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Nurse Education in Practice 12 (2012) 60e64
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Nurse Education in Practice
journal homepage: www.elsevier .com/nepr
A review of evidence for the practice learning environment: Enhancingthe context for nursing and midwifery care in Scotland
Karen Holland a,*, William Lauder b,**a School of Nursing and Midwifery, Mary Seacole Building, University of Salford, M6 6PU, UKbUniversity of Stirling, School of Nursing, Midwifery and Health, Stirling FK9 4LA, Scotland, UK
a r t i c l e i n f o
Article history:Accepted 19 May 2011
Keywords:Practice learning environmentPre-registration nursing and midwiferystudentsPractice placementsWorkforce development
* Corresponding author.** Corresponding author.
E-mail addresses: [email protected] (K. Holla(W. Lauder).
1471-5953/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.nepr.2011.05.008
a b s t r a c t
This paper considers the issues which will ensure practice learning excellence in the future and inparticular how these will impact on the delivery of high quality nursing and midwifery care in Scotlandin the United Kingdom (UK). This will include the inter-dependency of learning in practice for under-graduate pre-registration students and qualified practitioners, in particular continuing professionaldevelopment as a lifelong experience and its link to quality care provision. We contend that the practicelearning environment is the whole of an organisation which values and supports the development of itsworkforce through education. Partnership working between education and service providers is central toensuring an educated and professionally prepared workforce. Both nursing and midwifery are practice-based professions which are accountable for, and charged with assuring, effective public health andsafety. The initial paper which established the key issues discussed here was initially written as one ofthe key background papers for a consensus conference to inform NHS Education for Scotland’s nursingand midwifery workforce development over the next five years (NES 2009).
� 2011 Elsevier Ltd. All rights reserved.
Background
The delivery of care in any country is dependent on the skills andknowledge of its workforce. This care will be delivered throughmulti-agency working or on occasion uni-professionally and acrosssingle or integrated care contexts. These two distinct yet inter-connected approaches will raise a number of challenges, wheretraditional professional boundaries have, of necessity, had to bebroken down in order to ensure that the best possible care isdelivered. In addition, organisations themselves have had tobecome more enabling and if they are to be successful have tobecome learning organisations in their own right. Education of theworkforce therefore becomes a priority for both the providers andcommissioners of nursing and midwifery care, ensuring howeverthat the major health care needs of local and national populationsare considered. An example of a strategic direction with regards toeducation of the workforce was seen in the publication of NHSNorth West: Making Education Governance a reality in the NorthWest. The Director ofWorkforce and Education explains that this is:
nd), [email protected]
All rights reserved.
Similar to that of Clinical Governance, its purpose is to embedaccountability, transparency and continuous improvement into anorganisations’ culture- in this case with the education, learning,development and knowledge management function. (NHS NorthWest, 2008, p4).
Based on the definition of Education Governance developed byNHS Education for Scotland (2007a) this framework offers a seriesof benchmarks for organisations to measure achievement in rela-tion to organisation wide quality improvement in health carethrough education and learning activities, with partnershipworking between education providers and service being anessential component of success. The underpinning principle of theEducation Governance approach is that of being an effectiveLearning Organisation, with its focus on improvement of ‘personaland professional development and performance of its entireworkforce’ through the process of organisational learning.(University of Salford, 2005).
A similar innovative approach to embedding education andlearning within organisations for the benefit of community publichealth was published in the United States in 2004 (ASPH Council ofPublic Health Practice Coordinators, 2004). It advocated a collabo-rative approach between Public Health Schools and the publichealth workforce to deliver ‘excellence for practice-based teaching’involving eight guiding principles for its development and
K. Holland, W. Lauder / Nurse Education in Practice 12 (2012) 60e64 61
implementation. The critical message was that ‘without a frame-work of an academic/practice partnership to support public healtheducation, educational approaches that omit practice render publichealth education and training inadequate and incomplete’ (ASPHCouncil of Public Health Practice Coordinators, 2004, p1). Thisprinciple one could argue needs to resonate throughout anystrategy for the future of practice learning environment excellencein Scotland in 2020. This paper and its focus needs to be consideredas a broad overview of key issues in an ongoing strategic direction,and was initially written as one of the key background papers forthe consensus conference to inform NHS Education for Scotland’snursing and midwifery workforce development over the next fiveyears (NES 2009).
The changing context of nursing and midwifery care
If we accept the premise that the delivery of care is dependenton the knowledge and skills of its workforce then in turn we canaccept that health care organisations have a responsibility to ensurethat the workforce has the support to enable it to achieve its fullpotential for long term patient benefit. (NHS Education Scotland,2007) This begins with ensuring that the novice learner hasa safe practice learning environment inwhich to gain experience oftheir future role, whilst at the same time ensuring that those whoeducate and act as effective role models are afforded equality ofopportunity to enhance their own development and reach their fullpotential as individuals and professional careers.
The delivery of care by nurses and midwives is set against thechanging context of social and political change and this has to betaken into account in any decision as to the future of what isrequired in both the practice learning environment and that ofpartner organisations in further and higher education.
In the four United Kingdom countries the pattern of change hashad both similarities and differences, resulting in various stages ofpolitical devolution in Scotland and Wales which have impactedon the way in which care is both delivered and the workforcetrained and educated. (Welsh Assembly Government, 2009; NHSEducation Scotland, 2007) One of the most significant drivers,which is in fact a world-wide phenomenon, is the increase in anageing population, (which in the UK is the increase in the over 75year demographics) with its accompanying health and socialproblems.
Alongside this is the changing pattern of family life due to suchevents as unemployment and the influx in many countries ofrefugees and asylum seekers as international boundaries are tornapart through either man made or natural disasters.
In the UK health care delivery is being re-shaped, with the focuson changing the delivery away from the tertiary setting into thecommunity. In Scotland the policy underpinning this direction oftravel is Shifting the Balance of Care. However here again we havesome confusion inwhat is exactlymeant by a community setting, orwhat is termed by many as primary care. It could be argued, froma sociological point of view, that a small community hospital in the‘community’ remains a hospital, and that practice mirrors that of itsmuch larger counterpart of a city hospital. If we take communitycare to mean care that takes place in the ‘home’ whether that beone where an individual and their family resides or a residentialcare home where a group of unconnected individuals live,community care becomes an entirely different issue. Both settingshowever will require a care workforce with different yet compat-ible skills and knowledge as will care that is offered in a health carecentre where the first point of contact may be a district nurse,midwife or general practitioner. Ensuring a common under-standing of community or primary care environments is critical toensuring that any practice learning environment meets the
expectations of the organisation as well as individual futureeducation and training needs.
For mental health and learning disability services this haspossibly evolved over time, as has the work of the midwife withtheir integrated approaches to care delivery. The QA ScottishBenchmark statements for Midwifery (2008) highlights this:
Midwives work with women and their families to assess their needsand to determine and provide programmes of care and supportprior to conception and throughout the antenatal, intranatal andpostnatal periods. They focus on providing holistic care whichrespects individual needs, choices and cultures in a variety ofcontexts. Legislation enables midwives to carry out their roleautonomously, while expecting them to work in partnership withothers and across professional boundaries when this is in the bestinterests of women and their families. Midwives work in and acrossa wide range of settings, from women’s homes, communitymaternity units to acute hospitals. They also make a significantcontribution to the wider public health agenda.
On the other hand the complexity and confusion around thenursing profession’s role in community care, with the plethora ofrole titles and duplication and overlap of role function needs to beaddressed for the future. The Scottish Government HealthDepartment has already begun this work with its ModernisingCommunity Nursing initiative. A possible area for subsequentdebate is whether we should begin to consider nurses andmidwives regardless of their place of employment as communitypractitioners without differentiating between a hospital ora health care practice environment, as both offer a ‘communityservice’? A truly integrated care delivery service does not differ-entiate between these, and possibly this is where the ideal ofa community hospital in a rural setting involves the collaborativelearning environment where hospital care needs of an individualare integrated with their home needs. Of course this does notexclude the need for a set of skills and knowledge which wouldenable a nurse for example to work in an area such as an intensivecare unit, where the nature of nursing care is such that patientsafety cannot be compromised. For the future of nursing andmidwifery education in practice however there would appear to bean urgent need to consider these issues around ‘working in thecommunity’. Some similar issues have arisen in Victoria, Australiawhere a number of projects related to clinical placement learninghave been set up, including one for expansion of communityplacements. It had been found that there was a ‘significantpotential to expand clinical placements in the community healthsector but that feedback from community health services indicatedthat many are keen to offer placements to students but servicedelivery requirements and limited resources often limittheir capacity do so’ (http://www.health.vic.gov.au/workforce/placements/governance/student-placement).
Education and the future needs of the nursing and midwiferyworkforce
Education in practice is at the centre of developing both thefuture and current workforce.
As noted, both nursing and midwifery professions are practice-based but given that the focus of that practice is centred on thedelivery of care, to ensure effective and continuing education of anyworkforce requires the additional expertise and input of skilled andknowledgeable educators. This is not of course to say that withina practice environment there is not the capability to do this, but thecapacity, i.e. the human resources and the time is not - the focus inpractice has to be centred on the delivery of evidence-based qualitycare with the patient at its centre (NHS Scotland, 2006).
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The focus of nursing practice therefore could be said to bepatient care whilst that of the midwife is the woman’s care. Aninteresting parallel is that of social work where O’Connor et al.(2006, p9 cited by Walker et al., 2008) have defined social workpractice as:
... the interaction between people and social arrangements. Thepurpose of practice is to promote the development of equitablerelationships and the development of people’s power and controlover their lives, and hence to improve the interaction betweenpeople and social arrangements.
Walker et al. (2008) define practice learning as meaning ‘thelearning that takes place whilst a student is on placement ina practice setting’ and ‘designed to help students apply knowledge,skills and values into practice’ (p2).
If we transfer this into a nursing and midwifery context we canbe forgiven for initially considering this solely in the context of pre-registration nursing and midwifery education. However, given theneed for continuing education of the qualified workforce it can alsobe applied to them, opening up the potential for practice learningenvironments to be developed as ‘communities of learning’. It isimportant however when we look at this potential to rememberthat within that environment and indeed the main raison d’être forenhancing learning, is the person or persons requiring professionalcare.
The practice learning environment
The practice learning environment includes not only the focus ofthe practice experience but also the personnel who engagewith thelearner. In nursing and midwifery this has become a complex andindeed complicated scenario of nomenclature, with a myriad ofterms for those engaged in practice education. What has becomeproblematic in the United Kingdom generally, is the attachment ofone name, i.e. the mentor, to the teaching, assessing and supervi-sion of students, whilst in addition a plethora of other terms such aspractice educators, practice education facilitators, practice teachers,clinical teachers, preceptors have emerged without a clear andcommonly understood definition and what that role undertakes inrelation to each other. It is interesting to note that Walker et al.,2008 make it clear that a practice assessor role is set apart fromthe work-based supervisor/practice supervisor assessor and is’taken to mean the person who assesses the competence orotherwise of social work students’ and is a formal role, whilst thelatter may provide day to day supervision and support and informsthe assessment of the student. The plethora of education andeducation support role titles requires further consideration, inparticular as it impacts on the career pathways of qualified nursesand midwives. The adoption of a clinical academic careers pathwayfor example is focussing on research careers (UKCRC 2009) whilstthe UDINE Careers project (Jackson et al., 2009) has considered thenurse educator pathway across Europe. NHS Education Scotland(2009) have developed a framework for the latter pathway,however it is important to consider the articulation of this in thecontext of both the practice learning environment and the educa-tion and training investment required to implement it throughcollaborative partnerships.
One of the major challenges facing practice education fornursing and midwifery is to clearly differentiate between teachingand learning in practice and the assessment of that student’scompetence to practice as a qualified nurse. The mentor hasbecome ‘all things to all men’, and whilst there is evidence aboutthe issues involved in assuring ‘fitness to practice’ (Lauder et al.,2008) there is less in relation to how and what do mentors teachstudents in practice in order to be able to assess their competence.
Anecdotal evidence of some colleagues highlights that assess-ment of practice in a formal sense consists of ‘going through thestudent practice assessment document and asking questions of thestudent’ alongside asking colleagues who may have worked withthe student ‘how have they fitted in’ and ‘are they using theirinitiative and showing they want to learn how to do things?’. Ofcourse this is an exaggeration of reality and as Lauder et al. (2008)reported, there was confidence in managers and educators thatstudents were fit for practice at that point of registration. Howeverthere remains a dearth of evidence on the reality of the stu-dentementor relationship when it comes to assessment ofcompetence in relation to teaching and learning experiences. Rolemodelling also plays a critical part in the student experience inpractice, the students modelling their practice on what they deemto be excellent caring practitioners, who value not only the studentas learner but also the patient at the centre of their care. Murray &Main (2005) recommended role modelling as an effective teachingmethod for student mentors, but stressing that mentors needed toconsider how to ‘engage students in professional activities ifmentoring was to have a realistic chance of being successful’ (p30).
Smith (1987) established a methodology for explaining thenature of the relationship between caring and learning and inparticular the quality of each in relation to the other. Evaluation ofpractice learning environments now include questions on philos-ophy of care and care practices, evidence-based practice imple-mentation and development of staff’s educational needs. Thisprocess is a mandatory expectation of the UK Nursing andMidwifery Council (2008) but there is no standard evaluation toolacross HEI providers and their practice partners in the UK. InScotland however there is a set of Quality Standards for PracticePlacements (QSPP) and a QSPP audit tool which can form the basisof an assessment of practice placements (NHS Education Scotland,2008).
Models of practice education and practice-based learning
Examination of the literature on various models of practiceeducation across health and social care professions revealed onefundamental and common theme, that of collaboration (Crookeet al., 2003; Lougheed and Galloway, 2005; Budgen and Gamroth,2007; Edmond, 2001; Butler, 2007). Alongside this was the signif-icant variation in pre-registration student numbers allocated topractice placements across the health care professions and theprovision of suitable placements for learning. For example Martinet al. (2004) reported on a study comparing practice educationmodels in occupational therapy where the ratio of students topractice educators was either 1:1, 1:2 or 1:3 in a placement. Theyfound advantages and disadvantages in all three; however a keyadvantage of the 1:2 and 1:3 models was that they facilitated peerlearning opportunities which the students and educators used todevelop problem -solving and clinical reasoning skills as well assharing knowledge and practice skill development.
Developing more structured and supportive placement learningopportunities was clearly leading to more innovative practiceeducation models. Although the focus to most of these wasundergraduate learning experiences there was an implicit expec-tation that learning beyond registration took place in order toensure the quality of practice education and learning and in turnensure evidence-based quality of care delivery.
The quality of a practice learning environment is dependent notonly on the preparation of those involved in teaching and assessingstudents but also the delivery of care. It is expected that any modelof practice education takes cognisance of this, especially as one ofthe key components of a quality learning environment is the qualityof the care delivered; this is the care experience that the student
14. Practice learning is most effective when delivered as part of an overall learning and development strategy developed in partnership with all relevant stakeholders andsupported by educational governance arrangements.
15. Practice learning reflects the importance and value of informal learning opportunities in the development of nurses and midwives. It defines the delivery of nursing and midwifery services and nurse/midwife interactions with service users and those who support them as an opportunity for mutual learning and development.
16. Learning is an ongoing process that is supported and developed through interaction and therapeutic relationships. The quality of practice learning experiences isimproved through individual learners responding positively to feedback from service users and those who support them.
17. The importance of flexible approaches to delivering practice learning opportunities to support nursing and midwifery practice, including in remote and rural settings, isrecognised. This may include the need to develop and deliver innovative simulation and “virtual” environments.
18. The content and context of authentic practice learning and development activity should be designed in collaboration with learners, including those from urban, remote and rural settings.
Fig. 1. Nursing and Midwifery Education and Workforce Development Towards 2020: Consensus Statement (NHS Education Scotland, 2009).
K. Holland, W. Lauder / Nurse Education in Practice 12 (2012) 60e64 63
faces in each practice placement where they are expected to gainknowledge and skills for future practice. Their teachers are practi-tioners, and expected to have the required expertise in their ownpractice to be able to role model for the student and teach them thepractice experience of what they may learn in theory within theUniversity setting. This side of practice-based learning is oftenforgotten, the application of theory in practice and requires assur-ance of a strategic approach to practice education whereby theclinical knowledge and expertise of the practitioner is as importantas their ability to teach and help students learn.
The way forward for nursing and midwifery education
What canwe conclude therefore in relation to future models forpractice-based learning and education for nursing and midwiferycare? Although this paper focused mainly on the Scottish nursingand midwifery agenda there are implications for the whole of theUK, in particular since the release of the new Conservative-LiberalCoalition Government’s strategy for the future of the NHS (DohH2010). Firstly, the acknowledgement that the context of care envi-ronments is continually changing and that the balance of care isshifting from hospital based care to care in the community. Cog-nisance must be taken however that defining the boundaries ofthese is critical to the future development and delivery of educationin and for practice. Alongside this is a recognition of the need fora changing workforce and career structure for nurses andmidwives, together with clearer collaborative models of ensuringquality learning environments. Pre-registration midwifery andnursing programmes are delivered in both education and serviceareas; responsibility for this must be an equal one between thosewho work in Higher Education and Health Service and findinga way to deliver collaborative evidence-based education andpractice environments which are led by effective clinical andeducational leaders as well as practice educators, supervisors and
assessors with both the clinical knowledge and skills, plus thoserelated to their educational role, is essential. This should includejoint performance management of educational contracts unlike theposition at the present time where HEI’s are performance managedfor student outcomes when 50% of undergraduate time is spent inpractice. The models must also accommodate the inter-connectionbetween those who teach and facilitate learning in an educationalinstitution with those in practice. The creation of ‘Communities ofLearning in Practice’ rather than practice placements is one possiblemodel and one where the student learning experience is pivotal toits development.
The successful implementation and development will howeverbe dependent on the right leadership and the commitment tobecoming Learning Organisations, both in terms of academia andpractice, in order to transform the future of nursing and midwiferycare.
Acknowledgements
The authors wish to thank Dr Colette Ferguson, for her criticalreview of this paper and for the opportunity to contribute to andparticipate in the innovative: Nursing andMidwifery Education andWorkforce Development: Towards 2020 - the Consensus Confer-ence which took place on 18e19th November 2009 (Report pub-lished 8th March 2010).
This paper was initially written as one of the key backgroundpapers for the consensus conference to inform NHS Education forScotland’s nursing and midwifery workforce development over thenext five years (NES 2009).
http://www.nes.scot.nhs.uk/about-nes/news/nursing-and-midwifery-education-and-workforce-development-towards-2020-consensus-statement The consensus statements for PracticeLearning resulting from the event and the papers presented anddiscussed can be seen in Fig. 1. These need to be considered in thecontext of the full Consensus Statement.
K. Holland, W. Lauder / Nurse Education in Practice 12 (2012) 60e6464
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