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The challenges and conflictsof facilitating learning in practice: the experiences of two clinical nurse educators
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The challenges and conflicts of facilitating learning in practice: the experiences of two clinical nurse educators Anne-Marie Brennan and Ruth Hutt
Anne-Marie Brennan RN, DipHE, Practice Nurse, Morden Hill Practice, 21 Morden Hill, Lewisham, SE13 7NN, UK. (Formerly Return to Practice Support Nurse.) Ruth Hutt RN, DipHE, MSc, Public Health Specialist Trainee, Croydon Health Authority, Knollys House, 17 Addiscombe Road, Croydon, CR0 6SR, UK. (Formerly Education Development Nurse.) (Requests for offprints to RH) Manuscript accepted: 9 August 2001
This is a descriptive paper discussing the experiences of two clinical educators in practice. It highlights some of the practice issues around accountability, advocacy and role conflicts in clinical teaching roles. The issue of training nurses fit for practice given the recommendations of Fitness for Practice (UKCC 1999) and Making a Difference (Department of Health 1999) is discussed within the context of the reality of the clinical environment. The number of learners in the clinical area has increased in the last few years, and will continue to do so with the increase in nurses promised by the NHS Plan and new initiatives to attract nurses back into the profession. As a result of this the clinical environment, already stretched with service demands, requires additional support to facilitate the development of learners. Recommendations are made for the future of generic practice facilitative roles in the light of the current debate to get nurse educators back into practice. © 2001 Harcourt Publishers Ltd
Introduction Changes in nurse education in the United Kingdom (UK), and an increase in numbers of learners in the clinical environment, have meant that we have had to look at new and innovative ways to support both learner and practitioner to ensure that the clinical placement is a positive learning experience. The issue of developing ‘fit for purpose’ nurses has been high on the agenda of the nursing profession for nearly a decade. Within our local trust two posts were created with the assistance of funding from the local education and training consortium to develop clinical nurse educators. The education development nurse role was to set up a rotational programme for newly qualified nurses and provide practical clinical support at a ward level for these nurses and their preceptors.
© 2001 Harcourt Publishers Ltd doi:10.1054/nepr.2001.0031, available online at http://www.idealibrary.com on
The return to practice support nurse worked primarily with nurses undertaking the return to practice course. This was a joint appointment between two acute hospital trusts. Much is written in the literature about the theory practice gap, and the roles of joint appointments between higher education institutions (HEIs) and the service sector in bridging this divide (Williamson & Webb 2001). There is, however, very little written about the day-to-day clinical experience of these types of roles. In an effort to redress that balance, we have recorded some of issues that have been pertinent to us in our roles. This offers both the service sector and HEIs an opportunity to look at the whole picture, and enables them to re-think and re-examine where the interface between theory and practice learning belongs. We are seeing increasing political will and
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pressure to enable nurse educators to claim back their practice roles with a plethora of national documents, but to date this appears to have had little impact ‘on the ground.’ There needs to be considerable investment both financially and in valuing practice for this to become a reality and have an impact on practice based learning.
Background Over the last 10 years, there has been much commentary on the theory practice gap, and the impact of Project 2000 on the clinical skills of registered nurses. Fitness for Practice (UKCC 1999) has highlighted some of these issues, and we are now seeing a return to competency based learning outcomes. One of the assumptions made by the change back to clinical assessment of competency is that we have the capacity at a ward level to assess, coach and challenge students in the clinical area. In our experience of facilitating learners and trained nurses in practice this has not always been the case, both in terms of numbers of staff and appropriate skill mix. There has been a move over recent years to encourage HEI and trusts to work in partnership to ensure that learning in theory and practice are not mutually exclusive (Macleod Clark 1998). Indeed, there is strong political will behind this idea in both Fitness for Practice (UKCC 1999) and Making a Difference (DoH 1999): The number of jointly funded posts between service and education should be increased. We support the development of exchanges and secondments between HEIs and health services. (UKCC 1999, p. 46) We will be setting clear targets for boosting teacher support for students on placements … . We intend to create more opportunities for experienced staff to combine teaching and patient care so that students can acquire better practical skills. (DoH 1999, p. 27) There needs to be financial commitment from all sectors to enable these appointments to last beyond the existing post holder. With conflicting demands within finite resources to create nationally driven appointments such as
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consultant nurses and leads for cancer, coronary heart disease and clinical governance, lecturer practitioner type posts have had lower priority. It is impractical to suggest that nurse educators, who have been based in higher education for nearly a decade in some cases, should suddenly be able to return to the clinical environment and competently practise. Whilst some may be able to do this, they are probably a distinct minority. In research carried out by Day et al. (1998), lecturers felt that their educational training courses had ill equipped them for their practice role.
Clinical teaching roles In the past, the role of the clinical teacher was developed in an attempt to bridge the gap between theory and practice. Appointees reported discomfort with the lack of clarity of the role, and a feeling that their status was perceived as considerably lower than that of academically based nurse teacher (Owen 1993). Training for the clinical teacher role was discontinued in the mid-1980s. The contemporary role of lecturer practitioner seems to work in many settings (Childs 1995, Lloyd-Jones 1993). Locally, these roles tend to be associated with specialist areas, and are often linked with specialist courses such as critical care, accident and emergency or theatres. Yet the areas experiencing the most problems in terms of student facilitation, preceptorship and mentoring are often general wards. As general areas become increasingly depleted of experienced nursing staff, those remaining have to manage conflicting demands, increasing rate of bed usage, increasing patient dependency, government policy and the politics of an increasingly changing and challenging National Health Service (NHS). This undoubtedly has implications for the students we are training and the newly qualified colleagues we are supporting.
Assessors and learners There are increasing numbers of ‘learners’ in the clinical environment: return to practice nurses, adaptation nurses, health care assistants undertaking NVQs and nursing
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students. In addition to these demands, all newly qualified nurses are meant to have a period of preceptorship, many post registration specialist courses require a practice assessment component and we will soon have nurse cadets in many areas. With diminishing numbers of experienced staff nurses due to recruitment and retention problems, and increasing vacancies at all grades, there has been an impact on the level of clinical support offered to all our learners. This may well be exacerbated in the short term by the new framework for programmes for the preparation of mentors and teachers (ENB & DoH 2001).
Development of local roles At our South-London Trust, two posts were created to address some of these issues. One was the result of direct feedback from student nurses who felt that their practice assessors had often not had the time or motivation to teach and make the most of learning opportunities available. They voted with their feet at the end of their training, which meant a considerable loss for the trust in terms of investment in training. The other was a result of the national Return to Practice campaign for nurses who had been out of nursing for some time and needed a ‘refresher’ course. Both of these posts were trust-based (one was a joint appointment between two trusts), but with very close collaboration with the local HEI. Both these roles had an education and clinical focus, which also meant working shifts on wards with students and registered nurses. This has highlighted many issues for us around our own accountability and has given us a rare insight into how the educator in practice may work a decade on from losing our last clinical teachers.
Practice roles Interestingly, there is very little reported in published literature of the difficulties and stresses encountered by generic clinical skills teachers such as us. Many of the issues are similar to those reported by Williamson and Webb (2001) in their paper examining the roles of jointly appointed clinical educators. Whilst
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there are practice development nurses across the country who work in clinical settings, our roles were particularly large in that they covered the whole trust (and in the case of the return to practice nurse, two trusts). Both posts were responsible to the Assistant Director of Nursing-Education and Practice Development. It was envisaged at the outset that at least 60% of the education development nurse role would be clinical, and a similar amount for the return to practice support nurse. In reality this had been difficult to sustain for many reasons. Practice development, in our experience, has become everything and anything not currently being done by someone else; so we have been involved in many different (but linked) roles, from recruitment and retention to audit. We have found that the techniques we have developed to support and facilitate our two quite different genres of learners are similar, but with subtle differences. The main differences, we believe, are driven by the fact that the return to practice students are supernumerary, not paid and are on honorary trust contracts, so it is possible to tailor support to their learning needs and their pace of working. It also allows for them to be taken aside from the clinical workload of the area to focus specifically on one area of care, or to give full care to one or two patients. The newly qualified nurses, without student status, have an allocated part of the clinical workload for which they are responsible. This has benefits in that it reflects the real day-to-day conflicts they will have to face, but can be challenging for the facilitator. The challenges of the roles are many and varied, and in the remainder of this paper we aim to give the reader an overview of the conflicts and challenges we have confronted within the clinical element of our roles.
Clinical competence One of the most difficult issues for us has been working in diverse clinical settings, some of which we have never worked in before either as a student or registered nurse. Being new to the trust, we felt initially that we had to prove our own clinical competence (perhaps just to ourselves!) to justify the posts we held. Indeed, there is considerable debate in the literature
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about what a clinically competent nurse educator means (Cave 1994, Forrest 1996, Glen & Clark 1999). Day et al. (1998) distinguish between clinical competence and clinical credibility in their research into the role of the teacher/lecturer in practice. They found clinical competence viewed as the ability to deliver direct patient care, and clinical credibility as implying: … scholarship in the field and the ability to integrate theory and practice in the classroom and in practice settings. (Day et al. 1998) We would argue that both are essential to our roles, and that to not be clinically competent to deliver patient care would put student, educator and patient in an extremely vulnerable position. We both spent a lot of time working on wards to get to know the staff and get a feel for the environment. This paid off in terms of recognition for what we do, developing relationships with the ward staff and also enabled the wards to feel supported rather than just feel additional pressure when new learners were allocated to their areas. In a study analysing the changing role of the nurse teacher, Carlisle et al. (1997) found that one of the stresses faced by clinically based teachers was attempting to teach in a speciality which was not their own. When things start to go wrong it is incredibly difficult and stressful. There is also a tendency for the rest of the ward team to leave you to get on with it, as it is assumed that you know what to do. I have now struggled through a number of incidents on medical wards particularly where a patient deteriorates rapidly and I have felt very deskilled. The simplest problem in such a situation – such as not knowing where urgently needed equipment is stored can exacerbate the stress. (RH) It is often difficult not being part of the nursing team. We do not get to build up the relationships with the multidisciplinary team that permanent members of staff in a ward area have, and there is a danger that we become unsupported and isolated. We find that in sharing issues of concern between ourselves
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we both gain support. Also accessing regular, formalized clinical supervision helps us to map, analyse and resolve our concerns.
Accountability We are becoming increasingly aware of our own accountability, and although we would rarely document care, as this would be the learners role, we have become more conscious of the need to make our own notes at times and are rigorous in checking our students’ documentation. On a number of occasions, when arriving on a ward to work with students, we have found that we are the most experienced and senior person on duty, either due to staff shortage or sickness. This can give rise to situations which cause conflict with our facilitative remit. As accountable practitioners our own, supernumerary status is no protection. On one recent occasion due to nonappearance of two agency nurses I felt for the sake of patients safety my student and I needed to take patients other than those whose care would offer the student the optimum learning experience (at least until other help could be found). On another occasion a bank nurse who had been involved in a road traffic accident the previous day began to vomit in the sluice. The nurse in charge (a harassed, frantically busy E grade) did not appear to recognize the potential seriousness of the situation, so I found myself supporting her in managing the predicament leaving my student unsupervised. (A-MB) These are highly stressful roles clinically; an issue we perhaps underestimated when we took up our posts, and an issue we found was not represented in published literature. We are the clinical ‘Jacks of all trades, masters of none’.
Organization structure implications It has been difficult at times to encourage staff to participate in facilitating learners. All nurses within the Trust are professionally accountable to the Director of Nursing, but are directly managed within a clinical directorate structure. As we do not fit within the clinical directorate
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structures, it has at times been politically difficult to instigate and sustain change, and to get ward staff on board to work on some of the issues we raise. Without support at all levels, from service directors to ward sister, this is virtually impossible. We rely mainly on goodwill to support return to practice students through placement. The isolation and powerlessness of such roles has been recognized since the days of the clinical teacher (Smyth 1988). Vaughan (1990), in discussing the problems of registered clinical nurse teachers, highlights difficulties in broaching the theory practice gap. Since the teacher had no control over what was taught in theory or what was done in practice, the task was impossible. We too experience a constant balancing act, to be realistic about what is achievable with the given resources, whilst instilling in ward staff the concepts of clinical governance, patient advocacy and professional accountability. The return to practice nurses are returning to a new ‘rule book’; we do not lift patients, we manage risk, where cost appears to have taken priority over quality of service. We preach evidence based practice, but lack the resources, judgement and at times expertise to implement it. As clinically based educators, we have a responsibility to deliver the agenda, but are impotent in our political no man’s land to influence what actually happens. To some extent we rely on those same concepts of clinical governance: risk management, professional regulation, continuing professional development, to safeguard us in the clinical environment where we work.
Managing and challenging poor performance and practice In a situation where a student is failing to meet the desired competencies, our collaboration with the ward based practice facilitator enables the student assessment to be managed in an effective and fair manner. In the literature we find considerable reference to the phenomenon of students passing assessments when they demonstrate unsafe practice because their assessor is not skilled, experienced or committed enough to address the student’s failing (Duke
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1996). In a questionnaire sent to all ward based practice facilitators in the hospital, 17% said they had passed a student when they had felt unsure they were meeting the required standard. Interestingly, students are reluctant to talk about problems they experience on clinical placements for fear of failing, when the reality is that this is a very rare occurrence. It is far easier to pass a student than to fail a student. As objective, clinically competent ‘outsiders’ with direct first hand experience of the issues involved in assessment, we are able to assist clinical staff in reaching an impartial, just outcome. This is supported by Forrest et al. (1996). Having the skill and ability to address poor or inadequate practice is an essential requirement so that practice is challenged and learning maintained. Challenging poor practice is no less difficult for us, but our role forces us to do something about it. This is extremely difficult without management support. Similarly, witnessing poor or questionable practice in an area where we are supporting a student can be difficult to deal with. On one occasion I witnessed an elderly confused gentleman with a naso-gastric feed in progress. His hands were bandaged. On questioning the ward manager I was told it was the only way he could be prevented from pulling the tube out. I asked about sedation or insertion of a gastrostomy feeding tube and was told neither was appropriate at present. On questioning the doctor during the ward round my concern was dismissed as a nursing issue. I felt very uncomfortable about this situation, which was obviously difficult to manage, but possibly needed more thought and debate from within the multi-disciplinary team. (A-MB) Resolving and working through situations like this in real time, using an action learning approach, offers opportunities to allow the student to probe the issues and develop an advocacy role with the support of a mentor. The role of clinical supervision in supporting the educator is equally important so as to constantly question and challenge how we react, make decisions and interact in clinical settings.
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Newly qualified nurses The focus for the education development nurse role is on newly qualified nurses, where obtaining placements is relatively easy due to the staffing problems we experience within London. However, ensuring they have proper preceptorship is more difficult and in many cases this is still not occurring. Many nurses find themselves in a bay with six to 12 acutely ill patients very soon after qualifying, with minimal support. One of the most valuable parts of the role is providing them with a sounding board and giving them the opportunity to ask the questions as they arise in the course of a shift. It also enables us to do things together such as referring to other members of the multi-disciplinary team, assessing a wound and choosing a dressing or supervising their first catheterization; while ward staff tended to be more likely to do it themselves because it was quicker. The value in not being part of the ward team came as a result of the learner having more confidence to ask questions, and challenge practice without fear of causing friction as they tried to settle into their new ward. It also offered the opportunity to challenge them on their own practice and pick up mistakes and errors without exposing them to the team. This could be very frightening at times. In some areas they were doing drug rounds on their own within the first week of being on the wards. This was alarming as many had only had very limited experience as students. In one incident I found a nurse drawing up mls instead of mgs of a solution, another nurse asked if they could use frusemide instead of co-amilfruse. This was quite worrying and leads to speculation about what may have happened had there been no one there to ask (which in reality would have been the case). There is very little ward level supervision for students much less qualified nurses. How far through your career could you progress continuously giving the wrong tablet, or the wrong amount of medication? (RH) These particular incidents led to guidelines for all ward managers regarding newly qualified
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nurses administering drugs alone and pharmacy are also now invited to the induction week run for newly qualified nurses on the rotation programme.
Reflection as learning in practice Practically managing real life situations and reflecting back afterwards also enabled nurses to stop and think about what was going on around them. Talking them through managing a patient in chest pain with three infusions going is a much better learning experience than hearing about it on a study day. We enable them to manage the situation, but support them and offer guidance as they require it. The downside to this is being continuously aware that if we allow the student to work to their own timescale in picking up a subtle deterioration in the patient’s condition we could be endangering the patient’s safety or comfort. The problem is in knowing how far to let them manage the situation before intervening, aware that next time they would probably be on their own.
Advocacy It is often when nurses we are working with are discussing a patients’ care with medical staff that we find it hardest to be both learner and patient advocate. As an experienced nurse challenging a medical decision, or making suggestions for changes in treatment is often an important component of patient advocacy but it is often hard to do this without undermining the learner. It is sometimes necessary to remind oneself of ‘where they are’ in their career and that the confidence and competence to take control of situations comes through experiential learning. Role modelling in these situations becomes a powerful learning tool for the student.
Guests in the clinical area As ‘visitors’ we often come in blind to clinical situations. Our knowledge of the patient is based on the quality of handover and the accuracy of the nursing notes, which are variable. Lack of, or incorrect, information
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can lead to us administering inappropriate, ineffective or at worst dangerous care. On one occasion at handover we were not informed that a patient was suspected of having multi-drug resistant tuberculosis. It was only after the student had responded to the nurse call bell in the patient’s room that I noticed masks and protective wear on a trolley outside the room and began to ask questions. (A-MB) In addition, we enter the situation having no relationship with the patient. We then have a short time to build a rapport and attempt to secure the patient’s and sometimes their relative’s trust before we say goodbye at the end of the shift and begin again on another ward with another student and another group of patients the following day. In some ways it is rather like working permanent agency shifts, being in a different clinical environment every day. However there, the similarity ends. Facilitating a student on a one-to-one level is very intensive work. Teaching as we work, constantly pressing the student to prioritize and re-prioritize the care they deliver, being aware of what we need to achieve, the time constraints we have and being continuously aware of patient safety and comfort. It is difficult to feel clinically competent in situations that are new, or are long distant memories. It becomes increasingly hard to move from the classroom and the office, back into the real world of clinical practice. It is rare to meet a specialist nurse or nurse educator who would swap places with her ward-based colleague, but as Jarvis (1992) argued; Nurse teachers can not keep up with practice unless they are in practice.
Criteria for success Key to the success of these posts is recent clinical practice. Ideally these sorts of roles make good 6–9 month secondments for nurses interested in education and practice development, but wanting to stay in practice. There is potential for more impact if the posts are based within a limited area, over 2–4 wards. It is also vital that anyone in these type
© 2001 Harcourt Publishers Ltd
of roles has recent experience of working with students and assessing nurses in practice. An understanding of current training programmes and what is expected in terms of clinical competency, by the individual, the organization and the local HEI, is essential to the success of creating nurses fit for practice. Clinical supervision offers an excellent mechanism for supporting the post holder, and ensuring they are challenged on aspects of their own practice.
Future recommendations Nurse education is changing and we must change with it, but new skills are needed and the value of clinical teaching re-established. There has been a feeling amongst practitioners that academic qualifications are valued over clinical expertise. The fate of the English National Board Higher Award is perhaps an illustration of this (NHSE 1998). The idea that practice skills are taught by practice staff is good in theory, but in reality often leaves the most junior inexperienced nurses as the teachers of clinical skills (Clifford 1994). Ideally, all ward establishments should have education built into their staffing with carefully selected clinically competent appointees who are also well versed in the issues around nurse education and are professionally up-to-date. This team member could then ensure practice assessors are adequately prepared for and function well within their role. Recommendation 29 from Fitness for Practice (UKCC 1999) states: Funding to support learning in practice should be reviewed to take account of the cost of mentoring and assessment by practice staff and the cost of lecturers having regular contact with practice. They may formulate teaching programmes and act as liaison between the clinical areas and the contracted HEI. Nurses in practice need to regain control of nurse education, and begin to take responsibility for what nurses are able to do in practice as it is they that should be imparting the practice skills. There is still a long way to go, but with the support and commitment of the new confederations, HEIs and service providers we can re-equip our nurses in practice to be facilitators of practice.
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It is easy to lose sight of the fact that 50% of the pre-registration nurse education programme is still practice based.
Conclusion We hope to have provided some debate and discussion through our experiences, and are keen to see the recommendations from Fitness for Practice (UKCC 1999) and Making a Difference (DoH 1999) become a reality at a clinical level. Nurse education continues to evolve and we need to continuously re-emphasize that nursing is a practice based profession and that the practice based learning component is fundamental to the art and science of nursing. References Carlisle C et al. 1997 The clinical role of nurse teachers within a project 2000 course framework. Journal of Advanced Nursing 25:386–395 Cave I 1994 Nurse teachers in higher education – without clinical competence do they have a future? Nurse Education Today 14:394–399 Childs S 1995 Promoting the practice. Nursing Standard 9(36):51 Clifford C 1994 Assessment of clinical practice and the role of nurse teacher. Nurse Education Today 14(4):272–279 Day C, Fraser D, Mallik M et al. 1998 The role of the teacher/lecturer in practice. ENB Research Highlights, May 1998
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Department of Health 1999 Making a difference. Strengthening the nursing, midwifery and health visiting contribution to health and healthcare. Department of Health, London Duke M 1996 Clinical evaluation – difficulties experienced by sessional clinical teachers of nursing: a qualitative study. Journal of Advanced Nursing 23:408–414 English National Board and Department of Health 2001 Preparation of mentors and teachers. A new framework of guidance. English National Board, London Forrest S, Brown N, Pollock L 1996 The clinical role of the nurse teacher: an exploratory study of the nurse teachers’ present and ideal role in the clinical area. Journal of Advanced Nursing 24:1257–1264 Glen S, Clark A 1999 Nurse education; a skillmix for the future. Nurse Education Today 19:12–19 NHS Executive 1998 Integrating theory and practice in nursing. NHSE, London Jarvis P 1992 Theory and practice and the preparation of teachers of nursing. Nurse Education Today 12:258–265 Lloyd Jones N 1993 The lecturer-practitioner role and the development of intensive care in nursing practice. Intensive and Critical Care Nursing 9:232–236 Macleod Clark J 1998 Education for the future. Nursing Management 5:14–17 Owen S 1993 Identifying a role for the nurse teacher in the clinical area. Journal of Advanced Nursing 18:816–825 Smyth T 1998 Marginality and the role of the clinical teacher. Journal of Advanced Nursing 13:621–630 UKCC 1999 Fitness for practice. UKCC, London Vaughan B 1990 Knowing that and knowing how: the role of the lecturer practitioner. In; Kershaw B, Salvage J (eds) Models for nursing 2. Scutari Press, London; p. 106 Williamson G, Webb C 2001 Supporting students in practice. Journal of Clinical Nursing 10(2):284–292
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The challenges and conflicts of facilitating learning in practice: the experiences of two clinical nurse educators Anne-Marie Brennan and Ruth Hutt
Anne-Marie Brennan RN, DipHE, Practice Nurse, Morden Hill Practice, 21 Morden Hill, Lewisham, SE13 7NN, UK. (Formerly Return to Practice Support Nurse.) Ruth Hutt RN, DipHE, MSc, Public Health Specialist Trainee, Croydon Health Authority, Knollys House, 17 Addiscombe Road, Croydon, CR0 6SR, UK. (Formerly Education Development Nurse.) (Requests for offprints to RH) Manuscript accepted: 9 August 2001
This is a descriptive paper discussing the experiences of two clinical educators in practice. It highlights some of the practice issues around accountability, advocacy and role conflicts in clinical teaching roles. The issue of training nurses fit for practice given the recommendations of Fitness for Practice (UKCC 1999) and Making a Difference (Department of Health 1999) is discussed within the context of the reality of the clinical environment. The number of learners in the clinical area has increased in the last few years, and will continue to do so with the increase in nurses promised by the NHS Plan and new initiatives to attract nurses back into the profession. As a result of this the clinical environment, already stretched with service demands, requires additional support to facilitate the development of learners. Recommendations are made for the future of generic practice facilitative roles in the light of the current debate to get nurse educators back into practice. © 2001 Harcourt Publishers Ltd
Introduction Changes in nurse education in the United Kingdom (UK), and an increase in numbers of learners in the clinical environment, have meant that we have had to look at new and innovative ways to support both learner and practitioner to ensure that the clinical placement is a positive learning experience. The issue of developing ‘fit for purpose’ nurses has been high on the agenda of the nursing profession for nearly a decade. Within our local trust two posts were created with the assistance of funding from the local education and training consortium to develop clinical nurse educators. The education development nurse role was to set up a rotational programme for newly qualified nurses and provide practical clinical support at a ward level for these nurses and their preceptors.
© 2001 Harcourt Publishers Ltd doi:10.1054/nepr.2001.0031, available online at http://www.idealibrary.com on
The return to practice support nurse worked primarily with nurses undertaking the return to practice course. This was a joint appointment between two acute hospital trusts. Much is written in the literature about the theory practice gap, and the roles of joint appointments between higher education institutions (HEIs) and the service sector in bridging this divide (Williamson & Webb 2001). There is, however, very little written about the day-to-day clinical experience of these types of roles. In an effort to redress that balance, we have recorded some of issues that have been pertinent to us in our roles. This offers both the service sector and HEIs an opportunity to look at the whole picture, and enables them to re-think and re-examine where the interface between theory and practice learning belongs. We are seeing increasing political will and
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pressure to enable nurse educators to claim back their practice roles with a plethora of national documents, but to date this appears to have had little impact ‘on the ground.’ There needs to be considerable investment both financially and in valuing practice for this to become a reality and have an impact on practice based learning.
Background Over the last 10 years, there has been much commentary on the theory practice gap, and the impact of Project 2000 on the clinical skills of registered nurses. Fitness for Practice (UKCC 1999) has highlighted some of these issues, and we are now seeing a return to competency based learning outcomes. One of the assumptions made by the change back to clinical assessment of competency is that we have the capacity at a ward level to assess, coach and challenge students in the clinical area. In our experience of facilitating learners and trained nurses in practice this has not always been the case, both in terms of numbers of staff and appropriate skill mix. There has been a move over recent years to encourage HEI and trusts to work in partnership to ensure that learning in theory and practice are not mutually exclusive (Macleod Clark 1998). Indeed, there is strong political will behind this idea in both Fitness for Practice (UKCC 1999) and Making a Difference (DoH 1999): The number of jointly funded posts between service and education should be increased. We support the development of exchanges and secondments between HEIs and health services. (UKCC 1999, p. 46) We will be setting clear targets for boosting teacher support for students on placements … . We intend to create more opportunities for experienced staff to combine teaching and patient care so that students can acquire better practical skills. (DoH 1999, p. 27) There needs to be financial commitment from all sectors to enable these appointments to last beyond the existing post holder. With conflicting demands within finite resources to create nationally driven appointments such as
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consultant nurses and leads for cancer, coronary heart disease and clinical governance, lecturer practitioner type posts have had lower priority. It is impractical to suggest that nurse educators, who have been based in higher education for nearly a decade in some cases, should suddenly be able to return to the clinical environment and competently practise. Whilst some may be able to do this, they are probably a distinct minority. In research carried out by Day et al. (1998), lecturers felt that their educational training courses had ill equipped them for their practice role.
Clinical teaching roles In the past, the role of the clinical teacher was developed in an attempt to bridge the gap between theory and practice. Appointees reported discomfort with the lack of clarity of the role, and a feeling that their status was perceived as considerably lower than that of academically based nurse teacher (Owen 1993). Training for the clinical teacher role was discontinued in the mid-1980s. The contemporary role of lecturer practitioner seems to work in many settings (Childs 1995, Lloyd-Jones 1993). Locally, these roles tend to be associated with specialist areas, and are often linked with specialist courses such as critical care, accident and emergency or theatres. Yet the areas experiencing the most problems in terms of student facilitation, preceptorship and mentoring are often general wards. As general areas become increasingly depleted of experienced nursing staff, those remaining have to manage conflicting demands, increasing rate of bed usage, increasing patient dependency, government policy and the politics of an increasingly changing and challenging National Health Service (NHS). This undoubtedly has implications for the students we are training and the newly qualified colleagues we are supporting.
Assessors and learners There are increasing numbers of ‘learners’ in the clinical environment: return to practice nurses, adaptation nurses, health care assistants undertaking NVQs and nursing
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students. In addition to these demands, all newly qualified nurses are meant to have a period of preceptorship, many post registration specialist courses require a practice assessment component and we will soon have nurse cadets in many areas. With diminishing numbers of experienced staff nurses due to recruitment and retention problems, and increasing vacancies at all grades, there has been an impact on the level of clinical support offered to all our learners. This may well be exacerbated in the short term by the new framework for programmes for the preparation of mentors and teachers (ENB & DoH 2001).
Development of local roles At our South-London Trust, two posts were created to address some of these issues. One was the result of direct feedback from student nurses who felt that their practice assessors had often not had the time or motivation to teach and make the most of learning opportunities available. They voted with their feet at the end of their training, which meant a considerable loss for the trust in terms of investment in training. The other was a result of the national Return to Practice campaign for nurses who had been out of nursing for some time and needed a ‘refresher’ course. Both of these posts were trust-based (one was a joint appointment between two trusts), but with very close collaboration with the local HEI. Both these roles had an education and clinical focus, which also meant working shifts on wards with students and registered nurses. This has highlighted many issues for us around our own accountability and has given us a rare insight into how the educator in practice may work a decade on from losing our last clinical teachers.
Practice roles Interestingly, there is very little reported in published literature of the difficulties and stresses encountered by generic clinical skills teachers such as us. Many of the issues are similar to those reported by Williamson and Webb (2001) in their paper examining the roles of jointly appointed clinical educators. Whilst
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there are practice development nurses across the country who work in clinical settings, our roles were particularly large in that they covered the whole trust (and in the case of the return to practice nurse, two trusts). Both posts were responsible to the Assistant Director of Nursing-Education and Practice Development. It was envisaged at the outset that at least 60% of the education development nurse role would be clinical, and a similar amount for the return to practice support nurse. In reality this had been difficult to sustain for many reasons. Practice development, in our experience, has become everything and anything not currently being done by someone else; so we have been involved in many different (but linked) roles, from recruitment and retention to audit. We have found that the techniques we have developed to support and facilitate our two quite different genres of learners are similar, but with subtle differences. The main differences, we believe, are driven by the fact that the return to practice students are supernumerary, not paid and are on honorary trust contracts, so it is possible to tailor support to their learning needs and their pace of working. It also allows for them to be taken aside from the clinical workload of the area to focus specifically on one area of care, or to give full care to one or two patients. The newly qualified nurses, without student status, have an allocated part of the clinical workload for which they are responsible. This has benefits in that it reflects the real day-to-day conflicts they will have to face, but can be challenging for the facilitator. The challenges of the roles are many and varied, and in the remainder of this paper we aim to give the reader an overview of the conflicts and challenges we have confronted within the clinical element of our roles.
Clinical competence One of the most difficult issues for us has been working in diverse clinical settings, some of which we have never worked in before either as a student or registered nurse. Being new to the trust, we felt initially that we had to prove our own clinical competence (perhaps just to ourselves!) to justify the posts we held. Indeed, there is considerable debate in the literature
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about what a clinically competent nurse educator means (Cave 1994, Forrest 1996, Glen & Clark 1999). Day et al. (1998) distinguish between clinical competence and clinical credibility in their research into the role of the teacher/lecturer in practice. They found clinical competence viewed as the ability to deliver direct patient care, and clinical credibility as implying: … scholarship in the field and the ability to integrate theory and practice in the classroom and in practice settings. (Day et al. 1998) We would argue that both are essential to our roles, and that to not be clinically competent to deliver patient care would put student, educator and patient in an extremely vulnerable position. We both spent a lot of time working on wards to get to know the staff and get a feel for the environment. This paid off in terms of recognition for what we do, developing relationships with the ward staff and also enabled the wards to feel supported rather than just feel additional pressure when new learners were allocated to their areas. In a study analysing the changing role of the nurse teacher, Carlisle et al. (1997) found that one of the stresses faced by clinically based teachers was attempting to teach in a speciality which was not their own. When things start to go wrong it is incredibly difficult and stressful. There is also a tendency for the rest of the ward team to leave you to get on with it, as it is assumed that you know what to do. I have now struggled through a number of incidents on medical wards particularly where a patient deteriorates rapidly and I have felt very deskilled. The simplest problem in such a situation – such as not knowing where urgently needed equipment is stored can exacerbate the stress. (RH) It is often difficult not being part of the nursing team. We do not get to build up the relationships with the multidisciplinary team that permanent members of staff in a ward area have, and there is a danger that we become unsupported and isolated. We find that in sharing issues of concern between ourselves
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we both gain support. Also accessing regular, formalized clinical supervision helps us to map, analyse and resolve our concerns.
Accountability We are becoming increasingly aware of our own accountability, and although we would rarely document care, as this would be the learners role, we have become more conscious of the need to make our own notes at times and are rigorous in checking our students’ documentation. On a number of occasions, when arriving on a ward to work with students, we have found that we are the most experienced and senior person on duty, either due to staff shortage or sickness. This can give rise to situations which cause conflict with our facilitative remit. As accountable practitioners our own, supernumerary status is no protection. On one recent occasion due to nonappearance of two agency nurses I felt for the sake of patients safety my student and I needed to take patients other than those whose care would offer the student the optimum learning experience (at least until other help could be found). On another occasion a bank nurse who had been involved in a road traffic accident the previous day began to vomit in the sluice. The nurse in charge (a harassed, frantically busy E grade) did not appear to recognize the potential seriousness of the situation, so I found myself supporting her in managing the predicament leaving my student unsupervised. (A-MB) These are highly stressful roles clinically; an issue we perhaps underestimated when we took up our posts, and an issue we found was not represented in published literature. We are the clinical ‘Jacks of all trades, masters of none’.
Organization structure implications It has been difficult at times to encourage staff to participate in facilitating learners. All nurses within the Trust are professionally accountable to the Director of Nursing, but are directly managed within a clinical directorate structure. As we do not fit within the clinical directorate
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structures, it has at times been politically difficult to instigate and sustain change, and to get ward staff on board to work on some of the issues we raise. Without support at all levels, from service directors to ward sister, this is virtually impossible. We rely mainly on goodwill to support return to practice students through placement. The isolation and powerlessness of such roles has been recognized since the days of the clinical teacher (Smyth 1988). Vaughan (1990), in discussing the problems of registered clinical nurse teachers, highlights difficulties in broaching the theory practice gap. Since the teacher had no control over what was taught in theory or what was done in practice, the task was impossible. We too experience a constant balancing act, to be realistic about what is achievable with the given resources, whilst instilling in ward staff the concepts of clinical governance, patient advocacy and professional accountability. The return to practice nurses are returning to a new ‘rule book’; we do not lift patients, we manage risk, where cost appears to have taken priority over quality of service. We preach evidence based practice, but lack the resources, judgement and at times expertise to implement it. As clinically based educators, we have a responsibility to deliver the agenda, but are impotent in our political no man’s land to influence what actually happens. To some extent we rely on those same concepts of clinical governance: risk management, professional regulation, continuing professional development, to safeguard us in the clinical environment where we work.
Managing and challenging poor performance and practice In a situation where a student is failing to meet the desired competencies, our collaboration with the ward based practice facilitator enables the student assessment to be managed in an effective and fair manner. In the literature we find considerable reference to the phenomenon of students passing assessments when they demonstrate unsafe practice because their assessor is not skilled, experienced or committed enough to address the student’s failing (Duke
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1996). In a questionnaire sent to all ward based practice facilitators in the hospital, 17% said they had passed a student when they had felt unsure they were meeting the required standard. Interestingly, students are reluctant to talk about problems they experience on clinical placements for fear of failing, when the reality is that this is a very rare occurrence. It is far easier to pass a student than to fail a student. As objective, clinically competent ‘outsiders’ with direct first hand experience of the issues involved in assessment, we are able to assist clinical staff in reaching an impartial, just outcome. This is supported by Forrest et al. (1996). Having the skill and ability to address poor or inadequate practice is an essential requirement so that practice is challenged and learning maintained. Challenging poor practice is no less difficult for us, but our role forces us to do something about it. This is extremely difficult without management support. Similarly, witnessing poor or questionable practice in an area where we are supporting a student can be difficult to deal with. On one occasion I witnessed an elderly confused gentleman with a naso-gastric feed in progress. His hands were bandaged. On questioning the ward manager I was told it was the only way he could be prevented from pulling the tube out. I asked about sedation or insertion of a gastrostomy feeding tube and was told neither was appropriate at present. On questioning the doctor during the ward round my concern was dismissed as a nursing issue. I felt very uncomfortable about this situation, which was obviously difficult to manage, but possibly needed more thought and debate from within the multi-disciplinary team. (A-MB) Resolving and working through situations like this in real time, using an action learning approach, offers opportunities to allow the student to probe the issues and develop an advocacy role with the support of a mentor. The role of clinical supervision in supporting the educator is equally important so as to constantly question and challenge how we react, make decisions and interact in clinical settings.
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Newly qualified nurses The focus for the education development nurse role is on newly qualified nurses, where obtaining placements is relatively easy due to the staffing problems we experience within London. However, ensuring they have proper preceptorship is more difficult and in many cases this is still not occurring. Many nurses find themselves in a bay with six to 12 acutely ill patients very soon after qualifying, with minimal support. One of the most valuable parts of the role is providing them with a sounding board and giving them the opportunity to ask the questions as they arise in the course of a shift. It also enables us to do things together such as referring to other members of the multi-disciplinary team, assessing a wound and choosing a dressing or supervising their first catheterization; while ward staff tended to be more likely to do it themselves because it was quicker. The value in not being part of the ward team came as a result of the learner having more confidence to ask questions, and challenge practice without fear of causing friction as they tried to settle into their new ward. It also offered the opportunity to challenge them on their own practice and pick up mistakes and errors without exposing them to the team. This could be very frightening at times. In some areas they were doing drug rounds on their own within the first week of being on the wards. This was alarming as many had only had very limited experience as students. In one incident I found a nurse drawing up mls instead of mgs of a solution, another nurse asked if they could use frusemide instead of co-amilfruse. This was quite worrying and leads to speculation about what may have happened had there been no one there to ask (which in reality would have been the case). There is very little ward level supervision for students much less qualified nurses. How far through your career could you progress continuously giving the wrong tablet, or the wrong amount of medication? (RH) These particular incidents led to guidelines for all ward managers regarding newly qualified
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nurses administering drugs alone and pharmacy are also now invited to the induction week run for newly qualified nurses on the rotation programme.
Reflection as learning in practice Practically managing real life situations and reflecting back afterwards also enabled nurses to stop and think about what was going on around them. Talking them through managing a patient in chest pain with three infusions going is a much better learning experience than hearing about it on a study day. We enable them to manage the situation, but support them and offer guidance as they require it. The downside to this is being continuously aware that if we allow the student to work to their own timescale in picking up a subtle deterioration in the patient’s condition we could be endangering the patient’s safety or comfort. The problem is in knowing how far to let them manage the situation before intervening, aware that next time they would probably be on their own.
Advocacy It is often when nurses we are working with are discussing a patients’ care with medical staff that we find it hardest to be both learner and patient advocate. As an experienced nurse challenging a medical decision, or making suggestions for changes in treatment is often an important component of patient advocacy but it is often hard to do this without undermining the learner. It is sometimes necessary to remind oneself of ‘where they are’ in their career and that the confidence and competence to take control of situations comes through experiential learning. Role modelling in these situations becomes a powerful learning tool for the student.
Guests in the clinical area As ‘visitors’ we often come in blind to clinical situations. Our knowledge of the patient is based on the quality of handover and the accuracy of the nursing notes, which are variable. Lack of, or incorrect, information
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can lead to us administering inappropriate, ineffective or at worst dangerous care. On one occasion at handover we were not informed that a patient was suspected of having multi-drug resistant tuberculosis. It was only after the student had responded to the nurse call bell in the patient’s room that I noticed masks and protective wear on a trolley outside the room and began to ask questions. (A-MB) In addition, we enter the situation having no relationship with the patient. We then have a short time to build a rapport and attempt to secure the patient’s and sometimes their relative’s trust before we say goodbye at the end of the shift and begin again on another ward with another student and another group of patients the following day. In some ways it is rather like working permanent agency shifts, being in a different clinical environment every day. However there, the similarity ends. Facilitating a student on a one-to-one level is very intensive work. Teaching as we work, constantly pressing the student to prioritize and re-prioritize the care they deliver, being aware of what we need to achieve, the time constraints we have and being continuously aware of patient safety and comfort. It is difficult to feel clinically competent in situations that are new, or are long distant memories. It becomes increasingly hard to move from the classroom and the office, back into the real world of clinical practice. It is rare to meet a specialist nurse or nurse educator who would swap places with her ward-based colleague, but as Jarvis (1992) argued; Nurse teachers can not keep up with practice unless they are in practice.
Criteria for success Key to the success of these posts is recent clinical practice. Ideally these sorts of roles make good 6–9 month secondments for nurses interested in education and practice development, but wanting to stay in practice. There is potential for more impact if the posts are based within a limited area, over 2–4 wards. It is also vital that anyone in these type
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of roles has recent experience of working with students and assessing nurses in practice. An understanding of current training programmes and what is expected in terms of clinical competency, by the individual, the organization and the local HEI, is essential to the success of creating nurses fit for practice. Clinical supervision offers an excellent mechanism for supporting the post holder, and ensuring they are challenged on aspects of their own practice.
Future recommendations Nurse education is changing and we must change with it, but new skills are needed and the value of clinical teaching re-established. There has been a feeling amongst practitioners that academic qualifications are valued over clinical expertise. The fate of the English National Board Higher Award is perhaps an illustration of this (NHSE 1998). The idea that practice skills are taught by practice staff is good in theory, but in reality often leaves the most junior inexperienced nurses as the teachers of clinical skills (Clifford 1994). Ideally, all ward establishments should have education built into their staffing with carefully selected clinically competent appointees who are also well versed in the issues around nurse education and are professionally up-to-date. This team member could then ensure practice assessors are adequately prepared for and function well within their role. Recommendation 29 from Fitness for Practice (UKCC 1999) states: Funding to support learning in practice should be reviewed to take account of the cost of mentoring and assessment by practice staff and the cost of lecturers having regular contact with practice. They may formulate teaching programmes and act as liaison between the clinical areas and the contracted HEI. Nurses in practice need to regain control of nurse education, and begin to take responsibility for what nurses are able to do in practice as it is they that should be imparting the practice skills. There is still a long way to go, but with the support and commitment of the new confederations, HEIs and service providers we can re-equip our nurses in practice to be facilitators of practice.
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It is easy to lose sight of the fact that 50% of the pre-registration nurse education programme is still practice based.
Conclusion We hope to have provided some debate and discussion through our experiences, and are keen to see the recommendations from Fitness for Practice (UKCC 1999) and Making a Difference (DoH 1999) become a reality at a clinical level. Nurse education continues to evolve and we need to continuously re-emphasize that nursing is a practice based profession and that the practice based learning component is fundamental to the art and science of nursing. References Carlisle C et al. 1997 The clinical role of nurse teachers within a project 2000 course framework. Journal of Advanced Nursing 25:386–395 Cave I 1994 Nurse teachers in higher education – without clinical competence do they have a future? Nurse Education Today 14:394–399 Childs S 1995 Promoting the practice. Nursing Standard 9(36):51 Clifford C 1994 Assessment of clinical practice and the role of nurse teacher. Nurse Education Today 14(4):272–279 Day C, Fraser D, Mallik M et al. 1998 The role of the teacher/lecturer in practice. ENB Research Highlights, May 1998
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Department of Health 1999 Making a difference. Strengthening the nursing, midwifery and health visiting contribution to health and healthcare. Department of Health, London Duke M 1996 Clinical evaluation – difficulties experienced by sessional clinical teachers of nursing: a qualitative study. Journal of Advanced Nursing 23:408–414 English National Board and Department of Health 2001 Preparation of mentors and teachers. A new framework of guidance. English National Board, London Forrest S, Brown N, Pollock L 1996 The clinical role of the nurse teacher: an exploratory study of the nurse teachers’ present and ideal role in the clinical area. Journal of Advanced Nursing 24:1257–1264 Glen S, Clark A 1999 Nurse education; a skillmix for the future. Nurse Education Today 19:12–19 NHS Executive 1998 Integrating theory and practice in nursing. NHSE, London Jarvis P 1992 Theory and practice and the preparation of teachers of nursing. Nurse Education Today 12:258–265 Lloyd Jones N 1993 The lecturer-practitioner role and the development of intensive care in nursing practice. Intensive and Critical Care Nursing 9:232–236 Macleod Clark J 1998 Education for the future. Nursing Management 5:14–17 Owen S 1993 Identifying a role for the nurse teacher in the clinical area. Journal of Advanced Nursing 18:816–825 Smyth T 1998 Marginality and the role of the clinical teacher. Journal of Advanced Nursing 13:621–630 UKCC 1999 Fitness for practice. UKCC, London Vaughan B 1990 Knowing that and knowing how: the role of the lecturer practitioner. In; Kershaw B, Salvage J (eds) Models for nursing 2. Scutari Press, London; p. 106 Williamson G, Webb C 2001 Supporting students in practice. Journal of Clinical Nursing 10(2):284–292
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