The challenges of practice learning in the light of the Francis reports

1. The challenges of practice learning in the light of the Francis reports Professor Helen Allan Department Health Sciences University of York

2. Research based talk • Nurse researcher & teacher • Clinical nurse 23 years • Method [ethnography] gives in-depth data on realities of practice: • ‘I’m a nurse researcher. Did someone tell you I was coming?’ • ‘Oh great’ (ward sister) • ‘I can work while I research’ • Oh GREAT! Here’s a bay!’

3. Francis report (2013) • Key messages for education • Not as comfortable reading as Willis’ report, but some misunderstandings: • Compassion not taught • Recruitment & selection inadequate • “The NHS no longer appears to be a learning organisation” (Melia 2000)

4. Challenges to practice learning • Where is the Leadership for Learning in nursing & midwifery? • Using 3 projects over 8 years: • New role of the ward manager • Transitioning to newly qualified status • Midwives & complaints • Discuss challenges of practice learning in terms macro, meso & micro levels in the organisation of learning in health care

5. Macro • Structural reconfiguration of service delivery • Internal market • Foundation status • Structural reconfiguration nursing education • P2K • Fitness for Practice • UKCC 2000 national competencies • All graduate registration • Move into HEIs • Market mechanism for nurse education • Purchaser/provider split i.e.: splitting off of nursing practice from education (Allan et al 2009; Smith & Allan 2011)

6. Meso • Role changes in service • Ward managers • Mentors • Role changes in education • REF • Link lecturers • Lecturer roles (not tutors) • Student status • New relationships between nursing education & practice • Geographically • Contractually

7. Micro • Changing expectations of mentors & students • Learning contracts • Supernumerary status • Competencies

8. Projects • Study into Leadership for Learning – General Nursing Council Trust for England & Wales 2008/10 • Academic award and recontextualising knowledge - Centre for Research in Nursing & Midwifery Education 2011/14 • Responding Effectively to Service users’ and Practitioners’ perspectives ON care concerns: challenging Sustainable responses through collaborative Educational action research (RESPONSE) - Centre for Research in Nursing & Midwifery Education 2011/14

9. Methodologies – broadly qualitative in-depth case studies • Ethnographic case studies – 4 sites • 60 Interviews & participant observation [160 hours obs] • On-line survey [937 responses] • Ethnographic case studies – 3 sites • 50 Interviews & participant observation [198 hours obs] • Preceptor tool • Action research 1 site 2 yrs • Postal survey – 40 responses • Supervision groups – 7 midwives • Communications training – 4 midwives

10. Leadership for Learning study – ‘Feeling part of the team’ • Extract from notes (17/01/07 Site 1 day surgery morning shift; 3rd year, part-time student) • “At coffee student described how she felt they were told to be assertive and self-empowered in college and to be agents of change yet the NHS and nursing was hierarchical and bullying and I feel like I’m in the playground again. On ICU, nobody had said goodbye to her when she left, too busy doing internet shopping, obsessing about off duty and character assassination of anyone coming into the unit. She felt that staff referred to the students as ‘the student’ and staff didn’t bother to learn their names; rarely felt part of the team. She used the word ‘burden’ to describe how the mentoring relationship in the clinical areas” • Structure of course leads to not feeling settled • “Chopping and changing placements, you learn to learn” “Feel students are seen as stupid, clumsy, and that we’ll make mistakes” She resented this and felt nursing had to change.

11. ‘Doing things faster’ • Extract from notes (17/01/07 Site 1 day surgery morning shift) • coffee break with student nurse whose 1st placement was care home • “I asked what she’d learnt in the care home. She said immediately ‘confidence’ as she’d never done carework before and she felt she did all that there; she’d learnt confidence in meeting people, making relationships with them, getting to know them. And in surgery, these skills had given her confidence to cope with the faster pace and higher turnover.” • Later that shift during coffee break, “Very busy, short stay, patient turnover is high – have to be out in 23 hours. Student commented that having to work in bay with 6 patients on ½ hourly obs. was difficult ‘how do you keep up? You learn to do things faster’.”

12. ‘The blind leading the blind’ • Extract from notes 23/01/07 mixed surgical morning shift with 3rd year student ) • “Staff nurse and student allocated a bay and a transfer to bay from side room; staff nurse went straight away to do drugs asking student to move patient (very sick man) with HCA. Man needed to change to 40 % O2 from nasal cannula; sounded as if he had a chest infection; student went to fetch mask. Came back with no tubing; went to find some; came back with wrong tubing; came back with correct tubing and then started fitting mask and tubing. Hadn’t done so before, neither had HCA. There was a degree of fluster and patient got more breathless; HCA suggested turning up O2. Student went to ask sister who said yes and came back and turned up O2. I asked her if she felt okay and understood the reason for turning up O2. She said no; I explained rationale.” This went on for some time before the patient was successfully settled in his new bed; the staff nurse did not appear to supervise student with a very sick patient neither did the sister. • A similar situation arose when the staff nurse asked the student to do an ECG which she knew how to do. However then the staff nurse came in and the student asked her a question about ST elevation which she was unable to answer; student asked staff nurse how to stop trace interference; staff nurse didn’t know and it felt like the blind leading the blind.”

13. Challenge no. 1 • Reality of practice learning in busy NHS • Reality shock • 1st priority is safety of patients • Is learning always ethical? • Supernumerary status • Onus on student • Re-aligning practice & education at macro and micro level • Uncoupling • Supporting mentors • Link lecturer role

14. AaRK – what is practice learning as NQN? • Transition to newly qualified –reality shock • I’ve learnt the hard way really • they lack[ing] confidence if you like, not necessarily knowledge • Learning largely invisible and unsupported • The knowledge was there I just didn’t feel that it was there and I didn’t feel that I knew enough but then when I started talking about it and doing it and pulling things you know from wherever it was stored I thought ‘wow, I do know this’, you know, ‘wow, where did that come from’, I do know what it is to be a nurse … you look at yourself in the mirror and think ‘I can do this, I am a nurse’, you know I am a good nurse

17. Challenge no. 2 – learning as NQN • Support after qualifying • Preceptorship key • Need to develop ‘assumed’ skill • Recontextualisation of learning • Hidden curriculum & invisible learning • Expectations in teams and at management level of NQNs • Hit the ground running

18. RESPONSE – responding to complaints by ‘no longer assuming’ • "There are a couple of things that I have noticed I have changed on my practice. The first one is that I no longer assume that patients or even colleagues understand what I say in the way I mean to say it. I am constantly "checking for clues" (i.e. non verbal communication) to ensure that they understand exactly what I need them to.The second one is related to my ability to show empathy particularly to patients when their expectations are not met. I found quite helpful to verbalise more accurately my thought process. For instance, if someone has been waiting for an obstetric review for a long period of time and they complaint loudly. I find that patients (or patient's relatives) seem to calm down faster if they hear me saying something like "Oh dear! you must be tired by now. I'm very sorry about this. Let me find out why this has happened and see what we can do to fix this".I really appreciated that session and I wish we had something like this in other hospitals. I would love to know about the conclusions of your study when you finish."

19. ‘Paying more attention’ • "I think that I now pay more attention to the words that I use, in particular with patients and visitors however I'm not sure if this was due to a incident in practice which may have facilitated this change. I also think that the training has made me think more about communication in general in all aspects of my work including answering door bells, speaking to doctors. I have learnt not to assume that the reason for patients being angry/frustrated is always due to lack of information, rather than considering alternatives and asking the family directly about their concerns.

20. ‘Stop and think’ • "Following the training I have really taken the time to think about how I communicate with patients and have become aware of how many closed questions I ask. I have tried to ask more open ended questions, and have been trying to consider how I communicate with patients, including non-verbal communication. The training definitely helped me communicate with people from who don't speak English very well.I think I have become a little more confident, and found the session very useful to stop and think about what and how I say.

21. Challenge no.3 – learning & service development • How do we learn in practice to develop practice? • Busy-ness of NHS – hard to engage in practice and service development • Totalising systems (Goodman 2012) Compassionate individualised midwifery care within a ‘total’ health care institution: a possibility or a paradox? (Allan et al in review) • Stop, think, pay attention and don’t assume

22. Conclusions • There is huge willingness to learn among ward staff • Expectations that staff will learn by trust managers & desire to facilitate that • There is tension between patient and learning functions of NHS • “The NHS no longer appears to be a learning organisation” (Melia 2000) • Recoupling of NHS and HEIs

23. Allan H T, Smith P A, O’Driscoll M (2011) Experiences of supernumerary status and the hidden curriculum in nursing: a new twist in the theory-practice gap? Journal Clinical Nursing: 20: 847–855 • O’Driscoll M Allan H T Smith P (2010) Still looking for leadership – who is responsible for students nurses’ learning in practice? Nurse Education Today 30(3): 212-218 • Smith P, Allan H T (2010) We should be able to bear our patients in our teaching in some way’ theoretical perspectives on how nurse teachers manage their emotions to negotiate the split between education and caring practice. Nurse Education Today. 30(3): 218-223

24. Evans K,Guile D, Harris J & Allan H T (2010) Putting knowledge to work: a new approach. Nurse Education Today. 30(3): 245-251 • O’Driscoll M Allan H T Smith P (2010) Still looking for leadership – who is responsible for students nurses’ learning in practice? Nurse Education Today 30(3): 212-218 • Odelius , Allan H T Hunter B Bryan K Gallagher A & Knibb, W (2012) Reflecting on action research exploring informal complaints management by nurses & midwives in an acute NHS trust. Int. Journal Practice Development 2, 2.