The perils facing nurse education: A call for leadership for learning
Article Outline
This special edition was prompted by the report of a study published in 2008 (Allan et al., 2008) which investigated how changes in nursing leadership roles have influenced the ways in which student nurses learn in practice settings in the new NHS (Department of Health, 1999, Department of Health, 2000). The focus of the study was on new leadership roles and their influence on student nurse learning, given the change in the ward manager’s role during the 1990s and the move of nurse education into universities.
Following these changes, concerns emerged in relation to the ward learning environment especially with the shift in emphasis from college to practice settings (UKCC, 1999). A change also emerged in the public perception of nurses, with accusations that the move of student nurses into universities had rendered them “too posh to wash” resulting in a general lowering of standards, including poor hygiene and outbreaks of serious infection (Scott, 2004).
Given these changes to ward management, nursing leadership and nurse education, and using Smith’s (1992) framework to link emotions and learning to care, the purpose of the study was to investigate the relationship between nursing leadership roles and student nurse learning in clinical practice – in other words, who is responsible for the leadership of student nurse learning in clinical practice?.
The double effect of the move into higher education and the change in the ward manager’s role on student nurse learning are illustrated in great depth by the findings from this study. The data suggest that students experience an uncoupling of their learning in clinical practice from their learning of theory. For nurse teachers, the changes have meant an increasing lack of clinical confidence and a disconnection with practice, and mentors have been left with the daily responsibility of teaching.
This uncoupling may be part of a wider shift to skills and competency based education which Scott (2008) identifies, and a move from relational caring where emotional care is not identified as a key component of nursing and therefore not taught or assessed in education or practice. However the data from this study into clinical learning suggest that emotional care remains a strong feature of learning, mentoring and practice and that support is required to focus on how to manage feelings and learn from them. Further discussion of the findings from this study are reported in two of the papers in this edition (O’Driscoll et al.; Smith and Allan).
This special issue brings together papers which address current concerns in the profession around the state of nurse education internationally, the challenges facing nurse educators and clinical nurses in providing leadership, and the nature of leadership in the educational context. It also presents responses to these challenges in the form of five papers which report international, educational innovations.
It begins with two papers from the above study into Leadership for Learning funded by the General Nursing Council Trust. O’Driscoll et al. report that given the greater responsibility of ward managers for matters outside the immediate clinical area, mentors carry an increased burden of responsibility for the daily supervision and the leadership of student nurses’ learning. However they have to balance this mentoring role with the need to deliver patient care which must take priority over mentoring. Much of this delivery involves ward and patient management rather than bedside care. Therefore, role modeling of bedside care is delegated to health care assistants. This leaves student nurses being told in university that bedside care is integral to the registered nursing role, yet observing on the wards that trained nurses rarely deliver it.
Smith and Allan’s paper illustrates how nurse teachers working in the academy have been affected by the changes to nurse education and in particular, by education’s new relationship with practice constructed through the commissioning arrangements between universities and NHS trusts. This has led to an uncoupling for nurse teachers of the relationship between practice and education. This paper offers theoretical developments to the study of the emotional side of nursing by drawing on three theorists’ work: Menzies, 1970, Fabricius, 1995 and Smith (1992). These theoretical stances are used to understand how nurse teachers are positioned between the academy and practice and what emotions this raises for them.
The next paper discusses the underpinning theories of ethical leadership. Gallagher and Tschudin’s paper considers the nature of ethical leadership in nursing and some educational strategies to promote ethical leadership. They argue that to practice nursing ethically and provide ethical clinical leadership, students need to be educated in: particular knowledge, skills and virtues. For Gallagher and Tschudin, there is an urgent need to address the education of the future nursing workforce, which requires leadership from the present generation of nurse educators.
The analysis of the current position of nurse education and who leads student nurse learning is then broadened by three policy papers which explore three different national perspectives: Rich and Nugent analyse the challenges for nursing education in the United States; Salminen et al. discuss the situation in the European Union (EU) and Taylor et al. probe the current state of UK nurse education.
Rich and Nugent argue that there is a “call to action” in the USA due to the national shortage of nurses and they outline opportunities for nurse educators to respond to the shortage as well as the pending changes in the American health care system. It is clear from their paper that there are parallels internationally in the challenges nurse educators face across the world. There are too few nurses as well as too few nurse educators globally; there are continuing debates over whether degree entry is the best educational programme to offer for educating nurses to registration as first level nurses again globally. And lastly, increasing consumer demands and expectations, and concerns to promote standards are seen internationally.
Salminen et al.’s paper explores the specific challenges faced in the EU by harmonisation processes, namely the Bologna Agreement which has had a significant influence on education in Europe. They conclude that despite progress towards harmonisation, the EU nurse education system lacks coherence. The key challenges in harmonising systems may lie in the cultural differences between the health care needs, expectations and demands of the individual national populations in the EU. These differences make identifying a common core curriculum difficult at present. Salminen et al. also argue that there is a need for a consistent, systematic and harmonised educational programme for nurse educators across the EU.
The third policy paper by Taylor et al. explores the current state of nurse education in the UK. The four authors represent each country of the UK. They discuss issues which in their view affect the education of a future nursing workforce’s fitness for purpose; namely, recruitment and widening access; pre-registration preparation and post-qualification education and careers. They conclude that, although the future of nursing demands modernisation and a nursing workforce which is flexible, visionary and prepared to take risks, the current education system for pre-registration will not deliver registered nurses able to work in this way.
The next five papers discuss educational innovations which seek to address some of the challenges presented in the first few papers in this edition; namely, who leads learning, the theory–practice gap, changing health care needs and modernising the workforce. Evans et al’s paper discusses workplace learning outside the health care setting which may provide a new way of understanding the uncoupling of education from practice in nursing. It provides empirical findings from a national project on workplace learning across a range of disciplines including aircraft engineering, media and banking. The project tackled the age-old question of how students can integrate subject-based knowledge with work-based knowledge; how knowledge from the academic setting may be transferred effectively to the workplace. The authors conclude that the idea of transferring knowledge has prevented students from successfully integrating both forms of knowledge. They concentrate on different forms of knowledge and ways in which these are contextualized and ‘recontextualised’ in movements between different sites of learning in colleges and workplaces. The arguments they put forward are relevant to continuing debates within nursing around the theory–practice gap because they offer the possibility that if knowledges are integrated across practice and education, individuals can lead on research for practice.
The next paper builds on this idea of the integration of knowledges in practice in a discussion of a particular form of knowledge: leadership. Hendricks’ paper discusses a programme set up in Australia to equip 4th year undergraduate nursing students with the skills to undertake leadership roles when qualified. In the 3rd paper, Andre and Barnes discuss an educational response to two challenges outlined in the policy papers: the need to respond to changing global health needs and the need to achieve curriculum change which is meaningful for all stakeholders, educators, policy makers, patients and students. They conclude that the key to successful curricula re-design is to recognize that such change is both cultural and structural and that a broad-based support from across the community to meet health needs is essential.
The 4th paper by Holt et al. discusses a response to the challenge of ensuring that newly registered nurses are competent once qualified. Their project was a collaboration between five universities in the UK to identify common competencies across three domains of practice: communication, team working and ethical practice. While these results are interesting in themselves, their successful collaboration also illustrates how difficult it is for universities to work across structurally competitive boundaries caused by commissioning arrangements to provide leadership at both the strategic level and in developing innovative assessment criteria which can enhance student learning.
Lastly, developing the themes in Gallagher and Tschudin’s papers about leadership, self-awareness, responsibility, and personal leadership qualities, Jackson and colleagues’ paper discusses the “life-wide” curriculum approach which develops students’ personal, professional development and hence their potential for future leadership during their studies at university. The intention behind such a not-for-credit award is to recognize the wider learning which student nurses, midwives and operational department practitioners engage in which goes unrecognized upon qualification and graduation even in their portfolios. This paper provides some evidence of support for such an award among a small sample of students from the three disciplines. The evidence presented here shows that students encounter a wide range of experiences that effect their personal and professional development, and that strong vocational motivations have often been triggered by personal life experiences.
Some concluding comments
Allan and Smith’s (2009) article How student nurses’ supernumerary status affect the way they think about nursing: a qualitative study was headlined on the Nursing Times website as “‘clearing up poo will not help me learn’ – student nurses reject basic care”. The article demonstrates how the demands of learning to be a nurse in today’s climate of rapid patient throughput can produce such a reaction in a student. It also illustrates the dilemma faced by students and nurses to provide vital bedside care to patients while remaining at the heart of nursing. The response to our article, resulting in over ninety comments from students, nurses, health care assistants (HCAs), teachers and mentors demonstrates just how acutely and passionately that dilemma is felt. It seems to me that this passion is because, while we may believe in educating nurses differently, as a profession we still have a concern that nurses will be able on qualifying to deliver and supervise a high standard of bedside care. In other words, the emotional and intimate side of nursing remains important to nurses and nursing students. As Taylor et al. argue, graduate entry must combine theoretical and practical learning and develop strategies to ensure that the competency of newly qualified nurses is assured.
References
- Allan, H.T., Smith, P.A., 2009. <http://www.nursingtimes.net/whats-new-in-nursing/management/clearing-up-poo-will-not-help-me-learn-student-nurses-reject-basic-care/5008119.article> (accessed 12.12.09).
- Allan, H.T., Smith, P.A., O’Driscoll, M., 2008. Leadership for Learning, Final Report. <http://www2.surrey.ac.uk/fhms/research/centres/crnme/Completed%20Projects/Reports/GNC%20main%> (accessed 12.12.09).
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PII: S0260-6917(10)00004-3
doi:10.1016/j.nedt.2010.01.002
© 2010 Elsevier Ltd. All rights reserved.
