Using learning contracts to support change in nursing organisations

NURSE EDUCATION TODAY 0 Longman Group Ltd 1986

(1986) 6, 103-108

Using learning contracts to support change in nursing organisations Dirk Keyzer

This paper is taken from a research study in which learning contracts were negotiated with clinical nurses attempting to implement a nursing model in practice and in education (Keyzer 1985). The literature on learning contracts is reviewed and the findings of the study discussed. Learning contracts are viewed as a bridge between the school of nursing and clinical practice.

This

paper

is taken

(Keyzer

1985)

learning

contracts

from

in which with

ployed

in four wards

Health

Authority

a

the

attempts

practice

of

provided

a

means

of

nurse in her attempts

The

need

for

supportive

learning

con-

and

United 1982).

perceived

by

learning were,

need the

was identified

Central for

proto-

Council

further

UKCC

to

by the (UKCC

education lie

in

the

was gap

to perform.

One

of the

major

issues

D M Keyzer PhD MSc DANS RGN Projects Coordination Dfficer, Welsh National Board for Nursing, Midwifety and Health Visiting Manuscript accepted Februan/ 1996

in an earlier that

in

neither

needs

leagues The teachers

by

There

who

read

in the quality population.

contracts

of nursing

of informal

nurses

with their col-

a change

learning

edu-

individual

journals. nurses

the contents

in a school

(Keyzer

the nursing

their

for the patient

development

study

of clinical

reading

and perceived of

con-

value on in-service

individual

discussed

use

can

which

on the

did

supporting

however,

of care provided

the

value

nor were the majority

the

in the move

organisation

little

edu-

the nurse

needs of the nursing staff.

place much

active

the

between the existing level of practice and the new role that the ‘practitioner’ nurse was expected

cation, very

supporting

of a nursing model in

education

Kingdom This

recorded

for continuing

of support

placed

suggested

to implement education

involved

ward the implementation practice

Data

journals,

for nurses

has

tinuing educational

hierarchy

nursing process. grammes

hitherto,

an

1980)

need

from a bureaucratic

was

study

of this

expect

1980)

(Keyzer

tracts

staff in

out

is the degree

in

The informal

con-

arising cation

model

one

earlier that

in one

the clinical a nursing

education.

indicated

em-

1). The learning

an

which clinical

staff

of four hospitals

(Table

to promote

and

extension

study

negotiated

clinical

tracts were used to support their

research

the writer

by

nurse

could facilitate in-service

edu-

cation programmes based on individual and group needs for further education. The purpose of this learning the

paper

research

learning support

is to review

contracts

the

literature

on

and to discuss the findings of

study

(Keyzer

1985)

in

which

contracts were the vehicle used to change in the role of the nurse. The

formal educational the study were

programmes represented in the Diploma in Nursing 103

Facilitate the professional development of the nurse Promote a democratic management style, enhance the staffs job satisfaction, upgrade the quality of patient care

Compare and contrast other attempts to implement change

Unit staff Colleagues in other wards Medical staff

Nurse-tutors

Visits to other units in this and other Health Authorities

Peer group discussion

Individual and group discussion

Individual and group discussion

Staff will discuss with each other and experiment with the suggested plan for re-organising the workload, i.e. change in shift-work, named nurse for a set group of patients, link up a trained nurse with specific students and patient group for duration of students’ stay in unit

The fomrat must be acceptable to both staff and patients The redistribution of the workload will utilise the individual expertise of group members

Diploma in Nursing course

Charge-nurse (formal education)

Stimulate a learning environment in the ward for staff and patients

The data gathered will identify the patient’s strengths and weakness, hi priorities for care, hi contributions to the plan of care

The record will contain a nursing history, a plan of care and an evaluation sheet

School of Nursing Library Psychiatry Main teaching hospital

Self study (non-formal education)

To complete a nursing record which can bs used by all members of staff

Criteria for evaluation

strategy

Learning objective

Table 1 Example of a learning contract for clinical staff

NURSE

(London Joint

University,

Board

940/491. cally

The

based

tween

non-formal

the writer one

one

and

assessment

and community

of

that

pendent

be-

employed

in

geriatric

rehabilitation

in this attempt

ment

The

Course

negotiated

one long-stay

unit

unit;

and

general,

nurses were repre-

to promote

the role of the clinical

and the

inputs were the clini-

the nurses

psychiatric

psychiatric

Studies

contracts

hospital,

psychogeriatric

sented

Nursing

learning

one community unit,

Old Regulations)

of Clinical

change

in

nurse and the manage-

change

by

the

nursing

strategies

to foster

activities

have been described

and discussed by a number

these inde-

of educational&

terms which reflect their individual of how ‘independent’ 1969,

Ruddock

Bridge

1978,

Goldman

Ramsden

1980).

Percy

that it is unwise means

dence.

This,

means

of

&

to generalise

promoting

1977,

Percy

Ramsden

&

suggest

about

of achieving

they argue,

is (Rogers Elton

1979,

&

in

perceptions

such learning

1978,

Knowles

effective

105

TODAY

adopted

learning

adjusting

organisation.

EDUCATION

the most

student

indepen-

is best perceived

student

as a

motivation,

or

the pace of work so that it takes into

account

the

differing

abilities

of students

at

solving problems. In

LEARNING CONTRACTS: A VEHICLE FOR CHANGE Much

of the literature

of independent the attempts institutions It

is

programmes

by individual

to promote

dents following

higher

argued

responsibility

that

independence

the

his own learning been

approach

coined

self-directed initiated,

objectives.

use of contracts

Alexander

& Vynce

involvement

definition

( 1976)

of

the

( 1978)

Orem

( 1980)

an

agreement

of independent

the individual’s rewarded

an

control opment (Lamond

places nursing

and

the their

describe

that is motivated

own will to learn

in terms of its intrinsic

definition ditional

underlined

study

such study as any activity

less emphasis practices

which

by

and largely

value. on

Such a

those

tra-

diminish

the

exerted by the student over the develof his own learning programme 1974).

vehicle

programmes in education

for

Thus

independent

implementing

the

study

as

learning

needed to bring about the changes and practice

may

who

Donald formal

(1976)

manner

aspect

perceived

be the means

whereby nurse education moves toward comprehensive and unifying programmes to include formal and informal learning.

viewed

between

should be a document and the student

of the

persons for a

this agreement

and suggested

a

by Mayers

the purpose of their association

(Boud

in

was described

regarding

student-

student

and

process.

as an integral

process

and

education

the nursing

the nursing

in a

that the contract

drawn up by the teacher

in which they specify what the

student

will learn,

how this will be achieved,

within

what

span

measuring

active

of in-service

for implementing

it was

were an ac-

specific period of time.

1981).

the

form

1980),

contracts

and

study;

learning

(Keyzer

take Many

student-centred,

The

study learning

as

such

independent

and project-orientated

that

contracts

and the following

terms:

learning;

stu-

should

to describe

to adult education

are a few of these

in

his own work

terms

to and

programmes.

student

for pursuing have

refers

teachers

education

for planning

earlier

ceptable vehicle

on the implementation

learning made

an

suggested

(1978)

time

and

viewed the contract

informal

the

criteria

the success of the venture. manner

out of specific

for

Langford

in a broader,

more

and defined only the carrying

actions,

or the taking

of actions

to reach an agreement. The

learning

informal pants,

verbal

Esbensen contracts vation

may, therefore, between

or it may be a formal

is signed

chosen

contract agreement

by

the

teacher

be an

the partici-

document and

which

the

student.

(1969) indicated that a variety of were required and that the type greatly

and

influenced

progress.

tracts are available

Hence

the

learner’s

a variety

to the participants

in the implementation

of the nursing

motiof con-

engaged process

from ‘teacher made and assigned’ to ‘student made and initiated’. The flexibility of the contractual nature of

106

NURSE

EDUCATION

these learning the individual staff.

TODAY

programmes gives support for and group needs of the ward

In these small

groups,

it may

that some nurses will be happier discussion

whilst

structured

approach

contract

may,

climate

and

that

a

the handing

with firm definitions

right

(1969)

to learn’

to demand

in-

didactic,

teaching.

Very little has been written contracts

about

the use of

underlying education

Bernstein nurse

Ottaway

from

the

(1976)

in relation

dents

may

porting

full-time

programmes. perceived the

( 1979) as a means of sup-

students

Both

the contract

internal

external described

of

the

of the

those

effective methods to support

students to

confidence

leads to confusing

their

work.

behaviour.

The

student,

adopt

give

were used

confidence

in

lack

of

self-

and self-defeating

therefore,

commitment

to

to take risks and hence,

student

negotiated

in

an

used contracts

for learning

between

dent. Bouchard

outcomes

The

(1980)

resulting

of the learning

to

Independent,

presenting

data

their

old and tried Freire (1978)

control

challenges

with

to satisfy

the

peer group and relation-

learning nurse,

con-

but they

the traditional and

attitudes.

between

the

in the

of non-formal

the writer

in the process

as risk-taking

teacherThus,

process

area and the negotiation

be regarded

to

of power and con-

of the nursing

contracts

the

process, will

methods

to the trained

trol which

learning

over

in any attempt

non-formal

a redistribution

relationship

to

learning

not only a different way of

also reflect student

stu-

and the

of change,

ventures

may

which

are

likely to be opposed by colleagues in the ward, the school and by members of the learning group.

to share accountability

the teacher

& Steels

in

inherent

tracts are, therefore,

clinical

desired

and the stusuggested

that

formalised contracts improve teacher-student communication and enhance the student’s expressiveness.

ships.

the

fails to achieve contracts

attempt

threat

to traditional

implementation

students’ needs and interests through a flexible and yet demanding course of study. Crancer et al (1977)

to conform

resistance some

the freedom

insist that the reinstated.

the

nurses engaged

(1976)

nurses

that

of

trained

to promote by

Similarly,

be

finds it dif-

the preset goals. Searight

attempt

to accept

to

1978,

nature and

result in pressure from the teacher’s

to

an unstructured

This

student

be used to

fail

who lacked

and adopted

unquestioning any

to

assump-

Freire

will be met

access to knowledge

the it is

approach

1969,

self-directed

and

by

of learning

involve the student in the learning

the contracts

approach

to

could

who

argued

taken

Goldman

of study in spite of a desire to

their own ability

change,

relationships

the

that

study

more

activities

on the

traditional

The

hesitate

Goldman

ensures

the basic

(Rogers

establishment.

education

and

organisation.

students

do so. In this instance

ficult

student

how the contract

support

and

as a vehicle for meeting

needs

needs

in higher

Knowles

become

which

of the contract,

nursing

suggests

discussed their use in industry,

change and Goldman

the

1975).

(1978)

the

to take

approach

challenges

traditional

independent

in

nature asked

over of the control that

tions

Knowles

participation

of the

nurse

in nurse education. to worker

is not

of

& Steels underline

in the negotiation

the student

the

framework

which belong to the teacher.

Regardless

and ease, or to support Rogers

protective

responsibilities teacher

broad

Bouchard

the student

a

the ‘freedom

the student’s

classroom-bound

that

a more

the

the contract’s

be used to create

responsibilities.

acknowledged

learning

prefer

within

course objectives.

(Boud 1981). The learning

of proceedings

roles

cluded

might

therefore,

of informality

framework of

others

be found

with informal

solving

creativity

programme

in

the

are linked

to the security offered by the contracts to those students involved in the risk-taking of problem-

PRACTICAL IMPLICATIONS The data obtained by Keyzer (1985) indicate that learning contracts can be used to facilitate the personal and professional development of the nurse, in formal and non-formal education, at

school

of

nursing

and

tertiary

levels.

NURSE

Regardless

of the

used appears the

setting,

the

actual

format

to be of lesser importance

than

negotiation

of an agreement between and student. Given the pressures of the

teacher workload

and the variable

leagues

to change

commitment

towards

of col-

the implementation

curriculum

giving

emphasises

role of the nurse,

tion to the managerial expected more,

little

attention

role the student

is more

student

gramme. flexible

It

to facilitate falls

to

as possible

of the clinical

that

have clinical rank;

teacher

to

be

as

of expect-

their work patterns

of the course of study. It is

the teacher

credibility credibility

understanding

pro-

the constraints

instead

to change

to suit the demands

her

the

learning

in accepting

environment,

ing the learners also argued

the

of

cannot

purely is gained

the

expect

to

on the basis of through

demands

of

her

clinical

becomes

school of nurs-

the

direct

Further-

is paid

teaching

to the

to assume once she

a staff nurse. The change

tasks but

nurse involves

it also brings

relationships

nurse is

on graduation.

is expected

to trained

care-

but pays little atten-

role the trained

to perform

107

TODAY

models for care. The traditional ing

of nursing models in practice and education, it is unwise to be too rigid about which format likely

EDUCATION

with

with the patient,

in role from not only new

it a change

in

the doctors

and

all levels of nurse. The

practitioner

role

fession and supported is unrelated enced

in

trained

desired

by

to the organisational clinical

the

pro-

by the school of nursing

practice.

nurse experiences

role experi-

Thus,

the

difficulty

newly

in adapting

to her new role and the experienced

nurse has

of

difficulty

aspects

trying to carry out the tasks at hand as well as

her role.

practice

on the nurse’s

to implement

change.

ation of a learning respect a

between

contract

partners The 1985),

time and the strains The

a

(Keyzer

1980) can

in-service

education

bridge

by

those

contracts

in

the

the the

use

The

school

clinical

practice.

nurse is ill-prepared

clinical

role

(1982).

The

expected

of learning and

group

nursing

suggest

that

and the

for the advanced

of her

therefore,

study

and provide a of

data

(Keyzer

previous

individual

clinical

nurse,

study

programmes

between

equal

by

the

UKCC

the that

nurse’s

time

To

meet

and

skills,

all levels of nurse

contents

(Keyzer

finds herself in a

these demands the data

on

suggest

are in need of further

development

school of nursing devote a greater continuing The

be’ and ‘nursing between

the

amount

the

To promote

practitioner

role

the

need to

of time and money to

than

they

have

in

the

of traditional to suggest the

clinical

that trained

classroom-bound

training.

that

could

needs of all members will require

It would

one teacher

area

meet

they adopt

they make can inhibit

be unrealistic

the

alone

in

educational

of the nursing

of nurse and the recognition

contract approach

working

the active involvement

the policies

nurses prefer

of the learning

staff. This

of all grades

by nurse managers and the decisions

or promote

the changes

support.

the

role desired as it ought

to

as it is’ lies in the discrepancy ‘curriculum’

nurse’s

also to prescribe

of the

orientation

move

‘nursing

the study

not only to assess

and the organisation

data indicate

the action

education

by the profession. The schism between

and this

of

past.

they theoretically

towards

in

that the trained

but

education

a need for further

the

plans

to meet these needs.

in this study has identified

of the practitioner

care

recorded

needs,

care needed

that

to support

the

base is inadequate

education in all aspects of the nursing process. It is argued that the use of learning contracts

implementation

the clinical

1985) indicate

knowledge

the

of

contracts

to the more didactic,

position where she is unable to comply with the demands made on her by nurse-theorists and nurse-leaders.

The learning

the patient’s

the

of

that

facilitate

between

process.

obtained

support

the essence of

cooperation

in the learning

negoti-

depends on mutual

the participants;

is

data

successful

contract

in supporting

and

‘discipline’

CONCLUSIONS Learning contracts offer a vehicle for change and they should be used in future studies of the

108

NURSE

EDUCATION

TODAY

nurse’s role, the implementation in-service that

education.

further

learning education

study

contracts

It

be directed in the basic

programmes.

recommended

of change

and

is also recommended

In

to the

use of

and post-basic

particular,

that the use of learning

it

is

contracts

as a bridge between

school and clinical practice

be clarified through

action research

studies.

References Alexander M, Vynce A H 1976 Independent study in secondary schools. Holt, Rinehart and Winston, London Bernstein B 1975 Class, codes and control. Volume 1. Theoretical studies towards a sociology of language. Routledge and Kegan Paul, London Bouchard J, Steels M 1980 Contract learning: the experience of two nursing schools. The Canadian Nurse, January, 1980, pp 4448 Boud D 1981 Developing student autonomy in learning, Kogan Page, London Bridge W, Elton L 1977 Individual study in undergraduate science. Heinemann Educational Books, London Crancer J, Maury-Hess S, Dun J 1977 Contract systems and grading policies. Journal of Nursing Education 16(l): 2935 Donald J G 1976 Contracting for learning. Learning and development 7(5): 1 Esbensen T 1969 Working with individualised instruction: the Deluth experience. Fearon Publishers, Los Angeles Freire P 1978 Pedagogy of the oppressed. Penguin Books, Harmondsworth Goldman G 1979 A contract for academic improvement in: Hills P J (Ed) Study courses and counselling. Research into higher education, London

Keyzer D M 1980 Learning contracts: A non-formal approach to in-service education. MSc thesis, Manchester University Keyzer D M 1985 Learning contracts, the trained nurse, and the implementation of the nursing process: comparative case studies of the management of knowledge and change in nursing practice. PhD thesis, London University Knowles M S 1978 The adult learner: a neglected species, 2nd Edn, Gulf Publishers, Houston Lamond N 1974 Becoming a nurse. Royal College of Nursing, London Langford T 1978 Establishing a nursing contract. Nursing Outlook 26(6): 386-388 Mayers M G 1978 A systematic approach to the nursing care plan. Appleton-Century Croft, New York Orem D E 1980 Nursing: Concepts of practice. McGrawHill, London Percy K, Ramsden P 1980 Independent study: two examples from English higher education. Research into Higher Education, Monographs, London Ottaway R N 1976 A change strategy to implement new norms, new styles and new environment in the work organisation. Personnel Review 5( 1): 13 Rogers C R 1969 Freedom to learn. Merrill, Columbus, Ohio Royal College of Nursing 1981 A structure for nursing. Royal College of Nursing, London Ruddock J 1978 Learning through small group discussions: a study of seminar work in higher education. University of Surrey, Guildford Searight M W 1976 Perceptorship study: contracting for learning. In the second step: baccalaureate education for registered nurses. F A Davis Co, Philadelphia United Kingdom Central Council for Nurses, Midwives and Health Visitors 1982 Education and training: Discussion paper 3, Consultation Document, UKCC, London