eatnd manr rrsine clearts from a UK University participated in the study. Student accounts of their experi-
s the es emercent, 2into shnt safe
Nurse Education Today 34 (2014) 243247
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wwof the mental and physical distress caused, loss of trust in the systemby patient and loss of morale for health care professionals (Institute ofMedicine, 1999; Department of Health, 2000). However it is estimatedthat up to 50% of adverse events are avoidable suggesting a signicantpotential for nurses to improve the safety of care (Department ofHealth, 2006; Robson, 2012).
This paper reports on an initiative to develop the safety improve-ment and leadership capabilities of nal year nursing students usingAction Learning to support the completion of a safety improvement
and motivating peers, the ability to analysis complex issues and open-ness and courage.
Health care students as future providers of health care must learn topractise safe care but they must also be able to critically reect on thecare provided and be committed to nding ways to enhance care andsafety (WHO, 2011). However, learning to become a health professionalis essentially an enculturation process during which students aresocialised into the norms and values of the culture to which they seekto belong (Wenger, 1998). For nursing students this can mean a strongproject in the clinical setting. The aim olegitimise safety improvement as everyone'snewly qualied nurses' capability, condencety improvement.
Corresponding author. Tel.: +44 1695 650776.E-mail address: Christia@edgehill.ac.uk (A. Christianse
0260-6917/$ see front matter 2014 Elsevier Ltd. All rihttp://dx.doi.org/10.1016/j.nedt.2013.07.008ty is not the primary con-tions in the USA and theof safety lapses in terms
Francis report (2013) highlights the leadership qualities essentialfor ensuring patient safety, which includes listening and learningfrom patients and colleagues, the willingness to challenge, inspiringcern of health care organisations. Key publicaUK rst highlighted the scale, nature and costIntroduction
Patient safety has been described ahealthcare and keeping patients safe hachallenges facing health care today (VinThe Francis Report (2013) has broughtconsequences that can arisewhen patieFindings are discussed in relation to three categories including creating an enabling environment, learningthrough action and reection and the emergence of safety improvement and leadership practices. The studyndings provide valuable insights into how AL processes can engender personal leadership capabilities andsupport students to make a valuable contribution to safer care practices, both as students and as future healthcare professionals.
2014 Elsevier Ltd. All rights reserved.
motional heart of qualityged as one of the greatest010;WHO, 2011). Indeedarp focus the devastating
It is increasingly recognised that patient safety involves a com-plex interplay between organisational and individual factors andenhancing safety requires practitioners who can anticipate andinnovate in complex changing environments (Vincent, 2010). Theences were generated through focus group and individual interviews and data were subject to thematic analysis.
Pre-registration nurse education Learning. 52 nursing studenLearning in action: Developing safety impraction learning
Angela Christiansen , Trish Prescott, Judith BallEdge Hill University, Faculty of Health and Social Care, St. Helens Road, Ormskirk, L39 4QP, Un
s u m m a r ya r t i c l e i n f o
Article history:Received 15 December 2012Received in revised form 15 May 2013Accepted 10 July 2013
Keywords:Patient safetyAction learning
Patient safety is one of the grtunities for enhancing care aprofessions have capabilitiesnurse education. This papecapabilities of nal year nuimprovement project in thA qualitative, interpretive res
j ourna l homepage: wf the initiative was tobusiness and to ensureand commitment to safe-
ghts reserved.ement capabilities through
est challenges facing health care today and nurses are well placed to nd oppor-aking it safer. Nurse education has an important role to play in ensuring future
d condence to meet this challenge however this requires new pedagogies ineports on an initiative to develop the safety improvement and leadershipg students using Action Learning to support students to undertake a safetyinical setting.ch approachwas used to explore students' experiences of participation in Action
.e lsev ie r .com/nedtdesire to t in and conform to the rules of participation as they seek togain acceptance into the health care team. Such activities can be incom-patible with challenge, innovation and safety improvement (Cope et al.,2000). Preparation of nurses to provide safer care therefore requiresnew active learning pedagogies that empower students to developself-efcacy skills and greater awareness of their own agency or abilityto make choices in challenging contexts (Levett-Jones and Lathean,2009).
an information sheet and contact details were distributed via theuniversity e-mail system to a cohort of 240 nursing students. The letterconrmed students' ability to decline to takepart and assured them thatsteps would be taken to maintain condentiality and anonymity,although it was highlighted that disclosure of poor practicemay requirethe researcher to take action (Bradbury-Jones and Alcock, 2010).
Selection of Participants
The study employed a purposive sampling strategy in whichresearch participants were selected to inform the research ques-
244 A. Christiansen et al. / Nurse Education Today 34 (2014) 243247The introduction of Nursing and Midwifery Council (2010)Standards for Pre-registration Nursing Education at a Universityin England provided an opportunity to consider these issues and inte-grate opportunities for students to develop personal leadership andsafer care capabilities. This was focussed on the nal module of thepre-registration nursing programme. Curriculum content included;engagingwith patients and carers; being an effective teamplayer; under-standing systems and managing risk; understanding the role of humanfactors on safety; learning from errors and using improvement methodsto improve care (WHO, 2011). Action Learning was used to align thislearning with students' participation in clinical practice (Dunphy et al.,2010).
Students were required to undertake a small safety improvementproject while in the practice placement, the presentation of whichwas summatively assessed as evidence of critically informed learn-ing. Mentors, who supported students' practice learning and seniormanagers within the placement organisation, were supportive ofthe initiative. Students were guided to examine a patient experiencefor safety enhancement opportunities, to provide a rationale forchange based on patient safety evidence, to utilise a structured improve-ment tool and to consider issues of effectiveness and sustainability.Students were encouraged to consider the small things that patients sayimpact on their experience and to work within their own sphere ofinuence, recognising that this would expand as they progressedthrough their professional career.
Throughout the progression of the safety improvement projectstudents participated in Action Learning Sets (ALS) run predominantlywithin the university. Action Learning can be aligned to a variety oflearning approaches (Marquardt and Waddill, 2004). These include acognitivist perspective that focuses on conceptual change; constructivistapproaches that emphasise reection and personal meaning making(Schn, 1987; Kolb, 1983), and socio-cultural approaches that fore-ground learning as a social practice inuenced by context, relationshipsand interaction (Wenger, 1998). Action Learning was used as a contextspecic approach (Brook, 2010) to facilitate active learning, criticalthinking and reective inquiry (Lamont et al., 2010) and enablestudents to gain a greater awareness of their own ability to resolveworkplace issues (McGill and Brockbank, 2004).
Students were introduced to the principles of AL and were providedwith a supporting handbook prior to its commencement. The ALS werefacilitated by a member of academic staff. Each set had approximatelysix to eight participants to enable each member to have sufcient timeto introduce their issue or problem to the group, while providing thediversity of experience and questioning required for the student tobe exposed to other perspectives and ways of thinking (McGill andBrockbank, 2004). While use of AL has signicantly increased withinhealth care and nursing there is limited evidence of its use in pre-registration nursing. This study seeks to contribute to our understand-ing of how AL processes can engender condence, personal leadershipcapabilities and support students safer care practices.
The aim of the study was to explore students' experience of partici-pation in AL as a strategy for developing patient safety improvementand leadership capabilities. The study used a qualitative approachinformed by a social constructivist perspective in which knowledgeis regarded as constructed through human interaction. This is de-scribed by Denzin and Lincoln (2003) as a situated activity consistingof a set of interpretive practices that attempts to understand themeaning that people bring to their experiences.
Ethical approval to undertake the study was granted by the Universi-
ty Ethics committee. A letter inviting students to participate in the study,tions (Ritchie and Lewis, 2003). Those who responded to the callfor volunteers were invited to attend a focus group interview at an iden-tied time. Thosewho could not attend at the specied timewere invitedto a one to one interview. In total 52 students participated in the study.
Data were collected through a combination of individual and focusgroup interviews, designed to enhance data richness and depth ofenquiry (Lambert and Loiselle, 2008). Focus groups explicitly usedgroup dynamics to generate insights and gain access to participants'shared frame of reference (McLaffety, 2004; Barbour, 2007). Thisreected a social constructivist interest in shared meanings, languageand negotiated identities developed through social interaction (Ritchieand Lewis, 2003).
In total ve focus group interviews and sixteen individual inter-views, lasting approximately an hour were undertaken in a comfortablelocation within the university. Each focus group had approximately 67participants to optimise meaningful interaction (McLaffety, 2004). Thefacilitator used knowledge of group processes to create an environmentin which everyone could contribute, in which emergent issues could beexplored in-depth but premature consensus avoided (Barbour, 2007). Atopic guide was used for both individual and group interviews andparticipants were encouraged to reect on the process and outcome ofparticipation in AL. All interviews where digitally recorded and tran-scribed in full (Table 1 here).
To facilitate attention to individual voices and group interaction,interview transcripts were colour coded to enable the identication ofindividual contributions. Data were subject to a thematic analysis toestablish analytical categories. A coding frame was developed intowhich key categories and subcategories were integrated and rened(Barbour, 2007; Ritchie and Lewis, 2003). This was an iterative processthat included the search for examples that challenged emergingndings.
Qualitative analysis led to the construction of three key categorieswhich included creating an enabling environment, learning through
Table 1Demographic characteristics of focus group participants.
Female Male Age 2025 Age 2634 Age 35 andabove
Focus group 1 7 6 1 3 3 1Focus group 2 6 5 1 4 2 0Focus group 3 7 5 2 3 2 2Focus group 4 9 7 2 3 5 1Focus group 5 7 5 2 3 3 1Interviews 16 10 4 8 5 1Total 52 38 12 24 20 6
245A. Christiansen et al. / Nurse Education Today 34 (2014) 243247action and reection and the emergence of patient safety practiceseach of which contained a number of subcategories presented below.
Creating an Enabling Environment
When rst introduced to the notion of AL students felt daunted bythe prospect of moving away from the comfort zone of more familiarlearning and teaching approaches. Student clearly perceived key differ-ences between this approach and other learning strategies. AL was seenas more personal than a lecture and active participation did not allowanonymity or passivity as one participant suggested you have tocontribute, it's harder to sit back and it's hard to be invisible. The skill ofthe facilitator and the collaborative relationship established betweenset members were perceived as essential factors in the success of theALS. The setting of ground rules at the initial set meeting enabled setmembers to establish trust, create a supportive non-threatening envi-ronment and express their expectations of each other. An example ofthis is we wanted a group that worked together and who were alwaysgoing to turn up we knew who were the workers and who were theshirkers! The set facilitator was seen as essential for keeping the setfunctioning effectively. Participants suggested that the facilitatorbrought you back onto task if you were going off in a tangent, stoppedthe meeting being used for moaning and helped to manage dominantstudents.
Learning through Action and Reection
Participants found the idea of a safety improvement project scaryas it not only involved them taking the lead and actually implementingsomething but they feared that this might be too big for us. Theydoubted their ability to be innovative and to bring about effectivechange. Participants perceived that within clinical practice they wereexpected to t in and not to rock the boat and were apprehensiveabout being seen to be criticising practice. Students took strengthfrom knowing others felt the same and participation in the set gavethem a shared sense of purpose, energy and tenacity to persevere, forexample it sort of put you on track and kept you on track and it helpedme get straight in my mind what I had to do.
Students drew on a number of different perspectives to help themfocus on an area of safety improvement as illustrated below.
I was helping a patient to transfer into a wheelchair but she said I'mnot getting in that. She thought it had faeces on it but it was driedweetabix. But it made me think who actually cleans wheelchairs anddo they get cleaned in between patients?
The initial meetings helped students to test out their understandingof what was required to undertake the project expressed as it sort ofhelps to break it down and helps you to focus on what you're doing.Students found giving each other time to present, actively listeningand not offering easy solutions challenging as one participant suggestedI now have more awareness of how to let people have that 10 minuteswith...