Maintaining practice: Challenges for nurse educators?
Article Outline
This editorial focuses on the experience of two nurse lecturers in the UK who undertook a week’s experience within an NHS practice setting. These practice exposures had a profound effect on each author, and as such in this editorial we discuss our experience of being in practice and doing nursing in the context of meeting the regulatory body Nursing and Midwifery Council (NMC) requirements. In addition we consider ways of updating the self and reflecting upon our experiences, as well as stimulating a debate.
Background
In the UK it is current practice that all nurses and midwives are required to abide by the Nursing and Midwifery Council (NMC) requirements with regards to professional practice. Specifically that ‘nurse teachers [educators] should be able to demonstrate how they have maintained and developed their knowledge, skills and competencies as a teacher through regular updating’ (NMC, 2008, p. 40). In order to remain on the NMC register every nurse and moreover every nurse educator is required to address the following practice standard: a minimum of 450 h of practice in each area of practice during the three years prior to renewal of registration’ (NMC, 2008, p. 40). This is an on-going process so that those requiring annual renewal provide evidence of achieving the standard.
The NMC also suggests that one way for nurse educators to meet this requirement could be a time allocation of 20% of their teaching hours. This suggestion is guidance only and it is for Schools of Nursing in Higher Education Institutions in the UK to agree how to support staff to achieve the NMC requirements. We are aware that differences exist across the world due to the diverse ways in which nursing is regulated, though it is from our perspective in the UK that we pose two questions: what does regular updating encompass? How do we demonstrate this to satisfy the expectations of the NMC and our employers at the University?
Clearly, there are no definitive answers and we would argue that this is open to interpretation. However, there is an explicit dimension within the NMC framework that requires nurse educators to focus on the practice aspects of their roles. In addition emphasis is placed on ensuring that their knowledge of practice is contemporaneous and that their skills enable them to be fit for safe and effective practice. Debates about the value of nurse educators working in practice and doing nursing have featured extensively in this journal raising interesting points of view, thus it is our intention to add to these debates.
It is our understanding that there is a strong belief amongst many nursing educators (not all) that it is a good thing to have a direct and legitimate route into practice. This ‘route in’ is often termed the ‘link role’ or ‘link lecturer role’ and more often than not nestles within the remit of student placements, mentor development and the practice element of pre-registration nurse education. We would suggest that how this is valued and thus operationalised across the UK varies considerably. Arguably this leads to a hybrid of educational activities taking place in practice with minimal insights into what constitutes good practice and what works well for the benefit of learning and student nurses. In other words knowing how and what is a success for nurse education.
One way that we sought to embrace the NMC standards was to formally apply to the University Enterprise Fund (an initiative which encouraged employer engagement) to be able to spend a week in a practice setting. We were successful and with the support of our School of Nursing and colleagues we undertook this opportunity to re-engage with our clinical roots. Importantly we believe that pooling together our experiences to learn collectively and to develop the self we have gained some valuable insights for the benefit of nurse education more widely.
Both of us had very similar reasons for wanting to pursue this opportunity of being in practice. We were both seeking to extend our knowledge base in relation to contemporary nursing issues, re-visit some nursing skills and observe the student experience in practice. Interestingly, we were both provided with a timetable of work and planned visits very similar to that of student nurse exposure in these practice areas (a Sexual Heath Clinic and Thoracic Medicine Unit). We both wanted to fully engage in a typical day and a typical week within our individual placements of choice. Neither of us sought to acquire technical specialist nursing skills; however, observing such activities were important to our experience. The formal arrangements for ensuring our legitimacy for being in practice such as insurance, Criminal Records Bureau (CRB) and our NMC details were all dealt with by the University. It was our intention to observe and learn from practice and we both sought to work as pseudo student nurses, in that we were not directly responsible for patient care or absolute clinical decision making.
Overwhelmingly it was our depth of learning centered around fundamental aspects of nursing care; the things that you don’t forget, for example, therapeutic relationships and communication with patients that we valued highly. From this we have both been creative in taking the opportunity to collect a number of anonomised vignettes and cases from these practice exposures to use in teaching sessions with student nurses. This, in our view, is one simple way of capturing contemporaneous patient scenarios and relevant issues related to nursing care. Without exception, the vignettes and scenarios are concerned with the humanistic aspect of nursing care, the little things that matter to people, that are meaningful and can make the difference to patient experience. For example, the intuitive and appropriate behaviour that was witnessed between nurse and patient, the sensitive discourses and genuine non-judgmental approaches to patient care. Often these important features of nursing have been described as ‘basic’ or, more recently, ‘fundamental’. We argue that they are vital to the praxis and the essence of being a nurse often assumed will be learnt but not always practiced.
Conversely, we both grappled with the dualism between notions of voyeurism and genuine observation of care for a purpose. For example, the balance between respecting an individuals choice about observing their care, against the informed consent of a patient to allowing observation of care. In other words, valuing autonomy and privacy. Clearly this tension between observing and participating in patient care alongside individual choice is something students face in their everyday exposures to practice. This, for us, is real and not something to be underestimated or devalued. The balance between patient’s rights, nursing responsibilities, and learner exposure requires fine tuning and constant evaluation. Respecting people is real and serious in our view comes before students needs to have exposure.
Students seek much guidance and support throughout their education in preparation for being a nurse. When we discuss the transition from student to qualified nurse with our pre-registration students, we will often consider the social, cultural and individual impacts that this will have, and on a number of occasions, our students will share the very real anxieties that emerge in relation to this. Many of these anxieties centre on the expectations upon being a qualified nurse thus requiring being able to work more autonomously. In fact we would argue that for many nurse educators engaging in practice (linking), these anxieties can become a reality for them too. How, for example, does one enter an established social group? What behaviours are necessary to engage in (in order to fully integrate and become familiar) to enable the nurse educator an element of social inclusion? Moreover, is it a form of altruistic behaviour that encourages us to make provision in this way? After all, it could be argued that nurse educators have no right to assume that a week in practice can provide useful insight into the social and cultural context of nursing in order to fulfill their individual needs.
This said we have expectations from being practice connected to the notion of ‘knowledgeable doer’ with all of the necessary skills to enable full participation. Ramage (2004) found four categories when she investigated the role of the teacher in clinical practice, those of ‘gaining access’, ‘negotiating credibility’, ‘being effective’, and the central category, ‘negotiating multiple roles’. As educators engaging in practice, we experienced all of these aspects that impacted not only on the interface with qualified members of the interdisciplinary team, but also on the students within that team. Issues such as the exposure of ourselves as learners might have been a significant barrier to development of our inner self particularly to our experience in practice. The opportunity to observe and to some extent participate in the care and management of a variety of patients across age, social and cultural spectrums, went some way to address the NMC standards. Innovative and skilled nursing practice was evident and to some extent being forced into the position of learner helped to illuminate the very real feelings of our students. More importantly, was the perception that patients and clients might have about our role. ‘This person is here from the university, she teaches the students and she even taught me!’ was a common mantra of introduction within the placement setting. We feel that one needs to be very clear about the purpose for being in practice to ensure that we stay within the boundaries of safety thus do no harm.
From our perspective we are genuinely interested in the fields of practice as mentioned sexual heath and thoracic medicine, as well as their forming links to our teaching and research. Therefore having the opportunity to connect up with nursing practice and current issues in these areas has enriched our understandings of patient experience and the possibilities for student learning. It would be true to say that we were both curious to revert back to being in the practice setting and saw this opportunity as a personal challenge. Other motivating factors were to increase our knowledge base, to feel updated, to participate in nurse led initiatives and to establish contacts for research and scholarly opportunities.
Summary
To reiterate the purpose of this editorial was not to delve into, and debate, the research evidence to substantiate or refute the purpose of ‘linking with practice’, in fact quite the opposite. Based upon our experiences we hope to encourage further debate on the purpose of nurse educators being in practice. It could be argued that as each author self-selected to work in practice for a week, there was a positive bias towards success. Indeed without exception this opportunity to ‘be a nurse and do nursing’, albeit under-supervision, had the desired outcome in that we achieved our predetermined goals and expectations. On an individual basis, it was a success. We eagerly became learners and absorbed information like a ‘good’ student should and received excellent feedback from practitioners. Moreover, our ability to recall and draw upon our years of nursing experience rapidly came to the fore thus enabling integration and participation in the work of nursing practice from a critical and in-depth perspective. We therefore conclude that being in practice, engaging in nursing and caring for people not only was/is a privilege but serves to enrich nurse educator’s knowledge base. By origin we are all nurses, this was how we began and we feel strongly that this ‘route or link in’ should be strong, valued and respected as meaningful to being a nurse educator. After all we are not, (to coin the phrase rejected by the Royal College of Nursing in 2004) ‘too posh to wash or too clever to care’, in fact the opposite is the reality.
References
PII: S1471-5953(10)00105-8
doi:10.1016/j.nepr.2010.08.001
© 2010 Elsevier Ltd. All rights reserved.
