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An evaluation of how trainee nursing associates (TNAs) balance being a ‘worker’ and a ‘learner’ in clinical practice: an early experience study. Part 2/2Elaine Coghill, Deputy Chief Nurse, Northern Lincolnshire and Goole NHS Foundation Trust

Pryce-Miller in 2010 found that first-year students lacked understanding of self-directed learning, its concept, purpose and nature.

Moore also goes on to state that educational leaders must be aware of the ‘ethical tensions’ that can arise between frontline staff and managers who have been educated differently and must work with managers to replace traditional learning with work-based learning (Moore, 2007).

Moving forward, perhaps more needs to be done with managers to better understand ways they can support the TNAs to learn on the job through reflection, problem-solving and active learning, while still being able to maintain a high-quality service for patients.

Previous studies have shown that in particular the inclusion of a reflective component plays an important part in making the learner establish meaning and realistic links between education and practice (Smith, 1998; Green, 2002). Role modelling in undergraduate nursing has also been shown by Reader et al (2017) to be an effective way to support learning and one that leads to satisfaction.

Career progressionIn this study, the majority of TNAs said that they had applied for the role because

only ‘workers’ and had never studied at a higher academic level. To date in the northeast of England, four TNAs (4.3%) have stepped off the programme for various reasons not related to the programme; but coming up to the first year and assignment submission, it will be interesting to watch if this attrition rate stays the same as the national picture of 5%.

In studies relating to nursing students, it has been found that students that have accessed higher education previously are able to develop a range of coping strategies in relation to academic demands and caring responsibilities (Hinsliff-Smith et al, 2012).

Many quoted feeling overwhelmed by the amount of course work and trying to strike a good work/life balance. Some of the managers also said that they appeared to have a lot of coursework, but other managers felt that this was no different to the other students, therefore viewing them as ‘learners’. McKee and Burton (2005) argue that healthcare care workers must take a mature approach to independent learning to succeed. However, some professionals in academia and clinical practice think that learners are incapable of such self-management and that, therefore, work-based learning cannot work (Moore, 2005). A study at the University of Wolverhampton by

The results revealed in the first part of this article, published in June’s BJHCA (Coghill, 2018), give rise

to a number of areas for discussion: trainee nursing associate (TNA) demographics, academic demands, career progression, placement models, opportunities for learning, including role clarity and protected learning time, sense of belonging and being a ‘worker’ or a ‘learner’. In this second and final part, these areas will be explored in detail, giving many quotes from the 92 TNAs who took part in the survey.

Demographic data The majority of the 92 TNAs were aged 18-35 years of age (73%); 86% were female, 88% were full-time and 3% have left the programme to date. The demographic data obtained in this study appears to be similar to the national data that has been presented; however, it will be interesting to see what future cohorts look like when more TNAs are recruited in 2018 and 2019.

Academic demands In this study, the majority of TNAs’ prior qualifications were obtained at school or at further education colleges. Only 20% of respondents had previously studied at a university. Therefore, not many had been ‘learners’ before, but

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A cohort of trainee nursing associates from a northeast hospital about to start their training journey.

A group of trainee nursing associates from a northeast hospital presenting to their peers and key staff from across the North East England.

it was an opportunity to progress their career and it was a step towards doing a nursing degree. Nearly all of the TNAs wanted to be learners, but some did say they were also workers. Nationally, it is now expected that up to 50% of TNAs may go on to do their nurse training, which has been quoted by Professor Ian Cumming, CEO at Health Education England (HEE), in November 2017 at the national TNA conference.

Placement modelIn the northeast of England, a mixed-placement-model approach had been implemented, with the majority of TNAs having a base ward, from where they were released on block placements. Although not a UK study to explore the benefits of block placements, Birks et al (2017) found block placements foster consistency, as opposed to distributed placements. This too was found in this study, with the TNAs preferring their block placement release.

One issue that was highlighted from the TNAs during the focus groups was those that had stayed in the base ward where they had been an HCA, unless they were particularly assertive, found they were struggling to uncouple their previous HCA role from their new TNA role and get the rest of the team to see them differently.

Opportunities for learningThere appeared to be three areas raised here in relation to opportunities for learning. Early into the programme, the TNAs were struggling with the confidence to ask for learning opportunities, compounded by the fact that they had no protected time, coupled with the demanding workload in ward environments. However, community placements were overwhelmingly seen as great learning opportunities, with a more 1–to–1 mentoring model.

There was also an issue in relation to staff understanding what the role was. Thurgate (2010) stated that the understanding of role boundaries is critical in enabling the delegation of work if new roles are to succeed. She suggested that the issue of supervision in training, mentorship, supernumerary status and effective support while undertaking work-based learning were challenges that needed to be addressed. In this study, there were some issues in relation to role

clarity for the TNAs and the mentors and managers.

However, Elcock et al (2007) suggest supernumerary status creates new challenges for learning in practice, rather than enhancing it. Instead, they suggest learners need to be equipped with an array of skills that will allow them to take charge of their own learning in practice.

Assertiveness, however, is a skill that is highlighted by many authors as being important (Parahoo, 1992; Watts, 1992; Jowett et al, 1994; Gray and Smith, 1999; Begley and Brady, 2002), in order for learners to negotiate their learning needs. This was also apparent in this study, where the more assertive and confident

TNAs said they did not have difficulty asking for learning opportunities.

Support from students, fellow TNAs, mentors and patientsThe majority of TNAS commented on how supportive other student nurses had been and how they saw them as ‘learners’.

The TNAs had found great support from each other, particularly in relation to the one day a week at university where they all got together—and they embraced social media. The TNAs found these days were good opportunities to reflect on their different experiences and share what was working and what they were finding challenging. Rolfe et al (2001) found that

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there is strong support for reflecting in groups, with benefits being the effects of peer support and feedback, in addition to the shared experience.

There were some issues around TNAs getting time with their mentors because of working different shifts, not having protected time with them and the sheer workload in clinical areas, particularly ward areas. This has been reported in studies which state that lack of time is one of the biggest issues reported by mentors with their learners (Winterman et al, 2015), along with workload, lack of staff and patient dependency (Shaw and Bough, 2014). The Shape of Caring Review (Willis, 2015) recommended that mentors must be given protected time to perform their role.

Also reported in a study by Kilcullen (2007) is the impact mentors have: playing a major role in students learning through support, acting as role models, performing socialisation roles, and acting as assessors. This is echoed by Winterman (2015), saying that mentors play a vital role in shaping future nursing professionals, although Chandan and Watts (2012) state that there is lack of evidence supporting the effectiveness of mentors in practice.

Feedback from patients was overwhelmingly positive and they saw these nurses as learners with experience. They all thought it was a positive role

and were happy to find out more about it and how it could help support the registered nurses.

Sense of belongingThere was an overwhelming sense of belonging cited by all of the TNAs and managers and mentors. Despite the mixed placement models across the northeast of England in the nine organisations, there were no issues in relation to not fitting into the teams or with not feeling part of a team. This may be because the TNAs are still employees as well as learners. Nursing students report that they have difficulty being accepted into the community of practice, as they do not belong to the practice environment (Cope et al, 2000). However, Walker et al’s (2014) study found that belongingness is a fundamental precursor to learning and development. Vinales (2014) states that it is the mentors that are crucial to instil that sense of belonging.

‘Worker’ versus ‘learner’ perceptionsEarly into the evaluation, the TNAs saw themselves as both workers and learners. However, a few months later, the TNAs, although they still wanted to see themselves as learners, felt they were actually workers. This is also how most of the mentors and managers viewed the

More celebrations and networking at the 1st year TNA celebration events in the northeast of England.

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and not supernumerary. The patients, however, saw the TNAs as ‘learners with experience’.

This is consistent with research that suggests learning in the workplace creates tensions between the needs of the service, and those of the learner, particularly where there is a heavy workload or shortage of staff (Boud, 2001).

The TNA model is similar to the apprenticeship model that dominated nurse education in the twentieth century (Elcock et al, 2007), where students in order to ‘fit in’ and survive in practice, became ‘workers’ and not ‘learners’ (Melia, 1984). Is this what is being mirrored in the TNA model? What is clear from previous research with this model is that the role of the ward sister/manager is crucial in the quality of student learning and students need to be taught how to learn on the job and mentors/managers how to facilitate this (Pembry, 1980; Ogier, 1982).

ConclusionThis study has described the early experiences of the TNAs recruited in the ‘fast follower’ second pilot phase across the northeast of England. There are a number of issues that merit further investigation and discussion, including:

Role clarity: as a region, we need to look at how we can raise the profile of the TNA and the role they actually do and share this with staff and the public

Debate: are the TNAs ‘learners’ or ‘workers’? Clearly, being a worker gives the TNAs a sense of belonging, but do we need to look at the learning opportunities and how we can support the managers and mentors on how best to facilitate these learning opportunities? Do we need to debate the issue of protected time out for learning?

Mentorship: the study has found that mentorship is vital, but there are issues with having that time out with your mentor and the increasing demand on the number of learners that require mentors. Are different models of mentorship required, which will come with the new Nursing and Midwifery Council (NMC) Standards in 2019?

Placement models: the study found a mixed model; however, the block placement model was the preferred

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one. Also, TNAs recruited in the same areas were having difficulty uncoupling their previous HCA role with their TNA role; so, for the next cohort, should there be consideration about moving them to a different area?It is anticipated that the results in

the study will help to inform the third phase of TNA recruitment in 2018 in the northeast of England and will be fed back into the national evaluation. BJHCA

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The trainee nursing associates had found great support from each other, particularly in relation to the one day a week at university where they all get together.

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“A reflective component makes the learner establish meaning and links between education and practice”

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