- Email: [email protected]
Using a communication audit to improve communication on clinical placement in pre-registration nursing
Nurse Education Today (2005) 25, 119–125
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Using a communication audit to improve communication on clinical placement in pre-registration nursing Elaine Hogard*, Roger Ellis, Jackie Ellis, Chris Barker Social and Health Evaluation Unit, School of Health and Social Care, University College Chester, Parkgate Road, Chester CH1 4BJ, UK Accepted 18 October 2004
KEYWORDS
Summary This article describes a novel communication audit conducted with those concerned with the practice placements of pre-registration Nursing students. The study, uniquely, addressed all who were involved in communication concerning placement in what is described as an organisational analysis. The aim of the audit was to identify levels of satisfaction and dissatisfaction with present communication processes and to identify points for improvement. The audit used the Hogard–Barker Communication Audit of Practice a customised version of a well established tool, devised to cover issues relevant to practice placements. A key feature of the tool is the opportunity for participants to identify the amount of communication they are receiving on particular topics and issues against the amount they would like to receive. Participants in the audit included students, assessor mentors, ward managers, clinical facilitators and link tutors. Overall there was considerable dissatisfaction with what was perceived to be the insufficient amount of communication received on a number of topics including allocations, the curriculum, students’ learning outcomes and commitments in terms of college work. In addition to identifying points for improvement the audit provides a baseline against which progress can be assessed through a future audit. c 2004 Published by Elsevier Ltd.
Communication audit; Clinical placement; Organisational communication; Supervision; Assessor/mentor; Link tutor; Clinical facilitator; Audit tool
Introduction
* Corresponding author. Tel.: +44 12244 375444x3795; fax: +44 1244 381090. E-mail address: [email protected] (E. Hogard).
0260-6917/$ - see front matter c 2004 Published by Elsevier Ltd. doi:10.1016/j.nedt.2004.10.006
A previous study (Ellis and Hogard, 2003, 2001) evaluated a pilot scheme for the introduction of clinical facilitators into medical and surgical wards to work with pre-registration Nursing students.
120 Within a super-ordinate objective to improve the clinical competence and confidence of pre-registration nurses, the clinical facilitators had set themselves five key objectives, one of which was to improve communication around clinical placement. Whilst the clinical facilitators received very positive evaluations from students, ward staff, college staff and managers regarding four of their objectives, reservations were expressed regarding the extent to which they had improved communication. The evaluators pointed out that improving communication was the least well operationalised and most ambitious of the five objectives. It was, therefore, hardly surprising that stakeholders expressed most concern about its fulfilment. However, amongst their 18 recommendations, the evaluators included one that suggested that consideration be given to clarification of the respective responsibilities for communication of assessor/ mentors, link tutors and clinical facilitators. It was further recommended that a communication audit should be undertaken as a baseline for development and future evaluation. This proved to be a more original recommendation than was anticipated in that the literature on organisational communication in nursing placements was surprisingly slight and the communication audits used in other public and private organisations had not been applied in nurse education. This article then describes the development of a unique communication audit tool and its application to organisational communication involving clinical staff, college staff and students in relation to placements in the surgical wards of a general hospital.
Background Communication in practice education Despite the voluminous literature on communication in nursing and nurse education covering communication with patients, communication skills, and communication skills training (see, for example, Burnard, 1995; Kruijver et al., 2000; Chant et al., 2002) communication in practice education appears to be a relatively neglected area. In the vade mecum Placements in Focus (ENB, 2001), there is no explicit reference to communication although an emphasis on partnership between higher education and practice certainly implies it. Rather than a specific focus on communication as such, topics are addressed where communication
E. Hogard et al. is an implicit rather than explicit factor. For example, Last and Fulbrook (2003) in exploring the reasons for nursing student dropout mention communication between university and clinical areas in their abstract but do not develop this in the body of the article. Wilson-Barnett et al. (1995) researching clinical support for P2000 nursing students identify supervision, team spirit and organisation as key factors but make no mention of the communication that might be thought an essential component of each. Exploring stress in nursing students Timmins and Kaliszer (2002) highlight interpersonal relationships but fail to identify communication as a component in these. Arguably, the most important communication dyad in clinical placement is that between the student and supervisor or mentor. Andrews and Wallis (1999) review the literature on mentorship and manage to avoid any reference to communication but rather choose to emphasise relationships. Cahill’s (1996) qualitative analysis of student nurses’ experience of mentorship is similarly mute. Gray and Smith (2000) also address the students’ perspective and again avoid explicit attention to communication. However, Swann (2002) identifies communication explicitly as an essential component of the instructor–student relationship. Mamchur and Myrick, 2003) stress that problems between students and preceptors are about communication and interpersonal relations. From a search identifying a mere 57 articles notionally linking communication and student placement the authors found only a few containing any analysis of the various forms of communication, interpersonal and organisational, that characterise clinical placement in nursing and no reference to the use of communication audits. Langan (2003) investigating the roles of those involved in nursing student learning, found that lack of clear communication and the delineation of expectations amongst administrators, staff, faculty and students were the major factors in perceived role problems. These findings emerged from focus groups and interviews with a relatively small sample and could usefully contribute to and complement a more comprehensive audit. This review confirmed the relative novelty and potential utility of both an organisational as opposed to an interpersonal analysis of communication, and the use of a communication audit.
Communication audit In recommending a communication audit, the evaluators believed that a baseline was essential
Using a communication audit to improve communication on clinical placement against which improvements or decrements in communication could be detected. The idea of an audit was to identify the strengths and weaknesses of communication around clinical placement from the points of view of students, hospital staff and college staff. A communication audit has been defined as: ‘‘a comprehensive and thorough study of communication philosophy, concepts, structure, flow and practice within an organisation’’ (Emmanuel, 1985, p. 50) . It is essentially a process for acquiring data regarding communication for analysis (Downs, 1988). It can assist managers by providing them with knowledge of what is actually happening at the communication level, rather than what they thought, or were told was happening (Hurst, 1991a,b). A survey of available instruments for the communication audit highlighted the work of the International Communication Association during the 1970s (Goldhaber and Krivinos, 1977) and the scholarly interest this had attracted (e.g. Greenbaum and White, 1976). Goldhaber and Rogers (1979) identified key objectives to be achieved by a communication audit. These included the description of the major topics, sources and channels of communication, consideration of the quality and utility of information, and the identification of the positive and negative experiences of users with a view to effecting improvement. The International Communication Association developed an audit questionnaire that has been widely used in the US (Goldhaber and Rogers, 1979). However, we were unable to find any examples of its use with regard to the audit of communication concerned with clinical placement. Nor could we find any other instruments that had been used for this purpose. The ICA questionnaire is a comprehensive instrument in 13 sections. Completion depends heavily on the recollection and reporting of critical incidents in communication. Hargie and Tourish (2000) produced a simplified version which focussed on one critical incident rather than requiring a critical incident for each section. Arguably, the ICA questionnaire and the Hargie and Tourish adaptation need specific topics to make the instrument applicable to specific situations such as the pre-registration nursing clinical placement. The major development work for the instrument used in this study consisted therefore of devising specific references to participants in and aspects of clinical placement. The customised instrument is called the Hogard–Barker Communi-
121
cation Audit for Placement (HBCAP). It was piloted with a small sample of stakeholders to ensure comprehension and feasibility. It is described in greater detail below.
Methods The broad aim of the research was to identify effective and less effective features of communication around the practice placements of pre-registration nursing students using a specially devised communication audit tool. The instrument devised draws on the demonstrated validity and reliability of both the original international communication audit questionnaire (Goldhaber and Rogers, 1979;Downs, 1988) and Hargie and Tourish’s adaptation (Hargie and Tourish, 2000; Quinn and Hargie, 2004). The customising of the instrument for this purpose enhances face validity.
The audit questionnaire The HBCAP instrument was in the form of a questionnaire divided into 13 sections, each one dealing with a different aspect of communication together with a covering sheet for demographic information on participants. In seven of the sections, respondents were asked to rate the amount of communication received or sent and communication needed on a broad topic and its sub-sets according to the following values: very little (VL), little, (L) some (S), great (G) and very great (VG). The broad topics for these seven sections were: Amount of information received on eight topics grouped under new curriculum and allocations Amount of information received from 11 sources including individuals, organisational units and the ‘grape vine’ Amount of information received through 11 channels including face-to-face communication, documents and e-mails. Amount of information sent on seven aspects of placement Amount of information received on six important issues Amount of information sent on six important issues Action taken on sent communication by seven groups
122 Each section was further subdivided into specific topics relevant to pre-registration nursing clinical placement. In all the seven sections included 56 specific topics. Levels of satisfaction with communication for each section and its sub topics were determined by calculating the difference between the two raw scores for each question-the ideal score being ‘0’ which would indicate no difference between what was received and what was wanted. In order to identify potential problems areas, it was first necessary to compare the main question areas overall and then in relation to the different specific topics. Two further questions referred to how quickly information was received (timeliness) and to working relationships and trust. Within each question seven specific groups or individuals were included. Respondents were asked to rate their answers in terms of a five-point Likert scale. For timeliness communication could be rated as (N) never on time, (R) rarely on time, (SOT) sometimes on time, (MOT) mostly on time and AOT always on time. For working relations, the seven participant groups were rated for trust using markers of trust VL (very little) L (little) ŒS (sometimes) O (often) and A (always). Four sections, of a more open-ended nature, asked for strengths and weaknesses in communication regarding pre-registration student nursing clinical placement; for a description of a positive or negative communication experience (the critical incident); for comments on challenges ahead including the greatest challenge, the biggest priority in the workplace, and manager expectations; and suggestions for making communication better.
Sample The notional sample for the study was the complete population of trust and college staff and nursing students associated with the placement of three cohorts of students in six surgical wards five of which had 28 beds and one of which had 33. Potentially, there were 158 individuals who could respond.
Response rates Out of 158 questionnaires distributed a total of 74 were completed as follows. 53 from 96 possible students (54%) Seven from 10 possible ward managers (70%)
E. Hogard et al. Nine from 39 possible assessor/mentors (26%) One from one possible clinical facilitator (100%) Five from six possible link tutors (83%) Nil from three possible allocation staff. A 54% response rate from students is acceptable. The response rate from assessor mentors is disappointing and obviously raises questions regarding the effectiveness of dissemination from ward managers. The nil response rate from allocations staff reflected their concerns regarding anonymity, which could not be guaranteed for such a small identified group. Detailed demographic information is available for this sample but beyond the scope of this article.
Completing the questionnaire Typically the instrument took 30–40 min to complete and represented a significant investment in time and effort. Briefing sessions were organised for each group to explain the significance of the work and its potential impact. Participants volunteered to participate after a briefing. Forms were completed anonymously.
Ethical considerations The project was approved by the College Research Ethics Committee which judged it against the implicit criteria of the Royal College of Nursing (RCN, 2004) to assure beneficence, avoid of malificence, ensure informed consent, give equal opportunity, and assure technical competence.
Results Overall satisfaction On the comparative items differences were computed for all items overall, for each section and for each item in each section. A difference of 0 indicated satisfaction with minus or plus scores (up to a maximum possible of 4.0) indicating dissatisfaction with either too little information or too much. A difference of 2 or more is taken as indicative of dissatisfaction. Overall most groups, but especially the ward staff and first year students, were dissatisfied and believed insufficient information was being received or sent on a range of topics. The overall average difference for all sections and items was 2.1 indi-
Using a communication audit to improve communication on clinical placement cating a significant shortfall between what was received or sent and what was wanted. On the other hand more positive critical incidents were identified than negative and trust was generally positive.
Information received The link tutors were the only group involved in the audit who felt that they were receiving more information than they actually required particularly from the allocations office of the College. The other groups felt they were not receiving enough information from any source but particularly from allocations. The ward staff reported the greatest dissatisfaction ( 2.98) and this includes information about the new curriculum/programme. The audit took place shortly after the introduction of the new curriculum but also after a period when communication about the curriculum should have been at its most intense. With the exception of one source –‘‘the grapevine’’, where the ward managers felt they got an excess of information, all groups felt that did not receive enough information from the various sources available. Link tutors felt that they needed much more information from clinical facilitators. Some students (cohorts 2001/2000) required much more information from the link tutors. Among first year students (cohort 2001), e-mail and written communication were highlighted as desirable media for more communication while ward managers stressed the need for more clearly presented written material with audio-visual supplements.
Information received on important issues Information received on important issues is the section where the greatest overall deficit lies (mean 2.1). Within this the ward staff expressed the biggest deficit ( 2.62). For first year students the priority was more information on the development of the skills lab whereas for ward staff it was for information on the objective structured clinical examinations (OSCEs).
Timeliness of information Ward staff identified allocations as the least timely source of information. Link tutors felt that they received information when needed from each other but not from students. Students, reciprocally felt that information from link tutors was not timely.
123
Information sent All groups felt that they were not sending enough information regarding all the different topic areas. Reporting problems about clinical placements was an issue for first year students particularly. Ward managers felt they were not able to express opinions about clinical placements or to report success and achievements. Nevertheless, although the sending of information is seen as an issue, overall it is perceived to be the least problematic of the sections (mean 1.23).
Organisational outcomes/action taken Although all respondents felt that more action needs to be taken with regards to the information they are sending, the ward staff feel most dissatisfied with the allocation office whereas the link tutors feel that the allocations office along with the clinical facilitators are the people who take the most action on the information sent. These results are consistent with a general trend amongst staff as opposed to students towards less dissatisfaction with intra-organisational as opposed to interorganisational communication.
Working relationships The level of trust amongst those who took part in the audit appears to be fairly good. All respondents seem to trust the clinical facilitators the most. In terms of the lowest level of trust, this was attributed to the ward managers by the second year students (cohort 2000) although the other participants groups, including the other student cohorts, have scored this group fairly highly. Hargie and Tourish (2000) point out if the level of trust is fairly good it provides a starting point from which to enhance communication. Furthermore, they argue, as communication improves so do relationships.
Critical incident Respondents were invited to select and describe one effective or ineffective communication experience. Hargie and Tourish (2000) state that these so-called ‘critical incidents’ provide insight into whether staff feel positive or negative about the organisation in general. They point out that where communication is functioning at a reasonable level there should be a ratio of at least 50/50 between positive and negative incidents reported. Bearing this in mind, although only 63% of the respondents
124 completed this section, the positive communication experiences equate to negative in a ratio of 60/40. This suggests that, in general, the staff feel positive about pre-registration clinical placement.
Open-ended questions The responses to the open-ended questions generally confirmed the findings from the quantitative section of the questionnaire and in this, as Quinn and Hargie (2004) suggest, offer a form of triangulation. However, the results did suggest some positive aspects to communication which tended to be hidden in the quantified responses. These included accessibility of clinical facilitator to students and link tutors; opportunities to relate theory to practice for students; and the introduction of useful information packs for students on placement and its requirements.
Discussion In this case study, the audit has shown that although by one indicator communication in the clinical preregistration clinical placement is seen as a positive process, respondents overall are dissatisfied with communication and there are a number of issues that need to be addressed, many of which are interlinked. It may well be that the issues raised are typical of pre-registration placements but further work will be necessary to establish this. First, the audit identifies a need for more information to be sent and received. This applies particularly to the ward staff and students who do not feel that they get information as and when they need it. Ward staff want more information from the college and students want more from their link tutors. With the sole exception of information through the socalled grapevine where some thought too much information was provided, there is an overall need for more information to be made available between all groups on all significant topics. Second, there is a lack of awareness between participants regarding both roles and the structure of the curriculum. This applies particularly to the roles of assessors and link tutors and to the students’ curriculum structure, learning outcomes and non-rostered practice. Clearly, these are topics on which clearer and fuller information should be provided. Third, the audit revealed shortfalls and inconsistencies in student support possibly exacerbated by the increased numbers of students passing through the system.
E. Hogard et al. This research was prompted by the perceived failure of clinical facilitators to improve communication in clinical placement. The communication process around and within clinical placement proved to be a complex one involving students, college link tutors, college administrators, assessor mentors, clinical facilitators and other ward staff. Two major organisations are involved namely the college and the trust. Student numbers have increased significantly and there is pressure on both trust and college resources. In these circumstances, it is perhaps not surprising that participants express overall dissatisfaction with communication processes. The base line provided by this audit not only suggests a number of initiatives that need to be taken but will also, through a subsequent audit, allow progress to be gauged. Despite the high levels of dissatisfaction, respondents identified more positive than negative critical incidents and levels of trust between participants is high which gives cause for optimism provided the various issues raised in the audit are addressed formally and in partnership.
Conclusions This research is the first to study organisational communication as a whole in relation to nursing practice placement. Given this novelty it has not been possible to contextualise the results directly in previous similar work. Comparing results with communication audits in other contexts (for example Quinn and Hargie, 2004) suggests that the level of dissatisfaction found here is relatively high but not perhaps surprisingly so considering how underdeveloped and under-researched the area appears to be. Clearly, the communication deficiencies identified here leave no room for complacency and, if they are representative, have important implications for the partnerships between higher education and service advocated by, for example, the ENB and DoH (ENB, 2001) and for the learning environment of the placement. The audit tool developed by the authors – HBCAP – is unique and has proved its utility and feasibility in this study. It is available from Hogard for those who wish to replicate the work in other settings.
References Andrews, M., Wallis, M., 1999. Mentorship in nursing: a literature review. Journal of Advanced Nursing 29 (1), 201–207.
Using a communication audit to improve communication on clinical placement Burnard, P., 1995. Learning Human Skills: An Experiential and Reflective Guide for Nurses, (third ed.). Butterworth Heinemann, Oxford. Cahill, H.A., 1996. A qualitative analysis of student nurses’ experiences of mentorship. Journal of Advanced Nursing 24, 791–799. Chant, S., Jenkinson, T., Randle, J., Russell, G., Webb, C., 2002. Communication skills training in healthcare: a review of the literature. Nurse Education Today 22, 189–202. Downs, C., 1988. Communication Audits. Harper Collins, London. Ellis, R., Hogard, E., 2001. An Evaluation of the Pilot Project for Clinical Placement Facilitation. Chester Academic Press, Chester. Ellis, R., Hogard, E., 2003. Two deficits and a solution. Explicating and evaluating clinical facilitation using consultative methods and multiple stakeholder perspectives. Learning in Health and Social Care 2 (1), 18– 27. Emmanuel, M., 1985. Auditing communication practices. In: Reuss, C., Desilvas, R. (Eds.), Inside Organisational Communication. Longman, New York. English National Board (ENB) for Nursing, Midwifery and Health Visiting, 2001. Placements in Focus: Guidance for Education in Practice for Health Care Professionals. English National Board for Nursing, Midwifery and Health Visiting, London. Goldhaber, G., Krivinos, P., 1977. The ICA communication audit: process, status, and critique. Journal of Business Communication 15, 41–64. Goldhaber, G., Rogers, D.P., 1979. Auditing Organizational Communication Systems: The ICA Communication Audit. Kendall/Hunt, Dubuque Iowa. Gray, M.A., Smith, L.N., 2000. The qualities of an effective mentor from the student nurse’s perspective: findings from a longitudinal qualitative study. Journal of Advanced Nursing 32 (6), 1542–1549.
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Greenbaum, H., White, N., 1976. Biofeedack at the organisational level: the communication audit. Journal of Business Communication 13, 3–15. Hargie, O., Tourish, D. (Eds.), 2000. Handbook of Communication Audits for Organisations. Routledge, London. Hurst, B., 1991a. Negotiating research access to organisations. The Psychologist 9 (12), 551–554. Hurst, B., 1991b. The Handbook of Communication Skills. Kogan Page, London. Kruijver, I.P.M., Kerkstra, A., Francke, A.L., Bensing, J.M., van de Wiel, H.B.M., 2000. Evaluation of communication training programmes in nursing care: a review of the literature. Patient Education and Counselling 39 (1), 129–145. Langan, J.C., 2003. Faculty practice and roles of staff nurses and clinical faculty in nursing student learning. Journal of Professional Nursing 19 (2), 76–84. Last, L., Fulbrook, P., 2003. Why do student nurses leave. Suggestions from a Delphi study. Nurse Education Today 23, 449–458. Mamchur, C., Myrick, F., 2003. Preceptorship and interpersonal conflict: a multidisciplinary study. Journal of Advanced Nursing 43 (2), 188–196. Quinn, D., Hargie, O., 2004. Internal communication audits: a case study. Corporate Communications: An International Journal 9 (2), 146–158. RCN, 2004. Research Ethics: Guidance for Nurses. Royal College of Nursing, London. Swann, E., 2002. Communicating effectively as a clinical instructor. Athletic Therapy Today 7 (5), 28–33. Timmins, F., Kaliszer, M., 2002. Aspects of nurse education programmes that frequently cause stress to nursing students – fact-finding sample survey. Nurse Education Today 22, 203–211. Wilson-Barnett, J., Butterworth, T., White, E., Twinn, S., Davies, S., Riley, L., 1995. Clinical support and the Project 2000 nursing student: factors influencing this process. Journal of Advanced Nursing 21, 1152–1158.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Using a communication audit to improve communication on clinical placement in pre-registration nursing Elaine Hogard*, Roger Ellis, Jackie Ellis, Chris Barker Social and Health Evaluation Unit, School of Health and Social Care, University College Chester, Parkgate Road, Chester CH1 4BJ, UK Accepted 18 October 2004
KEYWORDS
Summary This article describes a novel communication audit conducted with those concerned with the practice placements of pre-registration Nursing students. The study, uniquely, addressed all who were involved in communication concerning placement in what is described as an organisational analysis. The aim of the audit was to identify levels of satisfaction and dissatisfaction with present communication processes and to identify points for improvement. The audit used the Hogard–Barker Communication Audit of Practice a customised version of a well established tool, devised to cover issues relevant to practice placements. A key feature of the tool is the opportunity for participants to identify the amount of communication they are receiving on particular topics and issues against the amount they would like to receive. Participants in the audit included students, assessor mentors, ward managers, clinical facilitators and link tutors. Overall there was considerable dissatisfaction with what was perceived to be the insufficient amount of communication received on a number of topics including allocations, the curriculum, students’ learning outcomes and commitments in terms of college work. In addition to identifying points for improvement the audit provides a baseline against which progress can be assessed through a future audit. c 2004 Published by Elsevier Ltd.
Communication audit; Clinical placement; Organisational communication; Supervision; Assessor/mentor; Link tutor; Clinical facilitator; Audit tool
Introduction
* Corresponding author. Tel.: +44 12244 375444x3795; fax: +44 1244 381090. E-mail address: [email protected] (E. Hogard).
0260-6917/$ - see front matter c 2004 Published by Elsevier Ltd. doi:10.1016/j.nedt.2004.10.006
A previous study (Ellis and Hogard, 2003, 2001) evaluated a pilot scheme for the introduction of clinical facilitators into medical and surgical wards to work with pre-registration Nursing students.
120 Within a super-ordinate objective to improve the clinical competence and confidence of pre-registration nurses, the clinical facilitators had set themselves five key objectives, one of which was to improve communication around clinical placement. Whilst the clinical facilitators received very positive evaluations from students, ward staff, college staff and managers regarding four of their objectives, reservations were expressed regarding the extent to which they had improved communication. The evaluators pointed out that improving communication was the least well operationalised and most ambitious of the five objectives. It was, therefore, hardly surprising that stakeholders expressed most concern about its fulfilment. However, amongst their 18 recommendations, the evaluators included one that suggested that consideration be given to clarification of the respective responsibilities for communication of assessor/ mentors, link tutors and clinical facilitators. It was further recommended that a communication audit should be undertaken as a baseline for development and future evaluation. This proved to be a more original recommendation than was anticipated in that the literature on organisational communication in nursing placements was surprisingly slight and the communication audits used in other public and private organisations had not been applied in nurse education. This article then describes the development of a unique communication audit tool and its application to organisational communication involving clinical staff, college staff and students in relation to placements in the surgical wards of a general hospital.
Background Communication in practice education Despite the voluminous literature on communication in nursing and nurse education covering communication with patients, communication skills, and communication skills training (see, for example, Burnard, 1995; Kruijver et al., 2000; Chant et al., 2002) communication in practice education appears to be a relatively neglected area. In the vade mecum Placements in Focus (ENB, 2001), there is no explicit reference to communication although an emphasis on partnership between higher education and practice certainly implies it. Rather than a specific focus on communication as such, topics are addressed where communication
E. Hogard et al. is an implicit rather than explicit factor. For example, Last and Fulbrook (2003) in exploring the reasons for nursing student dropout mention communication between university and clinical areas in their abstract but do not develop this in the body of the article. Wilson-Barnett et al. (1995) researching clinical support for P2000 nursing students identify supervision, team spirit and organisation as key factors but make no mention of the communication that might be thought an essential component of each. Exploring stress in nursing students Timmins and Kaliszer (2002) highlight interpersonal relationships but fail to identify communication as a component in these. Arguably, the most important communication dyad in clinical placement is that between the student and supervisor or mentor. Andrews and Wallis (1999) review the literature on mentorship and manage to avoid any reference to communication but rather choose to emphasise relationships. Cahill’s (1996) qualitative analysis of student nurses’ experience of mentorship is similarly mute. Gray and Smith (2000) also address the students’ perspective and again avoid explicit attention to communication. However, Swann (2002) identifies communication explicitly as an essential component of the instructor–student relationship. Mamchur and Myrick, 2003) stress that problems between students and preceptors are about communication and interpersonal relations. From a search identifying a mere 57 articles notionally linking communication and student placement the authors found only a few containing any analysis of the various forms of communication, interpersonal and organisational, that characterise clinical placement in nursing and no reference to the use of communication audits. Langan (2003) investigating the roles of those involved in nursing student learning, found that lack of clear communication and the delineation of expectations amongst administrators, staff, faculty and students were the major factors in perceived role problems. These findings emerged from focus groups and interviews with a relatively small sample and could usefully contribute to and complement a more comprehensive audit. This review confirmed the relative novelty and potential utility of both an organisational as opposed to an interpersonal analysis of communication, and the use of a communication audit.
Communication audit In recommending a communication audit, the evaluators believed that a baseline was essential
Using a communication audit to improve communication on clinical placement against which improvements or decrements in communication could be detected. The idea of an audit was to identify the strengths and weaknesses of communication around clinical placement from the points of view of students, hospital staff and college staff. A communication audit has been defined as: ‘‘a comprehensive and thorough study of communication philosophy, concepts, structure, flow and practice within an organisation’’ (Emmanuel, 1985, p. 50) . It is essentially a process for acquiring data regarding communication for analysis (Downs, 1988). It can assist managers by providing them with knowledge of what is actually happening at the communication level, rather than what they thought, or were told was happening (Hurst, 1991a,b). A survey of available instruments for the communication audit highlighted the work of the International Communication Association during the 1970s (Goldhaber and Krivinos, 1977) and the scholarly interest this had attracted (e.g. Greenbaum and White, 1976). Goldhaber and Rogers (1979) identified key objectives to be achieved by a communication audit. These included the description of the major topics, sources and channels of communication, consideration of the quality and utility of information, and the identification of the positive and negative experiences of users with a view to effecting improvement. The International Communication Association developed an audit questionnaire that has been widely used in the US (Goldhaber and Rogers, 1979). However, we were unable to find any examples of its use with regard to the audit of communication concerned with clinical placement. Nor could we find any other instruments that had been used for this purpose. The ICA questionnaire is a comprehensive instrument in 13 sections. Completion depends heavily on the recollection and reporting of critical incidents in communication. Hargie and Tourish (2000) produced a simplified version which focussed on one critical incident rather than requiring a critical incident for each section. Arguably, the ICA questionnaire and the Hargie and Tourish adaptation need specific topics to make the instrument applicable to specific situations such as the pre-registration nursing clinical placement. The major development work for the instrument used in this study consisted therefore of devising specific references to participants in and aspects of clinical placement. The customised instrument is called the Hogard–Barker Communi-
121
cation Audit for Placement (HBCAP). It was piloted with a small sample of stakeholders to ensure comprehension and feasibility. It is described in greater detail below.
Methods The broad aim of the research was to identify effective and less effective features of communication around the practice placements of pre-registration nursing students using a specially devised communication audit tool. The instrument devised draws on the demonstrated validity and reliability of both the original international communication audit questionnaire (Goldhaber and Rogers, 1979;Downs, 1988) and Hargie and Tourish’s adaptation (Hargie and Tourish, 2000; Quinn and Hargie, 2004). The customising of the instrument for this purpose enhances face validity.
The audit questionnaire The HBCAP instrument was in the form of a questionnaire divided into 13 sections, each one dealing with a different aspect of communication together with a covering sheet for demographic information on participants. In seven of the sections, respondents were asked to rate the amount of communication received or sent and communication needed on a broad topic and its sub-sets according to the following values: very little (VL), little, (L) some (S), great (G) and very great (VG). The broad topics for these seven sections were: Amount of information received on eight topics grouped under new curriculum and allocations Amount of information received from 11 sources including individuals, organisational units and the ‘grape vine’ Amount of information received through 11 channels including face-to-face communication, documents and e-mails. Amount of information sent on seven aspects of placement Amount of information received on six important issues Amount of information sent on six important issues Action taken on sent communication by seven groups
122 Each section was further subdivided into specific topics relevant to pre-registration nursing clinical placement. In all the seven sections included 56 specific topics. Levels of satisfaction with communication for each section and its sub topics were determined by calculating the difference between the two raw scores for each question-the ideal score being ‘0’ which would indicate no difference between what was received and what was wanted. In order to identify potential problems areas, it was first necessary to compare the main question areas overall and then in relation to the different specific topics. Two further questions referred to how quickly information was received (timeliness) and to working relationships and trust. Within each question seven specific groups or individuals were included. Respondents were asked to rate their answers in terms of a five-point Likert scale. For timeliness communication could be rated as (N) never on time, (R) rarely on time, (SOT) sometimes on time, (MOT) mostly on time and AOT always on time. For working relations, the seven participant groups were rated for trust using markers of trust VL (very little) L (little) ŒS (sometimes) O (often) and A (always). Four sections, of a more open-ended nature, asked for strengths and weaknesses in communication regarding pre-registration student nursing clinical placement; for a description of a positive or negative communication experience (the critical incident); for comments on challenges ahead including the greatest challenge, the biggest priority in the workplace, and manager expectations; and suggestions for making communication better.
Sample The notional sample for the study was the complete population of trust and college staff and nursing students associated with the placement of three cohorts of students in six surgical wards five of which had 28 beds and one of which had 33. Potentially, there were 158 individuals who could respond.
Response rates Out of 158 questionnaires distributed a total of 74 were completed as follows. 53 from 96 possible students (54%) Seven from 10 possible ward managers (70%)
E. Hogard et al. Nine from 39 possible assessor/mentors (26%) One from one possible clinical facilitator (100%) Five from six possible link tutors (83%) Nil from three possible allocation staff. A 54% response rate from students is acceptable. The response rate from assessor mentors is disappointing and obviously raises questions regarding the effectiveness of dissemination from ward managers. The nil response rate from allocations staff reflected their concerns regarding anonymity, which could not be guaranteed for such a small identified group. Detailed demographic information is available for this sample but beyond the scope of this article.
Completing the questionnaire Typically the instrument took 30–40 min to complete and represented a significant investment in time and effort. Briefing sessions were organised for each group to explain the significance of the work and its potential impact. Participants volunteered to participate after a briefing. Forms were completed anonymously.
Ethical considerations The project was approved by the College Research Ethics Committee which judged it against the implicit criteria of the Royal College of Nursing (RCN, 2004) to assure beneficence, avoid of malificence, ensure informed consent, give equal opportunity, and assure technical competence.
Results Overall satisfaction On the comparative items differences were computed for all items overall, for each section and for each item in each section. A difference of 0 indicated satisfaction with minus or plus scores (up to a maximum possible of 4.0) indicating dissatisfaction with either too little information or too much. A difference of 2 or more is taken as indicative of dissatisfaction. Overall most groups, but especially the ward staff and first year students, were dissatisfied and believed insufficient information was being received or sent on a range of topics. The overall average difference for all sections and items was 2.1 indi-
Using a communication audit to improve communication on clinical placement cating a significant shortfall between what was received or sent and what was wanted. On the other hand more positive critical incidents were identified than negative and trust was generally positive.
Information received The link tutors were the only group involved in the audit who felt that they were receiving more information than they actually required particularly from the allocations office of the College. The other groups felt they were not receiving enough information from any source but particularly from allocations. The ward staff reported the greatest dissatisfaction ( 2.98) and this includes information about the new curriculum/programme. The audit took place shortly after the introduction of the new curriculum but also after a period when communication about the curriculum should have been at its most intense. With the exception of one source –‘‘the grapevine’’, where the ward managers felt they got an excess of information, all groups felt that did not receive enough information from the various sources available. Link tutors felt that they needed much more information from clinical facilitators. Some students (cohorts 2001/2000) required much more information from the link tutors. Among first year students (cohort 2001), e-mail and written communication were highlighted as desirable media for more communication while ward managers stressed the need for more clearly presented written material with audio-visual supplements.
Information received on important issues Information received on important issues is the section where the greatest overall deficit lies (mean 2.1). Within this the ward staff expressed the biggest deficit ( 2.62). For first year students the priority was more information on the development of the skills lab whereas for ward staff it was for information on the objective structured clinical examinations (OSCEs).
Timeliness of information Ward staff identified allocations as the least timely source of information. Link tutors felt that they received information when needed from each other but not from students. Students, reciprocally felt that information from link tutors was not timely.
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Information sent All groups felt that they were not sending enough information regarding all the different topic areas. Reporting problems about clinical placements was an issue for first year students particularly. Ward managers felt they were not able to express opinions about clinical placements or to report success and achievements. Nevertheless, although the sending of information is seen as an issue, overall it is perceived to be the least problematic of the sections (mean 1.23).
Organisational outcomes/action taken Although all respondents felt that more action needs to be taken with regards to the information they are sending, the ward staff feel most dissatisfied with the allocation office whereas the link tutors feel that the allocations office along with the clinical facilitators are the people who take the most action on the information sent. These results are consistent with a general trend amongst staff as opposed to students towards less dissatisfaction with intra-organisational as opposed to interorganisational communication.
Working relationships The level of trust amongst those who took part in the audit appears to be fairly good. All respondents seem to trust the clinical facilitators the most. In terms of the lowest level of trust, this was attributed to the ward managers by the second year students (cohort 2000) although the other participants groups, including the other student cohorts, have scored this group fairly highly. Hargie and Tourish (2000) point out if the level of trust is fairly good it provides a starting point from which to enhance communication. Furthermore, they argue, as communication improves so do relationships.
Critical incident Respondents were invited to select and describe one effective or ineffective communication experience. Hargie and Tourish (2000) state that these so-called ‘critical incidents’ provide insight into whether staff feel positive or negative about the organisation in general. They point out that where communication is functioning at a reasonable level there should be a ratio of at least 50/50 between positive and negative incidents reported. Bearing this in mind, although only 63% of the respondents
124 completed this section, the positive communication experiences equate to negative in a ratio of 60/40. This suggests that, in general, the staff feel positive about pre-registration clinical placement.
Open-ended questions The responses to the open-ended questions generally confirmed the findings from the quantitative section of the questionnaire and in this, as Quinn and Hargie (2004) suggest, offer a form of triangulation. However, the results did suggest some positive aspects to communication which tended to be hidden in the quantified responses. These included accessibility of clinical facilitator to students and link tutors; opportunities to relate theory to practice for students; and the introduction of useful information packs for students on placement and its requirements.
Discussion In this case study, the audit has shown that although by one indicator communication in the clinical preregistration clinical placement is seen as a positive process, respondents overall are dissatisfied with communication and there are a number of issues that need to be addressed, many of which are interlinked. It may well be that the issues raised are typical of pre-registration placements but further work will be necessary to establish this. First, the audit identifies a need for more information to be sent and received. This applies particularly to the ward staff and students who do not feel that they get information as and when they need it. Ward staff want more information from the college and students want more from their link tutors. With the sole exception of information through the socalled grapevine where some thought too much information was provided, there is an overall need for more information to be made available between all groups on all significant topics. Second, there is a lack of awareness between participants regarding both roles and the structure of the curriculum. This applies particularly to the roles of assessors and link tutors and to the students’ curriculum structure, learning outcomes and non-rostered practice. Clearly, these are topics on which clearer and fuller information should be provided. Third, the audit revealed shortfalls and inconsistencies in student support possibly exacerbated by the increased numbers of students passing through the system.
E. Hogard et al. This research was prompted by the perceived failure of clinical facilitators to improve communication in clinical placement. The communication process around and within clinical placement proved to be a complex one involving students, college link tutors, college administrators, assessor mentors, clinical facilitators and other ward staff. Two major organisations are involved namely the college and the trust. Student numbers have increased significantly and there is pressure on both trust and college resources. In these circumstances, it is perhaps not surprising that participants express overall dissatisfaction with communication processes. The base line provided by this audit not only suggests a number of initiatives that need to be taken but will also, through a subsequent audit, allow progress to be gauged. Despite the high levels of dissatisfaction, respondents identified more positive than negative critical incidents and levels of trust between participants is high which gives cause for optimism provided the various issues raised in the audit are addressed formally and in partnership.
Conclusions This research is the first to study organisational communication as a whole in relation to nursing practice placement. Given this novelty it has not been possible to contextualise the results directly in previous similar work. Comparing results with communication audits in other contexts (for example Quinn and Hargie, 2004) suggests that the level of dissatisfaction found here is relatively high but not perhaps surprisingly so considering how underdeveloped and under-researched the area appears to be. Clearly, the communication deficiencies identified here leave no room for complacency and, if they are representative, have important implications for the partnerships between higher education and service advocated by, for example, the ENB and DoH (ENB, 2001) and for the learning environment of the placement. The audit tool developed by the authors – HBCAP – is unique and has proved its utility and feasibility in this study. It is available from Hogard for those who wish to replicate the work in other settings.
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