Debbie Roberts

Supporting student nurses learning in and through clinical practice: the role of the clinical guide

Practice learning is an important part of the curriculum and accounts for approximately 50% of the pre-qualifying nursing programme in the United Kingdom. However, the nature of practice learning is very often ill defined, and mentors and nurse teachers apply a range of models to enhance learning in practice settings. Supporting students to learn is an important function for both educators and practitioners, yet there is little consensus in the literature as to what constitutes appropriate support and more importantly which methods promote deep learning. Mentorship is widely relied upon not just as a support mechanism for students but also as the main vehicle for the activities associated with learning, teaching and assessment of practice. Although in recent years nurse education in the UK has embraced mentorship alongside the development of the lecturer practitioner and more recently practice educator roles, other models may be worth further examination, especially those that more overtly enable students to learn through clinical practice encounters. The Clinical Guide is a concept developed by the University of Salford as part of a response to the Fitness for Practice report (UKCC 1999), which encourages Higher Education Institutions together with health care providers to develop partnerships to support students and deliver and monitor learning in practice. The following account outlines the role of the Clinical Guide in relation to pre-registration nursing students and highlights some general inadequacies of the mentors role in developing deep learning in students in practice settings. It does acknowledge the part mentors have to play in the supporting students and relates to the research literature in this area.

Vicarious learning: A review of the literature

Experiential learning theory stresses the primacy of personal experience and the literature suggests that direct clinical experience is required in order for learning to take place. However, raw or first hand experience may not be the only mechanisms by which students engage in experiential learning. There is a growing body of literature within higher education which suggests that students are able to use anothers experience to learn: vicarious learning. This literature review aims to outline vicarious learning within a nursing context. Many of the studies regarding vicarious learning are situated within Higher Education in general, however, within the United States these relate more specifically to nursing students. The literature indicates the increasing global interest in this area. This paper reveals that whilst the literature offers a number of examples illustrating how vicarious learning takes place, opinion on the role of the lecturer is divided and requires further exploration and clarification. The implications for nurse education are discussed.

The theatre of high-fidelity simulation education

High-fidelity simulation is a useful mechanism to aid progression, development and skill acquisition in nurse education. However, nurse lecturers are daunted by sophisticated simulation technology. This paper presents a new method of introducing human patient simulation to students and educators, whilst seeking to demystify the roles, responsibilities and underpinning pedagogy. The analogy of simulation as theatre outlines the concepts of the theatre and stage (simulation laboratory); the play itself (Simulated Clinical Experience, SCE); the actors (nursing students); audience (peer review panel); director (session facilitator); and the production team (technical coordinators). Performing in front of people in a safe environment, repeated practice and taking on a new role teaches students to act, think and be like a nurse. This in turn supports student learning and enhances self confidence.

Problem based learning: developing the triggers. Experiences from a first wave site

In recent years the professional bodies in nursing have been promoting the concept of nurses being analytical practitioners who are able to demonstrate critical thinking and problem solve in the clinical setting (; ). Problem solving skills are widely recognised as an important part of nursing know-how, and educationalists are now required to use problem-based learning as a method within their teaching strategies (). Following the publication of Fitness for Practice () concerning the future of nurse education in England 16 pilot sites evolved to implement the recommendations contained within the report. The purpose of this paper is to describe the approach taken in one first wave pilot site to developing the problem based scenarios for student nurse learning. It is hoped that our experiences will help other educationalists who are new to scenario or trigger development.

Commentary on Secomb J (2008) A systematic review of peer teaching and learning in clinical education. Journal of Clinical Nursing17, 703-716.

Peer teaching and learning are becoming increasingly important within nurse education, this is evidenced by the global nature of studies: hence this timely review of the literature. Secomb (2007) is correct in her assertion that peer teaching and learning lacks definition in its implementation; but the practice in terms of incidental or informal learning is much more common than the review might suggest. Peer learning is often viewed as taking place informally, particularly in clinical practice and this is not without its difficulties. Respondents are unaccustomed to talking about their learning and may find it difficult to respond to a request to do so. If they do, they are more likely to refer to formal learning than informal learning because informal learning is perceived as part of their work and is therefore valued less (Eraut 2000). Eraut (2000) suggests that informal learning is often treated as a residual category to describe any kind of learning which does not take place within or follow from, a formally organised learning programme or event. However, he argues that this definition belies the importance of informal learning. The search terms used to conduct the review (peer, clinical education and undergraduate) are narrow in emphasis and reinforce the notion that peer learning and teaching lacks definition. As a result the studies unearthed for review may lead the reader into thinking that peer learning is intentional and formalised, whereas in reality, there may be no conscious awareness of peer learning. Opening up the search terms to include vicarious learning for example, leads to other studies from within Higher Education more generally which may be entirely applicable to professional education. Other terms which perhaps could have been considered to answer the question include story-telling and experiential learning. Eraut (1994) and Schon (1987) suggest that professional practitioners have a specific and unique way of learning. Eraut postulates that professionals learn on the job by deliberating on specific events, termed case-specific learning. However, he acknowledges that cases have to be viewed as special rather than routine and time must be set aside to deliberate their significance for learning to take place (Eraut 1994). Students can learn from each other using methods such as story-telling, (Bowles 1995) using fictional literature, (Fox 2003) listening to discussions between experts and students, (Cox et al. 1999) and sharing experiences (Diekelmann 1990, 1993, Nehls 1995). Story-telling is suggested to allow the students to construct and rehearse their thinking and provided opportunities for students to learn from each other. Spouse (2003) suggests that sharing experiences in this way is important for students because the stories carry a reality which is engaging for students. Students engaged in their story at any point by clarifying and enlarging various aspects or rehearsing parts that were especially pertinent. Students in the study used the storytelling and sharing of experiences to develop concepts of themselves in different roles according to who they were talking to. The story teller develops new insights to the situation based on the suggestions and sense-making activities of her friends. The group then benefits by developing a collective understanding. Indeed, those of the group who have not participated in the same nursing activity can gain what Spouse refers to as a ‘vicarious learning experience’ which helps them formulate suitable actions when they have to face similar situations. Therefore, raw or first hand experience may not be the only mechanisms by which students can engage in experiential learning.

Implications for operationalising the new education standards for nursing

Registrants and higher education institutions (HEIs) were recently invited to take part in the Nursing and Midwifery Council (NMC) consultation regarding its potential new standards for pre-registration nursing education. The consultation set out fresh standards for pre-registration nursing, together with an education framework that underpins the associated theory and practice. While these documents do not contain the final standards (NMC Council is set to approve them in spring 2018), they offer a glimpse of what the newly registered nurse should know and be able to do at the point of registration in order to practise safely and effectively and continue to develop their expertise. The draft proficiency standards are referred to in the document as being ‘ambitious in setting out the enhanced knowledge and skills that people can expect from nurses in the future’. It is interesting to look at the document in terms of practice learning, particularly in relation to by whom and how student nurses will be supervised and assessed in clinical practice and what the educational requirement should be. In this column, we offer some personal perspectives about the potential impact of these new standards in practice.

Reflection in nurse education: promoting deeper thinking through the use of painting

This paper explores the use of painting with a group of pre-registration nursing students, as one-approach educators might use to encourage deeper thinking and reflection. During the second week of their course, the students were asked to paint a picture of what they believed nursing to be, using colour to capture their feelings associated with nursing. On completion of their paintings, the students shared their ideas and beliefs with the group. This process was repeated at the start of the second year when, on completion of a second painting, their first picture was returned; with time devoted for the students to analyse both paintings and write a reflective account. Analysis was required on three levels: (1) to examine the content of each picture; (2) to explain why they had painted particular images, and explore factors influencing changes or similarities between pictures; and (3) at a deeper level, begin exploring how their values and beliefs had shaped their paintings. Through a facilitated group, students shared their analysis and associated feelings with their peers, the latter being encouraged to ask questions and discuss arising issues to develop their reflective and analytic skills. Examining personal and peer experience enables students to begin to recognise where, in terms of self and self in relation to others, they need to focus their attention. The findings provide tentative evidence that such innovative approaches, together with careful facilitation, can promote deeper insight into self and their chosen career.

Critical exploration of the new NMC standards of proficiency for registered nurses

Following its consultation with key stakeholder groups the Nursing and Midwifery Council (NMC) has launched Future nurse: standards of proficiency for registered nurses ( NMC, 2018a ). These compulsory new standards will be available for use in curricula by approved education institutions (AEIs) from the end of January 2019. In this article, the authors provide their personal perspectives on the potential impact of the new standards, particularly focusing on those relating to supporting and assessing students from within the practice environment. The new roles of practice supervisor, practice assessor and academic assessor are explored, making comparisons to the current mentorship role. There is a clear need for effective partnerships between AEIs and healthcare organisations as they lead on the implementation of the standards. They must think creatively about practice placements and provide opportunities for interprofessional supervision, so that students can learn about the roles of other disciplines and how to collaborate in a multidisciplinary team.

Early identification of wound infection: understanding wound odour

Malodorous wounds can be distressing for patients and their families, negatively impacting on quality-of-life outcomes. For health professionals malodorous wounds can also cause distress manifesting in feelings of disgust when faced with a wound emitting an unpleasant or repulsive odour. There has been investigation into the management of controlling odour particularly in relation to fungating wounds. However, there is limited research that explores techniques for early identification and recognition of wound odours that may be indicative of infection. Electronic nose technology has received some attention, but to date has not been integrated into either diagnostics of infection in wounds or education of health professionals to prepare them for the realities of clinical practice.

The unique contribution of community clinical nurse specialists in rural Wales

To date, quality indicators that have been developed for nursing tend to focus on acute, secondary care settings. It remains unclear whether such quality indicators are applicable to community settings, particularly in rural environments. This research aims to identify the consensus view among specialist nurses regarding their unique nursing contribution within their rural community. Identifying agreed aspects of the unique role within the rural community area will enable quality care metrics to be developed, allowing specialist nurses to measure their unique contribution to rural health care in the future. The research used the Delphi technique to identify a consensus view among a population of specialist community nurses working in a designated rural area in Wales. The strongest area of consensus related to clinical and teaching expertise, where participants perceive educational expertise as being at the forefront of their role. In terms of care for individuals, consensus was focused on four main areas: developing appropriate criteria for referral in to the service, collaborative working, education, and advocacy roles. The findings highlight similarities to models of care provision elsewhere. Specific quality indicators are required for clinical nurse specialists working in rural areas. Current quality indicators may not be applicable across all clinical settings. Further work is required to explore the nature of rural nursing practice.