Nurse Education Today 34 (2014) 243–247
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Nurse Education Today
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Learning in action: Developing safety improvement capabilities throughaction learning
Angela Christiansen ⁎, Trish Prescott, Judith BallEdge Hill University, Faculty of Health and Social Care, St. Helens Road, Ormskirk, L39 4QP, United Kingdom
⁎ Corresponding author. Tel.: +44 1695 650776.E-mail address: [email protected] (A. Christianse
0260-6917/$ – see front matter © 2014 Elsevier Ltd. All rihttp://dx.doi.org/10.1016/j.nedt.2013.07.008
s u m m a r y
a r t i c l e i n f oArticle history:Received 15 December 2012Received in revised form 15 May 2013Accepted 10 July 2013
Keywords:Patient safetyAction learningPre-registration nurse education
Patient safety is one of the greatest challenges facing health care today and nurses are well placed to find oppor-tunities for enhancing care andmaking it safer. Nurse education has an important role to play in ensuring futureprofessions have capabilities and confidence to meet this challenge however this requires new pedagogies innurse education. This paper reports on an initiative to develop the safety improvement and leadershipcapabilities of final year nursing students using Action Learning to support students to undertake a safetyimprovement project in the clinical setting.A qualitative, interpretive research approachwas used to explore students' experiences of participation in ActionLearning. 52 nursing students from a UK University participated in the study. Student accounts of their experi-ences were generated through focus group and individual interviews and data were subject to thematic analysis.Findings are discussed in relation to three categories including “creating an enabling environment”, “learningthrough action and reflection” and “the emergence of safety improvement and leadership practices.” The studyfindings 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.
Introduction
Patient safety has been described as the emotional heart of qualityhealthcare and keeping patients safe has emerged as one of the greatestchallenges facing health care today (Vincent, 2010;WHO, 2011). IndeedThe Francis Report (2013) has brought into sharp focus the devastatingconsequences that can arisewhen patient safety is not the primary con-cern of health care organisations. Key publications in the USA and theUK first highlighted the scale, nature and cost of safety lapses in termsof 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 significantpotential 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 final year nursing students usingAction Learning to support the completion of a safety improvementproject in the clinical setting. The aim of the initiative was tolegitimise safety improvement as everyone's business and to ensurenewly qualified nurses' capability, confidence and commitment to safe-ty improvement.
n).
ghts reserved.
Background
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). TheFrancis report (2013) highlights the leadership qualities essentialfor ensuring patient safety, which includes listening and learningfrom patients and colleagues, the willingness to challenge, inspiringand 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 reflect on thecare provided and be committed to finding 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 strongdesire to “fit 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-efficacy skills and greater awareness of their own agency or abilityto make choices in challenging contexts (Levett-Jones and Lathean,2009).
Table 1Demographic characteristics of focus group participants.
Groupsize
Female Male Age 20–25 Age 26–34 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
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The 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 final 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 ofinfluence, 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 reflection and personal meaning making(Schön, 1987; Kolb, 1983), and socio-cultural approaches that fore-ground learning as a social practice influenced by context, relationshipsand interaction (Wenger, 1998). Action Learning was used as a contextspecific approach (Brook, 2010) to facilitate active learning, criticalthinking and reflective 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 sufficient 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 significantly 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 confidence, personal leadershipcapabilities and support students safer care practices.
Methods
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 Considerations
Ethical approval to undertake the study was granted by the Universi-ty Ethics committee. A letter inviting students to participate in the study,
an information sheet and contact details were distributed via theuniversity e-mail system to a cohort of 240 nursing students. The letterconfirmed students' ability to decline to takepart and assured them thatsteps would be taken to maintain confidentiality 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-tions (Ritchie and Lewis, 2003). Those who responded to the callfor volunteers were invited to attend a focus group interview at an iden-tified time. Thosewho could not attend at the specified timewere invitedto a one to one interview. In total 52 students participated in the study.
Data Collection
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). Thisreflected a social constructivist interest in shared meanings, languageand negotiated identities developed through social interaction (Ritchieand Lewis, 2003).
In total five 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 6–7participants 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 reflect on the process and outcome ofparticipation in AL. All interviews where digitally recorded and tran-scribed in full (Table 1 here).
Data Analysis
To facilitate attention to individual voices and group interaction,interview transcripts were colour coded to enable the identification 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 refined(Barbour, 2007; Ritchie and Lewis, 2003). This was an iterative processthat included the search for examples that challenged emergingfindings.
Findings
Qualitative analysis led to the construction of three key categorieswhich included “creating an enabling environment”, “learning through
245A. Christiansen et al. / Nurse Education Today 34 (2014) 243–247
action and reflection” and “the emergence of patient safety practices”each of which contained a number of subcategories presented below.
Creating an Enabling Environment
When first 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 facilitator“brought 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 Reflection
Participants found the idea of a safety improvement project “scary”as 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 fit 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 suggested“I now have more awareness of how to let people have that 10 minuteswithout jumping in.” Participants suggested they were “respectful”when asking questions because they “didn't want to knock people'sconfidence.”
Gaining New Perspectives
Questions from other set members challenged students to criti-cally reflect on and make sense of the situation they were presenting.This included an examination of their own personal assumptions forexample,
“I came along to the group with my first idea but feedback from thegroup helped me realise that it wasn't really what the project wasabout.”
The ideaswere discussedwithin the group and exposure to differentperceptions of the problems, enabled students to gain new insights asone participant suggested
“Sometimes it takes someone else to point out what you have missedcompletely.”
Participants valued the immediacy of feedback from other set mem-bers. Through “bouncing ideas off each other” students gained access toother peoples sense making practices and a wider frame of reference,which in turn enable them to transform their own perspective. Partici-pants described critical thinking and problem solving processes thatinformed decision making as illustrated by the comment,
“Mymindwas set onwhat I wasworking on and so you are not thinkingoutside the box. But then six outsiders bring their ideas to the table andit makes you think.”
Participants also described the set meeting as an opportunity tomake connections between safety improvement, change managementand leadership theory they had been introduced to in the module.This is illustrated by the comment
“Even though I had a good idea I didn't know how this linked to my ob-jectives and to module learning outcomes but the group helpedmewiththis.”
In contemplating themselves as a change agent students were ableto consider the theoretical underpinning of change theory and considerits application to their personal context.
Taking Actions Forward
Perhaps the most significant difference students perceived betweenAL and other learning approacheswas the level of ownership, autonomyand responsibility embedded in the “actions”whichwere to be pursuedwithin the clinical setting and the notion of themselves as activeparticipants within the real world context. The set acted to supportthe creative process through the generation of ideas and potential solu-tions. Once students identified an intervention to pursue they wereoften struck by the simplicity of actions to be taken. The support andchallenge of peers enabled critical reflection on proposed or emergingactions. Group support enabled the validation of ideas and provided en-couragement and motivation to move forward for example “The ALSgroup really helped me get in my mind what I needed to do, who I neededto speak to, who I could go to find information.”
As the projects progressed the problems brought to the set repre-sented the issues, challenges and uncertainties that had arisen forthem in their endeavour to implement a safety improvement initiative(Table 2). These often related to themanagement of relationshipswith-in the clinical setting. Students were aware that they needed to get thesponsorship of mentors and the support of a wide range of otherclinicians, managers and support workers. Students suggested theneed to influence “difficult personalities” and persuade “resistant staff.”These interpersonal tactics were discussed in the set along with theuse of tools and resources to support their efforts, such as how to findsupporting evidence, how to implement an improvement tool such asPDSA cycle and how to measure the impact of the change.
Students brought challenges to the set and took agreed actions for-ward into clinical practice. This enabled students to grasp complex situ-ations and gave them a greater awareness of organisational structures,clinical governance processes and “who to speak to get things done.”Each member returned to the set at the next scheduled meeting withnew issues and insights arising from actions taken which were sharedwith set members, reflected on and explored before further actionswere agreed.
Table 2Examples of nursing students' safety improvement projects.
• A student nurse who had formerly worked as a phlebotomy assistant discovered outof date blood collection tubes within a clinic. The student challenged hospital protocolwhich resulted in a hospital wide change in policy.
• A student nurse on an acute mental health ward observed increased levels of self-harm due to drinks can tabs. The outcome of his safety improvement project was achange hospital policy and the introduction of plastic drinking bottles. There was asignificant reduction in self-harm as a result.
• A student nurse observed an issue concerning child allergies prior to surgery.Working collaboratively, a process was subsequently implemented which ensuredthat all children with allergies had red wrist bands introduced upon initialassessment.
• A student whilst in community placement observed a patient in cognitive confusionand potential relapse. She initiated collaboration between pharmacists', GPs and theconsultant, and patented a special patient's medication blister pack combined withmemory prompts to be placed in the patient's home.
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The Development of Patient Safety Capabilities and Practices
Undertaking the safety improvement project and participation in ALenabled the development key skills relating to the enhancement ofpatient safety. Students suggested they had gained a greater sensitivityto patients' perspectives and how small things can impact on patients'experiences, as illustrated here,
“My safety improvement project was such a simple thing but it hasmade me realise that even the things which are supposedly little things,can add up to a quite important things for the patient”.
In addition they had a greater awareness of risks to patient safety forexample “doing this project has raised my awareness so much of what cango wrong.”
Students describe key leadership, team working and collaborativepractices relevant to enhanced patient safety, including critical reflec-tion skills to examine clinical practices, relationships and the contextsof care. In gaining support for their projects, students perceived theyhad developed coping strategies and negotiation skills to extend outtheir sphere of influence. Enhanced interpersonal skills helped themto “interact with people and know how to put your feelings and thoughtsacross.” They suggested they had a better awareness of the politicaland cultural dimensions of organisational change and had gained confi-dence to interact with other professionals and to engage in decisionfor example “It's helped me to pick up the phone and speak to people likethe clinical governance team and to approach the consultant withconfidence.”
Students suggested they had developed active listening, construc-tive questioning and problem solving skills which enabled them tofeel more confident about constructively challenging establishedpractices. Furthermore through the active implementation of the pro-ject, they had tested out safety improvement tools, such as the PDSAcycle and had gained the confidence to use these resources to bringabout effective change as the following comments suggests
“I've started to question things a lot more and I feel I have the tools tosay we can improve this.”
At the completion of the project most students had introduced asafety improvement project to the clinical setting. Somewere small pro-jects impacting on only a few patients while others resulted in widescale change and a change to hospital policies and processes. Even forthose students who had been less successful, the process had resultedin different “ways of seeing” practice and greater personal awareness.Participants suggest that they had a greater sense of their own personalagency and their role as innovators of practice. This had impacted on
how they thought of themselves both in the present time and in theirfuture professional role as demonstrated here,
“I mean we should be patient focused and we should be trying to im-prove the patient's experience. But I will question practices more nowI'm pretty certain of it.”
Discussion
The study findings provide valuable insights into how active peda-gogies such AL can enable students to understand the contributionthey can make to safer care practices, both as students and as futurehealth care professionals. Findings suggest that through AL studentscan begin to cultivate the leadership qualities considered essential forensuring patient safety (Francis, 2013), including listening and learningfrom patients, the willingness to challenge, inspiring and motivatingpeers, the ability to analysis complex issues and openness and courage.
Working on real workplace strategies to improve patient safety, stu-dents were in effect leading change. However, the clinical workplace ischaracterised by complex interplay of relationships, values and expecta-tionswhichmakes initiating a changed practice particularly challengingfor students who are seeking to belong and fit in with the culture of theworkplace (Cope et al., 2000; Levett-Jones and Lathean, 2009). Findingssuggest that students were concerned about the perception of an im-plied criticism when safety improvements were suggested. Howeverthrough participation in AL students were able to openly acknowledgethese concerns, come to terms with uncertainty and gain increasedawareness of themselves and their practice within organisational andcultural contexts (Brook, 2010).
Action Learning is built around a task or that is pursued outside ofthe set. Study findings suggest that AL provided an authentic learningexperience where students could work on real problems they wereexperiencing in the “swampy lowlands of professional practice” (Schön,1987). Zuber-Skerritt (2002) suggests that challenges brought to ALSare areas of complexity for which there is not an immediate answer,while Dilworth (1996) suggests that questions flow from finding yourselfin unfamiliar and uncomfortable situations. Within the study studentsbrought their challenges, uncertainties and barriers that had arisen forthem while initiating a safety improvement project.
Working through these uncertainties involved the student in con-siderable emotional work. Feelings and emotions have previouslybeen identified as important aspects of the AL process (Dunphy et al.,2010). Surfacing discomfort may enhance learning as tension cantrigger reflection and critical thinking, central process for ALS (Lamontet al., 2010). Indeed discomfort and conflict are inevitable when learn-ing necessitates an unsettling rethinking of existing relationships anda change in personal perspectives. However working positively andreflectively with these emotions requires an ALS environment basedon trust, empathy and also challenge (Lamont et al., 2010; Haith andWhittingham, 2012).
As a vehicle for learning, AL utilises communal reflection, action andfeedback to promote personal development and help students to learnabout learning (Stark, 2006). ALS functions as a reflective space inwhich practice and personal assumptions are examined to reveal theirsignificance from different perspectives (Rooke et al., 2007). Findingssuggest that within ALS students made explicit their understanding ofthemselves, their emotions and the clinical contexts in which theywere participating. Insightful questions from other set memberschallenged students and sensitised them to the tacit assumptionsthat shaped the culture and practice of the clinical workplace (McGilland Brockbank, 2004; Stark, 2006).
Through a constructivist lens, interaction within the set can be seenas a way to expose students to others sensemaking activities, involvingparticipants in a shared process of meaning making (Marquartd andWaddill, 2004). This aspect is recognised by Glaze (2002) who suggests
247A. Christiansen et al. / Nurse Education Today 34 (2014) 243–247
that the set gives the participant the opportunity to frame and reframethe problem, appreciating different perspectives and gaining in-sights by using multiple ‘reflective lenses.’ From a socio-cultural per-spective reflective thinking, with its inherent doubt and perplexity,triggers the learner to generate creative solutions to preserve self-efficacy (Marquartd and Waddill, 2004). Connecting learning directlywith participation in the clinical context is a key strength as ALS butto be effective, set members must be able to take action by themselvesor be sponsored to do so (Stark, 2006). Within the study students weresupported to take action bymentors and servicemanagerswho acted asbrokers to the larger organisation.
AL has previously been associated with the development of leader-ship capabilities (Kellie et al., 2012). However without the legitimacyassociated with hierarchical positions, students had to work with influ-ence rather than formal power. Through AL studentswere able to devel-op considerable interpersonal strategies to gain sponsorship, negotiaterelationships and influence others within the clinical setting. The setprovided validation for students' ideas and empowered them to act aschange agents, enabling them to develop resilience and tenacity in theface of prevailing organisational cultures. The importance of practi-tioners having confidence to initiate patient safety initiatives withoutbeing constrained by entrenched cultures and practices has beenhighlighted by the WHO (2011). Indeed it is increasingly recognisedthat distributed leadership at all levels of the organisation is requiredto affect change and improve the quality and safety of care (Kellieet al., 2012).
Findings suggest that students had developed a greater sensitivity tothe patients' perspectivewhichhas been identified as central to enhanc-ing patient safety (Francis, 2013). Students perceived that they had de-veloped enhanced interpersonal skills and negotiation skills and copingstrategies to extend out their sphere of influence. Furthermore studentssuggested that they had increased self-awareness, attentive listeningskills, the ability to give and receive constructive feedback alongsidethe ability and willingness to challenge practice.
Findings suggest that ALS can achieve this by enabling students todevelop their own strategies to resolve real workplace issues (Haithand Whittingham, 2012) and deal with the uncertainty and challengeassociated with improving practice (Rivas and Murray, 2010). Further-more with the sponsorship of placement organisations, the study sug-gests that students can be an important source of innovation andcreativity and can contribute to enhanced patient safety. This can givethem a greater sense of their own agency and can transform theirsense of who they are and what they can achieve both as students andas future health care practitioners.
Conclusion
Patient safety is a key challenge in the fast paced, complex contem-porary health care environment and nurses are well placed to find op-portunities for enhancing care and making it safer. However they needkey leadership capabilities to work in organisations and confidence tochallenge cultures that can act as barriers to enhanced safety. Nurseeducation has an important role to play in ensuring that future profes-sionals have the capabilities and confidence to meet this challenge.However this requires innovative pedagogies that promote contextinformed active learning. The study findings provide valuable insights
into how AL processes can engender self-efficacy, confidence and per-sonal leadership capabilities and support students' understanding ofthe valuable contribution they can make to safer care practices, bothas students and as future health care professionals.
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