A contemporary examination of workplace learning culture: an ethnomethodology study

A nurturing and caring environment to facilitate nursing students' professional development in Rwanda: a focused ethnographic study

OBJECTIVES

To explore the values, practices, and behaviours that support nursing students' professional development in practice-based learning environments in Rwanda.

METHODS

A focused ethnographic approach was used. Nursing students (n=12), nurses (n=11), clinical instructors (n=7) and nurse leaders (n=8) from three teaching hospitals and an educational program participated in the study. Data was collected trough individual interviews and participant observation.

RESULTS

Participants embraced a culture of preparing nursing students for their professional roles as a professional responsibility, and a means of securing the nursing profession. Modeling the appropriate behaviours to students and respecting them as learners and humans constituted the caring attributes that sustain a positive learning environment for their professional growth.

CONCLUSIONS

Nurturing and caring environments offer students opportunities to integrate caring attitudes into their interactions with patients and to develop professionally.

IMPLICATIONS FOR INTERNATIONAL AUDIENCE

Findings underscore the need to enhance caring values within nursing curricula.

Patient perceptions and understanding of pressure ulcer risk in the community: Empirical Research Qualitative

AIMS

To explore patient perceptions and understanding of their pressure ulcer risk and how information is communicated between a nurse and patient in the home setting.

DESIGN

A pragmatic qualitative research design including community-dwelling patients, who were deemed at risk of developing a pressure ulcer.

METHODS

Observation of routine interactions between nurse and patient regarding their pressure ulcer risk and semi-structured interviews with 15 community patients following the nursing interaction.

RESULTS

Four key overarching themes emerged from the data analysis that were related to patient perceptions and understanding of pressure ulcer risk. These included Pressure Ulcer Awareness, Importance of Repositioning, Healthy Eating and Risk Interpretation.

CONCLUSION

Patient perception and understanding of pressure ulcer risk is different from the scientific, professional view. Patient risk perception was based on heuristics and wider personal factors and social influences.

IMPACT

The study provides important new insights into clinical practice in relation to how pressure ulcer advice and information are provided and interpreted in the community setting.

REPORTING METHOD

Adhered to the Standards for Reporting Qualitative Research (SRQR) PATIENT OR PUBLIC CONTRIBUTION: A small selection of patients within the NHS Trust in which the research was conducted contributed to the design of the study, in particular some of the interview questions and timing.

When theory beats practice: the implementation of competency-based education at healthcare workplaces : Focus group interviews with students, mentors, and educators of six healthcare disciplines

BACKGROUND

Work-integrated learning constitutes a large part of current healthcare education. During the last decades, a competency-based educational (CBE) approach has been introduced to reduce the theory-practice gap and to promote continuous competency development. Different frameworks and models have been developed to support CBE implementation in practice. Although CBE is now well-established, implementation at healthcare workplaces remains complex and controversial. This study aims to explore how students, mentors, and educators from different healthcare disciplines perceive the implementation of CBE at the workplace. The six-step model of Embo et al. (2015) was used as a base: (1) competency selection, (2) formulating learning goals, (3) self-monitoring performance, (4) self-assessing competency development, (5) summative assessment of individual competencies, and (6) summative assessment of global professional competence.

METHODS

Three semi-structured focus group interviews were conducted with (1) five students, (2) five mentors, and (3) five educators. We recruited participants from six different educational programs: audiology, midwifery, nursing (associate degree and bachelor), occupational therapy, or speech therapy. We used thematic analysis combining an inductive and deductive approach.

RESULTS

An overview of the predefined competencies was hard to find which complicated CBE implementation and resulted in a lack of consistency between the steps; e.g., the link between the selection of relevant competencies (step 1) and the formulation of learning goals based on these selected competencies (step 2) was absent. Furthermore, the analysis of the data helped identifying seven barriers for CBE implementation: (1) a gap between the educational program and the workplace, (2) a lacking overview of predefined competencies, (3) a major focus on technical competencies at the expense of generic competencies, (4) weak formulation of the learning goals, (5) obstacles related to reflection, (6) low feedback quality, and (7) perceived subjectivity of the assessment approach.

CONCLUSION

The present barriers to CBE implementation lead to a fragmentation of current work-integrated learning. In this way, theory beats practice when it comes to CBE implementation as the theory of CBE is not effectively implemented. However, the identification of these barriers might help to find solutions to optimize CBE implementation. Future research seems critical to optimize CBE so that theory can meet practice and the opportunities of CBE optimize healthcare education.

Student beliefs about their practice within a non-traditional mental health clinical placement

Therapeutic recreation programs utilize leisure to maximize a person's overall health and well-being. The focus of this study is a professional experience placement held within an outdoor recreation center involving student nurses and people with a lived experience of mental illness. The study aimed to explore student nurse's beliefs about their practice within the program setting. An ethnographic case study approach was used to focus on the development of student nurse practice in this setting. The analytic strategy derived the themes of the ethnographic case study, namely 'who's who', 'clinical contrast' and 'recreation as practice'. A non-traditional mental health clinical placement would seem to have the potential in providing a new set of skills and experiences to these future nurses that may complement the scope of recovery-orientated care. The therapeutic recreation program provided the student with an experience where they could develop therapeutic relationships with people a lived experience of mental illness.

"If somebody just showed me once how to do it": How are workplace cultures and practice development conceptualised and operationalised for early career nurses?

BACKGROUND

An imminent nursing shortage mandates attention to retention of early career nurses. One factor that impacts on intention to stay in the profession is the ability to do the work. Early career nurses rely on supportive cultures to develop the practical skills and knowledge specific to particular workplaces.

OBJECTIVES

This study was conducted to determine the impact of workplace culture on practice development for early career nurses.

METHODS

We undertook a qualitative study using semi-structured interviews conducted with eleven early career nurses at a single metropolitan hospital in Melbourne, Australia. Interviews were transcribed verbatim and analysed using thematic analysis techniques.

RESULTS

Themes identified were learning in the moment, active welcome, confidence, ambiguities in the culture of learning, bullying and navigating the space.

CONCLUSIONS

Early career nurses conceive practice development as the acquisition of skills and knowledge particular to the immediate needs of their patients, which they learnt by asking questions. Developing confidence was integral to all aspects of practice development. Complexity and risk on the wards could negatively impact on confidence. Where welcome was explicit and overt the nurses felt that practice development was facilitated. Transition to practice programs supported nurses and some individual nurses were active in assisting nurses to develop. However, workplace cultures were at times indifferent to the learning needs of the early career nurses and some experienced poor workplace behaviour and bullying.

How do undergraduate nursing students learn in the hospital setting? A scoping review of conceptualisations, operationalisations and learning activities

OBJECTIVES

Although clinical learning is pivotal for nursing education, the learning process itself and the terminology to address this topic remain underexposed in the literature. This study aimed to examine how concepts equivalent to 'learning in practice' are used and operationalised and which learning activities are reported in the nursing education literature. The final aim was to propose terminology for future studies.

DESIGN

The scoping framework proposed by Arksey and O'Malley was used to answer the research questions and address gaps in the literature. Two systematic searches were conducted in PubMed, EBSCO/ERIC and EBSCO/CINAHL between May and September 2018: first, to identify concepts equivalent to 'learning in practice' and, second, to find studies operationalising these concepts. Eligible articles were studies that examined the regular learning of undergraduate nursing students in the hospital setting. Conceptualisations, theoretical frameworks and operationalisations were mapped descriptively. Results relating to how students learn were synthesised using thematic analysis. Quality assessment was performed using the Critical Appraisal Skills Programme checklist.

RESULTS

From 9360 abstracts, 17 articles were included. Five studies adopted a general, yet not explained, synonym for learning in practice, and the other approaches focused on the social, unplanned or active nature of learning. All studies used a qualitative approach. The small number of studies and medium study quality hampered a thorough comparison of concepts. The synthesis of results revealed five types of learning activities, acknowledged by an expert panel, in which autonomy, interactions and cognitive processing were central themes.

CONCLUSIONS

Both theoretical approaches and learning activities of the current body of research fit into experiential learning theories, which can be used to guide and improve future studies. Gaps in the literature include formal and informal components of learning, the relation between learning and learning outcomes and the interplay between behaviour and cognitive processing.

New Graduate Nurse Experiences in Clinical Judgment: What Academic and Practice Educators Need to Know

AIM

The aim of the study was to determine if use of a structured reflection exercise using a clinical judgment framework would result in more practice-ready new graduate nurses (NGNs).

BACKGROUND

Clinical judgment is a critical skill for all nurses, yet it is identified as a deficit in NGNs.

METHOD

Seventy-four NGNs in two groups participated in this mixed-methods study in their first year in practice. Scores from two quantitative measures were collected for all participants. The Lasater Clinical Judgment Rubric framed the structured intervention.

RESULTS

Although the quantitative data showed no significant differences between the groups, use of the reflection exercise indicated a positive impact on NGNs. Qualitative data revealed four themes that present challenges for preparation of NGNs: enhancing communication, finding interprofessional support, responding to complexity of care, and appreciating the role of the nurse.

CONCLUSION

Implications provide guidance for academic and practice educators to smooth the transition into practice.

Student perceptions of knowledge development and consolidation in a clinical community of practice

The undergraduate nursing degree in the UK comprises both theoretical and practical elements with the practical component being a large and important aspect. Within the clinical environment students learn to become a nurse by gaining membership of a community of practice and learning the technicalities of nursing. As the future of health and social care looks set to see unprecedented changes, contemporary nursing practice will demand that nurse graduates are equipped with advanced knowledge and skills. By doing so, graduate nurses will go on to provide high quality care within this changing context. The aim of the research was to explore student nurse perceptions of knowledge development and consolidation in a clinical practice environment by utilising a community of practice theoretical framework to question whether the clinical community of practice prepares student nurses for contemporary nursing practice. Four themes emerged from the research: establishing a place in the community, shaping identity, initiating learning opportunities, preparation for future practice. The findings suggest that the clinical community of practice provides an opportunity for students to both learn the technicalities of nursing and develop their professional identity. However, whilst the learning environment may be functional in maintaining current practice, it may not facilitate the learning required for contemporary nursing practice.

New graduate occupational therapists' narratives of ethical tensions encountered in practice

BACKGROUND/AIM

Professionals in health and social care have high workloads and are working with diverse populations in hierarchical and complicated service delivery systems. There is increasing pressure on new graduates because they are expected to be immediately work ready and may not receive adequate support or supervision. It is well known that there can be issues with satisfaction and retention rates of new graduates due to the challenges they experience. Ethical tensions are an unavoidable part of occupational therapy practice and may contribute to unique challenges for new graduates who may not yet have the personal resources to make sense of these independently. New graduate occupational therapy perceptions of ethical tensions have not yet been explored and this study sought to fill this gap. Exploring the ethical tensions experienced by new graduates can inform appropriate policies, procedures, preparedness and standards.

METHODS

A qualitative study using narrative enquiry was undertaken in which stories were gathered from eight new graduate occupational therapists who had been working for 6-24 months. Semi-structured in-depth interviews were used to gather data. Transcripts were analysed following narrative analysis guidelines. Member checking, reflexivity and keeping an audit trail of methodological and analytical decisions were employed to strengthen the rigour of the study.

RESULTS

Analysis revealed six predominant themes: working in a business model, respecting client choice, dealing with aggression and death, mandatory reporting is hard to do, differing team values, and feeling devalued and unsupported.

CONCLUSION

The findings highlight the importance of understanding the ethical tensions faced by new graduates and of exploring ways to assist new graduates to respond constructively to ethical dilemmas, distress and uncertainties. To address the risk of attrition, graduates need systems in place for accessing support to increase preparedness to respond to ethical tensions when they do arise.

Ethical tensions: A qualitative systematic review of new graduate perceptions

Background:

New graduate transition into the workforce is challenging and can involve managing ethical tensions. Ethical tensions cause new graduates to doubt their capabilities due to their lack of experience. To support new graduates, we need to know what these ethical tensions are.

Objectives:

To explore the ethical tensions perceived to occur in practice for new graduate health professionals.

Research design:

This qualitative systematic review involved a search of five databases (Medline, EMBASE, AMED, CINAHL and Scopus) which resulted in the retrieval of 3554 papers. After the two-phased screening process, eight studies were identified that met the inclusion criteria and had rich data on the review question. Articles were read several times, critically appraised and analysed through thematic analysis.

Ethical considerations:

No ethical approval was required for the systematic review. The review was conducted following well-established reporting guidelines enabling transparency and rigour.

Findings:

Studies originated from Australia, United States, Iran and China. One study included speech pathologists and seven were with nurses. Four themes included the following: (1) enduring an unknown workplace culture that generates uncertainty without support for new graduates; (2) being vulnerable because of distress from bullying, exclusion and being a scapegoat; (3) constraining systems and institutional restrictions that cause dilemmas; and (4) experiencing disillusionment from lost ideals about ethical practice.

Discussion:

This review has brought to light the vulnerability of new graduates to negative workplace culture and collegial incivility. In addition, new graduates are subjected to ethical tensions created by institutional constraints which can create dilemmas and uncertainties through practice that does not align with what they anticipated.

Conclusion:

Understanding ethical tensions experienced by new graduates enables provision of informed support. There needs to be considerable cultural change for orientation and socialisation of new graduates to enable them to learn and manage ethical tensions.

Physiotherapists' perceptions of workplace competency: a mixed-methods observational study

Objectives Workplace-based competency is increasingly considered fundamental to patient safety and quality healthcare. The aim of the present study was to identify and describe physiotherapists' perceptions of workplace competency. Methods The present study was a mixed-methods cross-sectional observational study. Thematic and descriptive analysis of qualitative and survey data were undertaken. Forty-six physiotherapists employed at a metropolitan acute public hospital participated in interviews or focus groups; a subgroup of 31 participants also completed an online survey. Results Five main themes were identified: (1) despite the availability of workplace learning opportunities and supports, less-experienced staff reported limited confidence; (2) assessment and feedback around workplace competency was limited, predominantly informal and unstructured, with less than half of the cohort (42%) agreeing feedback received was useful for improving their workplace skills; (3) practicing within individual scope is an important aspect of workplace competency as a physiotherapist; (4) most (81%) agreed it was important for them to self-determine their learning and development goals, and they relied primarily on informal discussion to achieve these goals; and, (5) physiotherapists felt motivated regarding workplace learning, with 97% interested in developing their workplace skills however, nearly half (45%) did not feel they had sufficient time to do so. Conclusions The perceptions of physiotherapists working in a metropolitan acute public hospital are reflected in five themes. These themes elucidate how workplace competency is supported, maintained and developed among physiotherapists in this setting. These themes also highlight key challenges of workplace learning faced by this cohort of physiotherapists and allude to methods that may assist with improving feedback mechanisms and knowledge acquisition. What is known about this topic? Studies investigating employee perceptions around workplace competency, knowledge, skills and learning are found across a range of industries. Workplace-based competency is increasingly considered fundamental to patient safety and quality health care. There is little known about physiotherapists' perceptions of workplace competency. What does this paper add? This study has identified and described themes around physiotherapists' perceptions of their workplace knowledge and skills. What are the implications for practitioners? The themes identified provide support for the development, implementation and evaluation of a workplace-based competency framework for physiotherapists.

Nursing students' perceptions of using the Clinical Education Assessment tool AssCE and their overall perceptions of the clinical learning environment - A cross-sectional correlational study

BACKGROUND

Clinical education is a vital part of nursing students' learning; the importance of assessment tools and feedback in stimulating student learning has been stressed, but this needs to be studied in more detail.

OBJECTIVES

To examine relationships between nursing students' perceptions of using an Assessment tool in Clinical Education (AssCE) during their mid-course discussion and final assessment, the content discussed during these meetings between the student, preceptor and nurse teacher and the students' overall perception of the clinical learning environment.

DESIGN

A cross-sectional, correlational design was used.

SETTING AND PARTICIPANTS

A convenience sample of 110 nursing students from one Norwegian university college with two campuses.

METHODS

Data were collected with self-developed questionnaires and analysed using logistic regression with SPSS and the PROCESS macro for mediation analysis.

RESULTS

There was a positive relationship between nursing students' perceptions of using the assessment tool AssCE and their overall perception of the clinical learning environment. This relationship was, in turn, mediated by the content discussed during the formative mid-course discussion and summative final assessment.

CONCLUSIONS

Our conclusion is that the assessment tool AssCE supported students' clinical learning and that this relationship, in turn, was mediated by the degree to which the conversation during the assessment meeting focused on the student's knowledge, skills and professional judgement.

Clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland; a qualitative study

BACKGROUND

A preceptorship model of clinical teaching was introduced to support the new all-graduate nurse education programme in Ireland in 2002. Little is known about how this model impacts upon the pedagogical practices of the preceptor or student learning in clinical practice leading to question what constitutes effective teaching and learning in clinical practice at undergraduate level.

AIM

This study aimed to explore the clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland and identify when best practice, based on current theoretical professional and educational principles occurred.

METHOD

A qualitative research study of a purposively selected sample of 13 students and 13 preceptors, working together in four clinical areas in one hospital in Ireland. Methods were semi-structured interviews, analysed thematically, complemented by documentary analysis relating to the teaching and assessment of the students. Ethical approval was gained from the hospital's Ethics Committee.

FINDINGS

Preceptor-student contact time within an empowering student-preceptor learning relationship was the foundation of effective teaching and learning and assessment. Dialoguing and talking through practice enhanced the students' knowledge and understanding, while the ability of the preceptor to ask higher order questions promoted the students' clinical reasoning and problem solving skills. Insufficient time to teach, and an over reliance on students' ability to participate in and contribute to practice with minimal guidance were found to negatively impact students' learning.

CONCLUSIONS & IMPLICATIONS

Concepts such as cognitive apprenticeship, scaffolding and learning in communities of practice can be helpful in understanding the processes entailed in preceptorship. Preceptors need extensive educational preparation and support to ensure they have the pedagogical competencies necessary to provide the cognitive teaching techniques that foster professional performance and clinical reasoning. National competency based standards for preceptor preparation should be developed.

Estágio de administração em enfermagem: repercussões para a equipe em unidades clínico-cirúrgicas

RESUMO Objetivo Conhecer as percepções de enfermeiros e técnicos de enfermagem de um hospital universitário sobre o processo interativo com estagiários de administração em enfermagem. Método Estudo qualitativo, exploratório, descritivo, mediante 11 entrevistas semiestruturadas com enfermeiros, técnicos e auxiliares de enfermagem de unidades clínico-cirúrgicas. As informações, coletadas entre dezembro de 2013 e janeiro de 2014, foram submetidas à análise temática e discutidas à luz de Pichon-Rivière. Resultados Agrupados em três categorias: Acadêmicos e equipe de enfermagem: interação que pode propiciar aprendizado, ajuda mútua e satisfação; Apesar da pré-tarefa, o trabalho tem que continuar; e, Equipe de enfermagem: a facilitadora do estágio. Conclusões O início da convivência é repleto de ansiedades básicas, mas é no movimento de elaborá-las que o grupo se constitui e se transforma para o trabalho em equipe. Nessa lógica, quesitos como paciência, empatia, comunicação e coerência facilitam o processo interativo, além de serem fundamentais para a (re)leitura crítica da realidade.

"That's your patient. There's your ventilator": exploring induction to work experiences in a group of non-UK EEA trained anaesthetists in a London hospital: a qualitative study

BACKGROUND

European health systems depend increasingly on the services of health professionals who obtained their primary medical qualification from other countries. There has been a significant increase recently in fully qualified specialist doctors arriving from the European Union to provide short term or longer-term solutions to health human resources needs in the UK National Health System. These doctors often take up senior consultant positions. As a result, the NHS has had to learn to deal with both expatriation and repatriation of EU doctors as a constant dynamic characteristic of its own ability to deliver services. We conducted a qualitative study to explore the acclimatisation experience of EU doctors with qualifications in anaesthesia arriving in the United Kingdom to take up clinical employment in the NHS. The question we ask is: how do specialty registered anaesthetists who trained in other European countries experience the process of acclimatisation to practice in the United Kingdom in a large hospital in London?

METHODS

We did individual interviews with non-UK, EU-qualified doctors with Certification of Completion of specialty Training who were registered with the General Medical Council in the UK and could practice in the NHS as specialist anaesthetists. The doctors were all interviewed whilst working in a large NHS teaching hospital in London, UK. We analysed qualitative data from interview transcripts to identity themes and patterns regarding senior doctor's acclimatisation to the British system.

RESULTS

Acclimatisation conceived of as transfer of clinical expertise was problematic for doctors who felt they lacked the right kind of support. Doctors sought different opportunities to share wider perspectives on care deriving from their previous experience.

CONCLUSIONS

Hospital conceptions of acclimatisation as a highly individual process can offer an idealized view of clinical work and learning in the new system. Socio-cultural theories suggest we create regular learning opportunities for international staff to critically reflect on practice with local staff to acclimatise more effectively.

Integrating learning assessment and supervision in a competency framework for clinical workplace education

Although competency-based education is well established in health care education, research shows that the competencies do not always match the reality of clinical workplaces. Therefore, there is a need to design feasible and evidence-based competency frameworks that fit the workplace reality. This theoretical paper outlines a competency-based framework, designed to facilitate learning, assessment and supervision in clinical workplace education. Integration is the cornerstone of this holistic competency framework.