Implementing contract learning in a clinical context: report on a study

Supervision contracts for mental health professionals: a systematic review and exploration of the potential relevance to psychiatry training in Australia and New Zealand

OBJECTIVE

The use of formal supervision contracts has been strongly advocated across non-medical mental health professions. However, the use of such agreements is not a feature of the RANZCP Competency-Based Fellowship Program. This paper critically examines the evidence to support the use of formal supervision contracts.

METHOD

A systematic review of empirical studies relating to the outcomes of supervision contracts was completed. Included records were subject to quality appraisal.

RESULTS

Two studies met the inclusion criteria; both were assessed to be of poor quality. One study found improved supervision effectiveness associated with the use of supervision contracts, and the other found no significant differences associated with formal contracting.

CONCLUSION

Despite strong advocacy, limited empirical evidence was found to support the value of formal supervision contracts across mental health professions. PROSPERO registration - PROSPERO 2018 CRD42018104142.

The impact of the learning contract on self-directed learning and satisfaction in nursing students in a clinical setting

Background: The most important responsibilities of an education system are to create self-directed learning opportunities and develop the required skills for taking the responsibility for change. The present study aimed at determining the impact of a learning contract on self-directed learning and satisfaction of nursing students. Methods: A total of 59 nursing students participated in this experimental study. They were divided into six 10-member groups. To control the communications among the groups, the first 3 groups were trained using conventional learning methods and the second 3 groups using learning contract method. In the first session, a pretest was performed based on educational objectives. At the end of the training, the students in each group completed the questionnaires of self-directed learning and satisfaction. The results of descriptive and inferential statistical methods (dependent and independent t tests) were presented using SPSS. Results: There were no significant differences between the 2 groups in gender, grade point average of previous years, and interest toward nursing. However, the results revealed a significant difference between the 2 groups in the total score of self-directed learning (p= 0.019). Although the mean satisfaction score was higher in the intervention group, the difference was not statistically significant. Conclusion: This study suggested that the use of learning contract method in clinical settings enhances self-directed learning among nursing students. Because this model focuses on individual differences, the researcher highly recommends the application of this new method to educators.

Clinical placements in mental health: a literature review

Gaining experience in clinical mental health settings is central to the education of health practitioners. To facilitate the ongoing development of knowledge and practice in this area, we performed a review of the literature on clinical placements in mental health settings. Searches in Academic Search Complete, CINAHL, Medline and PsycINFO databases returned 244 records, of which 36 met the selection criteria for this review. Five additional papers were obtained through scanning the reference lists of those papers included from the initial search. The evidence suggests that clinical placements may have multiple benefits (e.g. improving students' skills, knowledge, attitudes towards people with mental health issues and confidence, as well as reducing their fears and anxieties about working in mental health). The location and structure of placements may affect outcomes, with mental health placements in non-mental health settings appearing to have minimal impact on key outcomes. The availability of clinical placements in mental health settings varies considerably among education providers, with some students completing their training without undertaking such structured clinical experiences. Students have generally reported that their placements in mental health settings have been positive and valuable experiences, but have raised concerns about the amount of support they received from education providers and healthcare staff. Several strategies have been shown to enhance clinical placement experiences (e.g. providing students with adequate preparation in the classroom, implementing learning contracts and providing clinical supervision). Educators and healthcare staff need to work together for the betterment of student learning and the healthcare professions.

Benefits and limitations of an employer-led, structured logbook to promote self-directed learning in the clinical workplace

A structured logbook, consisting of a competency log and a learning contract, was designed and implemented as part of a two-week structured work placement for final-year veterinary students to help them become more self-directed in the workplace. The competency log encompassed 48 core skills and, along with the learning contract, was reviewed at the start and end of the placement. To assess their perceptions of the logbook in promoting self-directed learning, students and supervisors were asked to complete a questionnaire pre- and post-placement and to participate in focus groups (students) and interviews (supervisors) after the placement. The study found significant increases pre- to post-placement in students' perceived levels of competence in all 48 skills and their confidence in being self-directed. However, student attitudes toward the logbook significantly decreased in terms of it encouraging supervisors to take a clearly designed role in structuring learning and facilitating alignment of employer and student expectations. Although supervisors were generally positive about the logbook, some had not been able to review it with their students, which affected students' perceptions of the logbook's usefulness. Some supervisors felt they had not received enough training, and most, erroneously, believed the logbook to be an external research initiative rather than having been designed by the head of their own organization. This study demonstrated that a structured logbook may be useful in helping students become more self-directed; however, supervisor support for the logbook is critical. To facilitate this, supervisors require training and support from senior management.

Participants' engagement with and reactions to the use of on-line action learning sets to support advanced nursing role development

Professional role development in nursing is occurring at a rapid pace in the UK as elsewhere. Internationally, finding relevant, flexible, sustainable educational solutions to support the preparation of nurses for new roles presents significant challenges for Higher Education Institutions, health service managers and the clinical practitioners who are would-be students. The use of on-line learning is frequently advocated as one means of resolving these difficulties. This paper discusses participants' engagement with, and reactions to, the use of on-line Action Learning Sets (ALS) as part of a national pilot development pathway for Advanced Nursing Practice in Scotland. Data collection included: survey of participants' views of on-line ALS; survey comparing perceptions of ALS with other educational experiences within the pathway; in-depth interviews with case-site participants. A range of benefits and limitations of on-line ALS was identified. The benefit of flexible access and sharing experiences with others was emphasised. Conversely, multiple commitments and lack of group cohesiveness significantly interfered with the effectiveness of this process. Key recommendations for future implementation acknowledge participants' preference for a blended approach, with face-to-face sessions to provide 'getting-to-know-you' opportunities, enhancing commitment to the group process.

Challenges in designing an All-Wales professional development programme to empower ward sisters and charge nurses

AIM

To discuss the challenges of designing a professional development programme for ward managers working in in-patient facilities in Wales.

BACKGROUND

In 2008, the Minister of Health launched the Free to Lead, Free to Care initiative to empower ward managers. One work-stream involved the creation of a universal professional development programme to ensure they had the skills and knowledge to function effectively in their roles in the newly restructured NHS in Wales.

METHODS

A collaborative, staged approach, involving multiple stakeholders, resulted in the design of a programme founded in principles of action and work-based learning tailored to the needs of the individual in attaining accredited competencies.

KEY ISSUES

Achieving buy-in and ownership from stakeholders are essential to ensure standardization and consistency of implementation of a universal programme. Shared responsibility and acceptance of key principles underpinning an individualized, work-based programme are fundamental to ensuring equity of outcome achievement. IMPLICATIONS FOR MANAGEMENT: Managerially facilitated cultural change is needed to embed individual work-based professional development programmes in the clinical environment, with practitioners supported through a variety of learning strategies appropriate to their learning needs.

Student nurses' experiences of using a learning contract as a method of assessment

The purpose of this study was to describe final year undergraduate nurses' experiences of assessment through the use of a learning contract. Using a qualitative descriptive design, data was collected from a purposive sample of final (fourth) year undergraduate student nurses. Two approaches were taken for data collection, anonymous evaluative questionnaires and interviews. The study was approved by the local university research and ethics committee. Data was thematically analysed. This article presents and discusses the findings from the interviews. Findings suggest that students' approach to the assessment strategy influenced engagement with the learning contract. Three themes were identified: skills, perceptions, and actions. Within these themes three types of learner were identified: happy, pragmatic and fearful. Factors found to influence successful completion of the learning contract were: support, relevant skills, prior experiential learning and required theoretical knowledge. Recommendations include the need for educators to consider module assessments that recognise the learning needs and preferences of the student within a supportive environment.

Clinical clerkships: students can structure their own learning

In clinical clerkships, student learning is often unstructured and diverse. Even when curriculum objectives are explicit, they are seldom used by students to guide their learning. Student-determined learning objectives may help students to structure their learning. This study aimed to assess whether students can use this method to meet widely differing learning needs within the general practice clerkship and considered the relationship of student objectives to overall curriculum objectives. Students allocated a 5-week clerkship in general practice from April 2000 to April 2001 were required to set and meet personal learning objectives within a supportive learning environment. They recorded the strategies they used, how well objectives were met and which curriculum objectives they met. Objectives were categorised using a hierarchical system. A total of 143 (85%) students recorded 1549 objectives. Four categories accounted for 1092 (70%) of objectives: Consultation Skills; Study of Diseases; Practical Procedures, and Therapeutics. Otherwise the range of objectives set was wide, encompassing all curriculum objectives. A total of 1043 objectives were rated as satisfactorily or highly satisfactorily met and 185 (12%) were not met at all. Strategies that students used to meet objectives included clinical experience with doctors but also with practice-based nurses. Students were able to use student-determined learning objectives to meet a diverse range of learning needs within the general practice clerkship. The objectives set reflected the breadth of curriculum objectives. This method allows students to address gaps in their knowledge in a clerkship where teaching is largely based on opportunistic contact.

A Remediation Process for Nursing Students at Risk for Clinical Failure

The authors propose a remediation process for nursing students at risk for clinical failure. The process is embedded within the context of clinical evaluation and includes the use of a learning contract as an integral component. The strengths and limits of the process and suggestions for further development are included.

Clinical teaching and support for learners in the practice environment

The purpose of planned clinical experience for students of nursing is primarily to provide students with the opportunity to develop their clinical skills, integrate theory and practice, and assist with their socialization into nursing. Nursing, in the main, is a practice-based profession. To this extent, it is essential that nurse education continues to have a strong practical element despite its full integration into higher education institutions (Department of Health, 1999). However, providing adequate support and supervision for learners is challenging. Undoubtedly, exacerbated by increasing numbers of learners, staff shortages and mentors training deficits. This article aims to critically analyse several strategies, which can be used to promote clinical learning.

Professional competence: factors described by nurses as influencing their development

AIM

To discuss the results of a study that explored factors that may influence competence development.

BACKGROUND

Competence, a controversial issue in health care settings, affects many aspects of the nursing profession, including education, practice and management. Although a number of research and discussion papers have explored the issue, in particular the meaning and assessment of nursing competence, to date little research has explored factors identified by nurses themselves as influencing their development of professional competence.

METHODS

A purposive sample of 27 registered nurses was recruited from two university-affiliated hospitals. Data collection was by tape-recorded semi-structured interviews. Interviews were transcribed verbatim and analysed according to the qualitative methodology of content analysis.

FINDINGS

Six descriptive categories were identified from the data: experience, opportunities, environment, personal characteristics, motivation and theoretical knowledge.

CONCLUSIONS

The findings suggest that the factors influencing the process of developing professional competence in nursing extend across personal and extra-personal domains. An understanding of these factors may enhance the ability of nursing managers and educators to enable student and qualified nurses to pursue effective competency development pathways to prepare them to provide a high standard of care. These findings, which may have important implications for nursing practice, management and education, are being further tested in a larger study.

Are Residents Ready for Self-Directed Learning? A Pilot Program of Individualized Learning Plans in Continuity Clinic

Changes in training and certification requirements demand that trainees and practitioners take charge of planning and documenting their ongoing learning. Individualized learning plans (ILPs) have been proposed as a tool to guide this process. We report on a pilot program using ILPs as part of the pediatric continuity clinic experience.

OBJECTIVE

The goal of the project was to explore residents' and faculty members' reactions to using ILPs when ILPs were offered as an optional tool.

METHODS

A group of 42 residents and 13 faculty members volunteered to use ILPs in continuity clinic. Nine months into the intervention, residents and faculty completed questionnaires about their experiences using ILPs. We performed a content analysis of questionnaire responses to identify perceived benefits and barriers to using ILPs.

RESULTS

ILP users reported that the program was helpful in providing a framework and focus for learning and in amplifying their awareness of the learning process. Barriers to using ILPs included lack of time and difficulty establishing and working with learning goals.

CONCLUSIONS

Our results suggest that residents are unaccustomed to taking active roles in planning their own learning. To prepare trainees for lifelong learning and continuous professional development, residency programs need to provide explicit education in the process of self-directed learning.

AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients

Increasing student numbers and changes in healthcare delivery are making inpatient settings less ideal for teaching undergraduate students. As the focus of healthcare provision shifts towards ambulatory care, increasing attention must now be given to developing opportunities for clinical teaching in this setting. This Education Guide describes the opportunities to be made available by introducing clinical teaching into ambulatory care venues not usually used for undergraduate teaching as well as different models for maximizing student/patient interaction in traditional outpatient clinics. In general there has been only a limited development of teaching initiatives in such ambulatory care areas as accident and emergency departments, clinical investigation units, radiology and imaging suites or the departments of professions allied to medicine. Each of these venues provides different resources suitable for clinical teaching and has its own advantages and disadvantages. A variety of models for facilitating student groups in these venues can be used. Practical advice is provided for the clinical tutor about to supervise clinical teaching in any of these ambulatory care settings. In contrast the development of a dedicated Ambulatory Care Teaching Centre allows the use of specific instructional strategies and can focus teaching on specific body systems illustrated by clinical volunteers invited to attend from a 'bank' of previous patients with stable clinical conditions. Finally, a teaching programme based on the day surgery unit is described as a way of achieving a variety of educational objectives in a busy resource that may not previously have been used for teaching.

The use of learning contracts in mental health nursing clinical placement: an action research

This paper examines the implementation of learning contracts with a cohort of undergraduate nursing students in Hong Kong during a mental health nursing clinical placement. An action learning approach was used by the researchers. Data collection methods included questionnaires and semi-structured interviews. Results showed that students' autonomy and motivation in clinical learning increased through the use of learning contracts. There was more sharing between students and teachers and the quality of teaching and learning was improved. The report concludes that contract learning should be integrated into the curriculum of nurse education as a learning strategy for nursing students.