Introduction
Irrespective of whether you are a newly qualified practitioner, a healthcare worker starting your first appointment, an experienced clinician providing temporary relief or a student on a new placement, you will share the sense of being an outsider to the ‘resident’ team or the community of practitioners who normally work and interact in the setting. Finding someone to take you under their wing, to sponsor you or simply to befriend you will be the most important predictor of your experience in the setting, as well as the length of time you are likely to stay there (Nicholson, 1987). Without such support, most newcomers adopt a low profile, out of the way of the general hurley-burley of everyday events and becoming increasingly marginalized and disenfranchised until they either leave or suffer high levels of sickness or absence (Fuhrer, 1993). Learning to become an insider is vital if you are to become a member of the community of practice and if you are to develop the language and skills of the resident experts. In this chapter, you will be introduced to some of the ways that will help you to become an insider and some strategies that will help you to develop your professional expertise in the clinical field.
Research by Spouse (1998a) and Spouse (2003) indicated that pre-registration students are concerned to develop their professional knowledge in seven specific areas of clinical practice. These are:
■ relating to patients and their carers
■ learning to bundle activities together (management skills)
■ developing professional craft or finger-tip knowledge
■ relating to, and functioning within a clinical team (the community of practice)
■ managing feelings and emotions appropriately (both their own and those of patients and relatives)
■ developing the essence of practice, which promotes therapeutic action.
The research investigated how nursing students from adult, mental-health and children’s nursing developed their professional knowledge and found these seven areas of personal and professional development to be core to their development as nurses. It is possible that practitioners entering an unfamiliar clinical setting will have similar learning needs relating to the unfamiliar clinical speciality but their learning is faster because of their existing foundations of professional knowledge.
This chapter introduces you to the six principles of successful learning in and from practice experiences, and you will find detailed examples of each of them as they relate to the seven areas of professional development mentioned above.
The six principles of learning in and from clinical practice are as follows:
1. Getting to know your supervisor.
2. Developing and documenting a plan for your learning experiences.
3. Implementing and evaluating your success in achieving the plan.
4. Working as a collaborator with healthcare practitioners.
5. Flying solo: working under distant supervision.
6. Making connections between practice and theory.
Getting to know your practice setting and your supervisor
Entering an unfamiliar practice setting can be daunting and many newcomers worry about how they will be accepted by the resident team of practitioners. These teams are often a tightly knit community of people who have shared expertise in the clinical speciality and are committed to providing high standards of care. You can make your first few days successful by some good preparation and detective work.
Making contact with the practice-setting manager before your first day gives you a chance to introduce yourself (and for them to meet you) before starting work in the placement; to know the hours of working and any other important requirements, such as dress code. It also gives you time to find out about clinical activities that are practised in the setting and thus an opportunity to arrive better informed. Healthcare students who change placements fairly regularly can arrive knowing something about the kinds of patients cared for in the setting, having an understanding of the different routines of the placement and knowing a little about the clinical speciality. You will be equipped with some of the vocabulary that might otherwise be completely unfamiliar and this will boost your confidence.
Most healthcare organizations (such as a voluntary, private or charitable organization, an NHS Trust or a Foundation Trust) have dedicated websites with information about the clinical specialities on offer. In addition, there is usually an intranet website with photographs or names of key personnel for each of the different departments, wards, units or health centres. Studying the dedicated website (perhaps through the library or study room) of your new practice setting will help you to find out about the place, to know the names of key staff and perhaps even to recognize some of the staff when you first start working. Making a good entrance by appearing on time, smartly dressed according to the local uniform and dress code, being serious about your learning and respectful of the staff, as well as having some knowledge of the setting, will normally earn you respect and thus the support of the staff. If you have the opportunity, it is often worth spending some time working through a toolkit of activities that you will find on http://evolve.elsevier.com– these are designed to help you learn about your new workplace and the healthcare needs of your clients.
Establish contact with your placement manager at least 1 week before you are due to start and learn as much as you can about the placement and the clinical specialisms, so you start with a good foundation of knowledge.
Establish contact with your placement manager at least 1 week before you are due to start and learn as much as you can about the placement and the clinical specialisms, so you start with a good foundation of knowledge.Sponsorship
Having got off to a successful start, how do you fit in? Your placement manager should have arranged for you to be attached to a sponsor; this may be a mentor, a preceptor, supervisor or a member of staff who has responsibility for looking after new staff or students on arrival. Arrangements should also have been made for you to be supervised during your placement. The person in this supervisory role will normally be someone who is in the same profession as you and who is knowledgeable about your potential needs (especially if you are studying for an academic or professional award). If you are a newly qualified nurse then you should have a staff member who will be your preceptor for at least your first 6 months.
Your sponsor has responsibility for inducting you to the setting. This means that he or she must ensure that you understand your responsibilities, the boundaries of your role, how to implement your role and where to find help. Below is a case study of a first-year nursing student, David, who is on the first day of his third clinical placement.
This was my first day in the community centre, and everything was so different to my earlier placements. The pace seemed slower but everyone seemed very focused on their jobs. The telephone was ringing all the time. I felt so out on a limb. Fortunately, I had popped into the centre a couple of weeks before and had met the deputy manager who was working that day. It was a relief to see a familiar face. She introduced me to Sasha, who was to be my mentor during the 10-week placement. Sasha was very friendly and told me she had a reduced workload that morning so she could look after me. We went and sat down in the staff coffee room and had a chat for about 40 minutes. This was great as I ended up feeling she was really listening to what I wanted to achieve during my placement. It also reassured me to know that she had a lot of experience of working here and also of supporting students. I showed her all my assessment documents and my placement passport with the comments from my earlier mentors. After we had had a coffee, Sasha gave me a tour of the centre, showed me where the different policy and procedure books were stored and gave me a general overview of the place. As I was going to be shadowing her for the rest of the week I felt quite reassured that I was not going to be thrown into the deep end and left on my own.
During his first week, David worked alongside Sasha and assisted her when she was conducting an examination or a procedure. The kind of activities Sasha asked David to do were tailored so that she could observe his communication and technical skills. These might have been simply holding the client’s hand and helping her to relax, fetching pieces of equipment or dealing with samples. However mundane the activity that Sasha gave David, it helped him to learn new things about the centre and to meet different people. It also gave David the opportunity to observe a skilled practitioner deliver care, thus providing opportunities for him to develop new knowledge. Working as a legitimate member of the team and undertaking essential activities or tasks in this way, David gained quite a high profile within the centre and by the end of his first week he also felt at home with almost all the members of staff. Working together also gave Sasha opportunities to monitor David’s conduct and assess his strengths and areas where he needed or wanted to develop further. It gave her the opportunity to decide how much she could safely delegate to David and where he needed to work under close supervision:
If you find that no one has been designated as your supervisor, or they are not on duty when you arrive, alert your placement manager as soon as possible and no later than the end of your fi rst week so that suitable arrangements can be made.
■ Sasha was consequently able to honour her commitment to her professional Code of Conduct and client safety by ensuring David only undertook activities that he was safe to deliver.
■ David made a good start to his placement by taking responsibility for his own learning, by his preparation and willingness to share his aspirations, his learning history and his programme documents with his new mentor.
If you find that no one has been designated as your supervisor, or they are not on duty when you arrive, alert your placement manager as soon as possible and no later than the end of your fi rst week so that suitable arrangements can be made.Planning your placement experience
The second principle of working and learning in practice is to develop an appropriate learning plan, or a learning agenda. Over his first week, David and Sasha developed a good working relationship and also a sense of what learning David was capable of.
At the end of the first week, Sasha and David had a private meeting in a quiet place and discussed David’s learning plan for the first part of his placement. This they agreed could be used to structure his mid-way assessment and they could then plan his learning for the second half of his placement. By documenting this agreement both David and Sasha were clear about what had been agreed and could monitor his progress.
Agreeing goals
David was preparing for registration as a nurse and his programme is structured around the requirements of the professional statutory body (the Nursing and Midwifery Council; NMC). Clinical placements constitute 50% of all approved nursing and midwifery programmes. By the end of each placement period, students are expected to achieve pre-specified learning outcomes. These learning outcomes are deliberately generalized so that students can be placed in a wide range of placements and still achieve the outcomes as they relate to the clinical speciality of the setting. The clinical speciality in David’s placement was community care, including a day centre for older people and children with chronic healthcare needs. During his placement, David would be exposed to a wide range of healthcare situations, but would still be able to learn how to plan and deliver care and to evaluate its effectiveness.
David’s mentor, Sasha, was able to advise David on the range of services and staff he could learn about. Sasha had also assessed David’s capability and knew that he would develop his skills quickly by spending some of his time in the different clinics and on home visits. She gave David a menu of the kinds of experiences he could have throughout his placement and they agreed what would be most suitable for the first 5 weeks. They agreed that if all went well and he made good progress, he would have the opportunity to conduct a clinic under distant supervision and spend more time visiting clients in their homes, either assisting the community nurses or under their more distant supervision. Together they compiled a learning plan for weeks 2–5 (Table 11.1).
| GOAL | CLINICAL ACTIVITY | ACHIEVEMENT CRITERION |
|---|---|---|
| Understand the community services for older, mentally frail adults | Participate in the respite clinic for older, mentally frail adults and enjoy effective relationships with the clients | Able to contribute to the daily work of the team, by knowing and following the routines, procedures and policies of the unit Able to deliver safe and effective care with distant supervision |
| Understand the role of members of the multidisciplinary team (MDT) | Work with physiotherapist, occupational therapist, podiatrist, nurses, healthcare assistants, geriatrician | Able to communicate sensitively and effectively with the clients Able to discuss knowledgeably the different contributions of the MDT to the health and wellbeing of clients and their carers |
| Develop knowledge and understanding of care planning and care delivery | Admit 2–3 older persons to the clinic Make a routine assessment of existing clients’ condition, to develop assessment skills, communication skills, documentation skills Talk with clients’ carers to understand their experiences | Can document an accurate and comprehensive assessment of a new client and provide a full verbal handover to the client’s key worker Able to recognize and document accurately changes in clients’ condition; communicate such changes promptly and accurately to the nurse in charge Where necessary, be able to take prompt and effective remedial action Have a comprehensive understanding of the everyday experiences of carers and the client in their homes |
| Understand the role of the community nurse | Attend 3 home visits | Be able to dress and conduct self in an appropriate manner whilst visiting clients’ homes Be able to document the care provided accurately Discuss the pros and cons of home care provision and clinic provision for the client and the service |
| Understand the community services for children (and their carers) with chronic disorders | Participate in the clinic for children with chronic disorders and enjoy effective relationships with them and their carers | Able to contribute to the daily work of the team, by knowing and following the routines, procedures and policies of the unit. Able to deliver safe and effective care with distant supervision. Able to communicate sensitively and effectively with the children and their carers |
| Understand the role of members of the MDT | Work with physiotherapist, occupational therapist, dietician, nurse, healthcare assistant, paediatrician | Able to discuss knowledgeably the different contributions of the MDT to the health and wellbeing of clients and their carers |
| Develop knowledge and understanding of care planning and care delivery | Make a routine assessment of existing clients’ condition, to develop assessment skills, communication skills, documentation skills Talk with children and their carers to understand their experiences | Able to recognize and document accurately changes in clients’ condition and to communicate such changes promptly and accurately to the nurse in charge Where necessary, be able to take prompt and effective remedial action Have a comprehensive understanding of the everyday experiences of children and their carers in their everyday life |
Assessing David’s progress
David’s learning plan covers a wide range of skills and an even wider range of knowledge that David hopes to achieve by the mid-point of his placement. He has already practised some of these skills in his earlier placements, but using them in an unfamiliar setting is more difficult and takes some rehearsal. Similarly, he has probably had taught sessions and read about caring for the different client groups that he will be meeting on this placement. However, research (Spouse, 1998a) suggests that this knowledge is not recognized as being salient until students feel part of the team and able to perform many of the local skills and techniques that they see being used in the setting.
David knows that Sasha and her colleagues will be monitoring and assessing his development throughout this next 4-week period. They have some minimum expectations of David’s achievement by the end of this first period that can be identified under four headings.
1. Safety of the clients: in addition to knowing the normal safety procedures, David should also be able to recognize the common situations that can arise when working with vulnerable adults and children. He should be taking steps to identify and prevent incidents such as slips, trips and falls by older clients; ensuring they have sufficient nutrition and hydration and that they remain continent during their stay at the centre.
2. Communication skills: David is expected to be able to recognize regular clients and call them by their preferred name, to communicate effectively with them and their carers; to make newcomers feel welcome. He is also expected to seek help if he is unsure about anything. Most practitioners are reassured if their student discusses their actions (potential and actual) as it implies that the student is aware of their boundaries and can be trusted.
3. Wellbeing of the clients: David is expected to demonstrate that he has the interests of the clients foremost in his mind and that he is willing to take trouble and effort to meet their needs appropriately. He should also be prompt and thorough in responding to requests for help and to comply with the Trust procedures and best practice when delivering care.
4. Understanding of the routines, policies and procedures of the unit: David needs to have sufficient knowledge of the two clinics to help with preparing for the day, to anticipate the routines and to know where equipment is stored, and to carry out the policies and procedures effectively.
These are the minimum standards that David is expected to achieve, and he will be encouraged and supported to develop beyond that minimum. If David showed signs of struggling, Sasha has a duty of care – both to her clients and to David – to give him prompt feedback and to revise the action plan into smaller ‘steps’, and to ensure that he has closer supervision and support until he makes progress. Sasha will also be required to document his progress and any change of learning plan so David’s record is an honest and accurate reflection of his performance during his placement.
Towards the end of this 4-week period, Sasha and David met to review and document his progress. Then they developed another plan for his remaining 6 weeks in the placement, which would help him to achieve all his required learning outcomes and to learn additional skills and knowledge as he had made such good progress.
So how can a student or a newcomer develop this knowledge and understanding?
Working and learning as a collaborator with your supervisor, mentor or preceptor
Why collaboration as the ‘junior’ partner is a helpful learning opportunity
Working alongside experienced practitioners provides opportunities to observe and listen to how situations and techniques are managed by different people. It also helps novices to develop their professional knowledge both in terms of the technical skills required and the vocabulary used, as indicated by the following extracts taken from research into nursing students’ experiences of learning in clinical placements.
My mentor really helps as well and it makes a big difference. It’s like having a personal tutor there all the time. If you need something you can just go and ask her and she talks about it. In addition, the other people in the team, the associate nurse is really helpful to me … I was more listening to her [the mentor’s] instructions and helping her, but I didn’t feel under pressure at all because she was showing me how to do it. When she goes through it, she reflects on things that you might think in your head but wouldn’t necessarily say. I felt at ease with her because she was helping me, as opposed to watching and criticizing me.
Helen describes how she was able to ask questions and receive explanations, suggesting that she recognized that she noticed something unfamiliar and that there was a question to ask. It takes some time for novices to notice and to have the necessary language to frame questions. The advantages of being the novice assistant or observer are described by Nicola, a mental-health nursing student.
Veronica’s been really good this term, because we’ll do something together and she’ll turn round and say, ‘What do you think of that?’ I’ll tell her [how] I thought it went and we’ll have a bit of discussion about it. She does quite a bit of CBT [cognitive behavioural therapy], that’s her speciality. So I sit in on her several times when she’s doing that with patients. And she’s been quite good talking me through what’s she’s doing while she does it. I suppose I’m learning all the time, but it doesn’t seem like learning. It’s like I’ve opened my pores up to being receptive to everything that’s there.
An important aspect of your learning plan must include times when you and your mentor work together in partnership, sharing in providing care to the same client at the same time. Sometimes it is more appropriate that you work in a more menial or low-key way, but as you gain in confidence and understanding you need to negotiate with your mentor to take the lead in a procedure, with your mentor or supervisor coaching you through the process as illustrated in the two extracts below.
It was quite a technical placement, so we were doing things [together]. The drugs, techniques, and she would go through it all: ‘This is the drug chart, this is what it means’. We might look up a drug because neither of us knew what it did. It struck me as much more a learning situation. I really felt I was not a burden on her. I was working with her. I was helping her.
[I] changed dressings. My mentor would be there and helping me and helping me to think about how it should be done and saying, ‘Yes you are doing it right. The padding needs to be a bit thicker there, or don’t do the padding so thick.’ I’ve seen my mentor do it before. She never said ‘Well you’re doing it totally wrong’. So it’d be more me talking myself through the stages, telling her what I was going to do and she’d say ‘Yes that’s OK’.
In both situations the students enjoyed a trusting relationship with their mentor and could be honest about their concerns and their learning. In Marie’s narrative, she describes how leading a specific task with the help and guidance of her mentor gave her confidence, especially if things did not go smoothly. Talking aloud as she practised the technique helped Marie to learn the procedure. This collaborative process meant their patient was receiving safe care of a high standard and Marie’s mentor could assess her progress and give her feedback immediately.
As a healthcare student, you should have opportunities to work alongside your supervisor or mentor for 40% of your placement hours (NMC, 2008a) and during the remaining time be supervised – either directly or indirectly – by another registered practitioner. The following example from a different setting illustrates the importance of this.
Some things are so obvious and you don’t think. Like doing post-operative checks for the first few hours. You concentrate on the blood pressure, fine; and [my mentor] said, ‘Did you check the wound site?’ I didn’t look at that. He’d had major abdominal surgery and I suddenly thought how obvious it was. She’d say ‘What I do Ruth, for post-op is the observation per the chart, but more than just the chart. This man has had a big operation on his leg, so look at his leg. His temperature might be fine for the next 5 minutes but he might be bleeding profusely the whole time’. That’s so obvious and I didn’t think of it!
Receiving this kind of support is vital to your own professional development as well as to the safety of your clients. Ruth’s inexperience is not unusual, and without her supervisor’s presence and support during her placement (irrespective of the stage in her programme), she would not have learned this very simple piece of nursing care. Here Gilles is describing the learning he achieved in a children’s ward by watching his mentor Robyn.
In some ways, seeing how Robyn dealt with the little lad was how I dealt with the [child] … plus experience at the children’s hospital and the children’s ward. Pooling your knowledge together, not remembering one bit of it. We were certainly looking at that, how they are and giving them reassurance and telling them what’s happening. A lot of the wards I’ve worked on are very busy. You don’t have time to stand still. Whereas Robyn almost made time, even if we were busy she had time.
Learning by watching more experienced practitioners is sometimes described as role modelling (Bandura, 1977) or social–cultural learning (Vygotsky and Luria, 1970; Vygotsky, 1978), where learning is achieved through a social relationship with an expert. The process of participating in activities that contribute to the overall workload of the team is known as legitimate peripheral participation (Lave and Wenger, 1991; Spouse, 1998b). It provides an important opportunity for newcomers to learn by watching others while contributing to the immediate process in hand. Once newcomers can demonstrate understanding and can conduct the same processes safely, then they can work on their own with distant supervision and thus contribute to the overall workload of the team.
Working and learning in and from practice: flying solo
Agreeing an achievable workload and support availability
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