘I felt privileged being trusted with that person.’’ ‘‘I felt really humbled at one point with the VIP. . .. It was them thanking me for being there because she had laughed and she hadn’t laughed for weeks and I found that really humbling because I was only going about my business. . ..’’ This suggests that this student had felt the confidence to use humour and so ‘‘appeared more human, sensitive and trustworthy to patients’’ (Hyrkas, 2005, p. 221). It may be that such a placement enabled the student to have the confidence to be humourous and the intensity of such a placement facilitated this by creating a closer sense of rapport and deeper relationship than would normally have been possible. ‘‘. . .it’s just that bit different a relationship you have got with them because they are not patients they become friends.’’ As Downie and Calman (2003) suggest to become part of the patient’s life and to be told about his problems, is a privilege. These comments imply that the student is identifying with two of the key aspects of a therapeutic relationship: respect and trust (Chambers, 2005). The students emphasized the feeling that there was time to develop trusting and meaningful relationships. As indicated by Henderson et al., (2007) a close relationship in the acute care setting is limited due to ‘‘increased workloads and reduced staffing levels’’. It also
319 seemed that the students welcomed being trusted to provide one-to-one care and, in so doing developed more meaningful relationships. Being trusted seemed to boost their own confidence. To achieve holistic care requires developing meaningful interaction between individuals, ‘Across’ provided this in abundance. Rather than depersonalise, ‘Across’ personalised nursing care through its unique environment. This important issue was raised by the students who all described the positive ‘relationships’ which developed between themselves and the VIPs. As suggested by McDade (2005) from a spiritual perspective, these relationships were much more than simply interacting, but incorporated ‘sharing their time and themselves’. There is no doubt that caring is a central aspect of nursing (Kyle, 1995). Many definitions exist. These can be complex, but all have many key factors in common, e.g. establishing relationships based on trust and respect, and the importance of listening. Trust was discussed several times by students and was viewed as important to promote a therapeutic relationship as well as being trusted with the care of someone else. Likewise, interpersonal skills stood out as a central theme. An existing model of caring, from the perspective of student nurses, developed by Wilkes and Wallis (1997) located communication as the link between core actions of caring. These actions were: comfort, competence, commitment, confidence, courage and conscience, with compassion as the core. Wilkes and Wallis (1997) suggest that possible constraints within student learning environments, including lower nurse to patient ratios and lack of time, may affect these actions. However, the limited evidence from this evaluative suggests that the ‘Across’ environment encourages rather than hinders, the development of such caring attributes. More evidence is needed to support this and one suggestion would be to incorporate such a model in future research.
Conclusion In conclusion, ‘Across’ provided a clinical learning environment in which meaningful relationships could be developed. This was possible because of the increased carer to VIP ratios, the increased time available and the compassion shown by all involved in this charity. This environment promoted the development of student nurses understanding of holistic care and, in particular, the development of the perception of caring and some of the key aspects that this entails. It is the NMC’s (2006)
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intentions to increase the emphasis on caring and compassionate skills for pre-registration students. This placement seems to be one way of achieving this. In addition, delivering nursing care in this setting boosted the students’ confidence. On the basis of this evaluative study, similar innovative placements should be encouraged.
Acknowledgements We would like to give particular thanks to the students who participated in the study. In addition, special thanks are due to Margaret McElroy, Yvonne Pearson, Dr. Alan Green and all who helped facilitate the Across placements for student nurses. Special thanks are due also to colleagues, Library Staff from the UWS and all others who helped to raise funds and made these placements possible.
References Across, 2006. ACROSS.
Henderson, A., Van Eps, M.A., Pearson, K., James, C., Henderson, P., Osborne, Y., 2007. ‘Caring for’ behaviours that indicate to patients that nurses ‘care about’ them. Journal of Advanced Nursing 60 (2), 146–153. Holland, K., Jenkins, J., Solomon, J., Whittam, S. (Eds.), 2003. Applying the Roper–Logan–Tierney Model in Practice. Churchill Livingstone, Edinburgh. Hyrkas, K., 2005. Taking ‘humour’ seriously – an analysis of the concept ‘humour’. In: Cutcliffe, J.R., McKenna, H.P. (Eds.), The Essential Concepts of Nursing: Building Blocks for Practice. Elsevier, Edinburgh, pp. 213–228. Kyle, T.V., 1995. The concept of caring: a review of the literature. The Journal of Advanced Nursing 21, 506–514. McCance, T., 2005. A concept analysis of comfort. In: Cutcliffe, J.R., McKenna, H.P. (Eds.), The Essential Concepts of Nursing: Building Blocks for Practice. Elsevier, Edinburgh, pp. 33–50. McDade, K.J., 2005. The Human Spirit in Health and Illness: A Handbook for Carers. APS Publishing, Salisbury. NHS Education for Scotland, 2002. The Development of Quality Standards for Practice Placements. Nursing and Midwifery Council, 2002. Practitioner–client relationships and the prevention of abuse. NMC, London. Nursing and Midwifery Council, 2004. The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. NMC, London. Nursing and Midwifery Council, 2006. Advance Information to Programme Providers Regarding the NMC’S Intention to Introduce Essential Skills Clusters for Pre-Registration Nursing Programmes. NMC Circular 35/2006. Parahoo, K., 2006. Nursing Research Principles, Process and Issues, second ed. Palgrave MacMillan Hampshire. Robson, C., 2002. Real World Research, second ed. Blackwell Publishers, Oxford. Roper, N., Logan, WW., Tierney, AJ., 2000. The Roper, Logan Tierney Model of Nursing. Churchill Livingstone, Edinburgh. Shattell, M., 2004. Nurse–patient interaction: a review of the literature. Journal of Clinical Nursing 13 (6), 714–722. Smith, M.E., 2002. Spiritual issues. In: Lugton, J., Kindlen, M. (Eds.), Palliative Care: The Nursing Role. Churchill Livingstone, Edinburgh, pp. 115–139. Taber, S.M., 2003. Managing risk in a Health Care Organization. In: Hinchliff, S., Norman, S., Schober, J. (Eds.), Nursing Practice and Health Care, fourth ed. Hodder Arnold, London, pp. 345–368. Wensley, M., 1995. Spirituality in nursing. St Vincent’s Nursing Monograph: Selected Works. Sydney: Nursing Monograph Series (Online). Wilkes, L.M., Wallis, M.C., 1997. A model of professional nurse caring: nursing students’ experience. Journal of Advanced Nursing 27, 582–589.
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