several months sitting in the waiting room of a massage parlour before any of the ...... Through Responsive and Naturalistic Approaches, San Francisco, Jossey.
-i-
CONTENTS Preliminaries CONTENTS ......................................................................................................................I ACKNOWLEDGEMENTS................................................................................................... VI TABLES ........................................................................................................................ VII FIGURES ...................................................................................................................... VII DEDICATION ............................................................................................................... VIII INSPIRATION ................................................................................................................ IX DECLARATION................................................................................................................ X SUMMARY ..................................................................................................................... XI TRANSCRIPT CODES ..................................................................................................... XII
Main Text CHAPTER 1: INTRODUCTION: CONTEXTUAL AND CONTENT OVERVIEW ........................................................................................... 1 1.1 INTRODUCTION.............................................................................................................1 1.2 OVERVIEW OF THE STUDY ................................................................................................1 Aims of the Study ........................................................................................................2 Organisational Framework ............................................................................................4 1.3 CONTEXT OF THE STUDY .................................................................................................7 1.4 NEED FOR THIS STUDY ....................................................................................................8 1.6 WRITING IN THE FIRST PERSON ....................................................................................... 10 1.7 SUMMARY ................................................................................................................. 11
CHAPTER 2: LITERATURE REVIEW: CLINICAL LEARNING AND COLLABORATIVE PRACTICES............................................................. 13 2.1 INTRODUCTION........................................................................................................... 13 2.2 UNDERSTANDING COLLABORATION AND COLLABORATIVE PRACTICES ........................................... 13 Nature and meaning of collaboration ........................................................................... 14 The value of collaboration .......................................................................................... 16 Evidence of the benefits and problems of collaboration .............................................. 17 Context for collaboration; the rhetoric and reality ......................................................... 20 The policy context .................................................................................................. 20 The education context ............................................................................................ 22 Evidence of collaborative development through integrated teaching......................... 23 Collaborative development through other educational trends .................................. 24 The practice context ............................................................................................... 25 Teamwork as rhetoric or reality ............................................................................ 25 Identifying collaborative practices ......................................................................... 28 2.3 OVERVIEW OF MEDICAL AND NURSING EDUCATION ................................................................ 34 Structure and aims of the undergraduate medical programme ....................................... 34 Culture of medical education and practice .................................................................... 37 Changing medical education ....................................................................................... 39 Structure and aims of the pre-registration nursing programme ...................................... 41 Culture of nurse education.......................................................................................... 44 2.4 UNDERSTANDING CLINICAL LEARNING................................................................................ 46 The purpose of the clinical learning experience............................................................. 47 How people learn....................................................................................................... 51 Learning as individual cognition ............................................................................... 51 Learning as a 'situated activity' ................................................................................ 56 Implications of learning as a ‘situated activity’ for the clinical learning arena ............ 59 2.5 SUMMARY ................................................................................................................. 60
- ii -
CHAPTER 3: METHODOLOGY AND FIELDWORK DESIGN ................... 62 3.1 INTRODUCTION........................................................................................................... 62 3.2 OVERVIEW OF DATA COLLECTION AND ANALYTICAL METHODS ................................................... 62 3.3 SELECTING A METHODOLOGICAL APPROACH ......................................................................... 67 The case for using a grounded theory method ............................................................. 67 The process of the grounded theory method ................................................................ 69 The case for introduction of other methodological approaches ....................................... 70 Assuring quality in the study ....................................................................................... 72 3.4 THE ROLE OF THE RESEARCHER....................................................................................... 73 Being a nurse researching medicine and nursing .......................................................... 73 Researcher impact on context ..................................................................................... 75 3.5 THE PROCESS OF DATA COLLECTION.................................................................................. 76 Situation ................................................................................................................... 77 Subjects.................................................................................................................... 80 Medical and nursing students .................................................................................. 80 Practitioners........................................................................................................... 82 Instruments and procedures ....................................................................................... 83 Documentary analysis ............................................................................................. 83 Critical incident interviews ....................................................................................... 85 Informal interviews................................................................................................. 88 'Limited interaction' observation............................................................................... 90 3.6 ANALYSIS OF THE DATA ................................................................................................. 93 Data avoidance strategy: writer’s block and fear of complexity ...................................... 93 Dealing with the Data ................................................................................................ 96 3.7 SUMMARY ............................................................................................................... 100
CHAPTER 4: CLINICAL EXPERIENCES: 'ATTACHMENTS', 'PLACEMENTS', ORGANISATION AND ASSESSMENT ................................................. 102 4.1 INTRODUCTION......................................................................................................... 102 4.2 'ATTACHMENT' OR 'PLACEMENT': A NOTE ON TERMINOLOGY ................................................... 103 Medical ‘attachments’ ............................................................................................... 104 Nursing ‘placements’ ................................................................................................ 105 4.3 INFLUENCE OF LOCATION ON THE CLINICAL LEARNING EXPERIENCE .......................................... 108 Location of medical student attachments ................................................................... 109 Teaching and learning in teaching hospitals and district general hospitals.................. 109 Student numbers and ‘production line’ learning ....................................................... 110 Effects of clinical presence and absence on student inclusion ................................... 113 Medical student inclusion in specialist and generalist areas....................................... 114 Inclusion and geographical diversity....................................................................... 115 Location of nursing student placements ..................................................................... 117 Inclusion and geographical localisation ................................................................... 117 Nursing student inclusion in specialist and generalist areas ...................................... 119 4.4 DURATION AND PATTERN OF THE CLINICAL LEARNING EXPERIENCE ........................................... 120 Duration and pattern of medical student attachments ................................................. 120 Duration and pattern of nursing student placements. .................................................. 125 4.5 MONITORING AND ASSESSMENT OF CLINICAL PRACTICE ........................................................ 127 Assessment as a disciplinary device ........................................................................... 128 Monitoring and assessment of clinical medical practice ................................................ 129 'Study guides', check-lists and portfolios for supporting learning ............................... 130 Monitoring and assessment of clinical nursing practice ................................................ 134 4.6 SUMMARY ............................................................................................................... 137
- iii -
CHAPTER 5: FACILITATION OF LEARNING: SUPERVISION, TEACHING STYLES AND NEGOTIATED LEARNING ............................................. 140 5.1 INTRODUCTION......................................................................................................... 140 5.2 SUPERVISION OF CLINICAL LEARNING .............................................................................. 140 Supervision of medical students ................................................................................ 141 Role and relationship with the supervisor................................................................ 141 Features of collaborative supervisory contexts......................................................... 145 Junior house officers as supervisors ....................................................................... 147 Supervision of nursing students ................................................................................ 150 Supervision and the influence of relationships and structure..................................... 151 5.3 CONTRASTING TEACHING STYLES FOR MEDICAL AND NURSING STUDENTS ................................... 154 'Toughening up' medical students ............................................................................. 155 'Doing nursing' to learn ............................................................................................ 156 'Personal benchmarking' ........................................................................................... 158 5.4 NEGOTIATED PARTICIPATION AND SELF-DIRECTED LEARNING ................................................. 160 5.5 SUMMARY ............................................................................................................... 167
CHAPTER 6: PARTICIPATION AND MODES OF ENGAGEMENT IN PRACTICE......................................................................................... 169 6.1 INTRODUCTION......................................................................................................... 169 6.2 CONCEPTUALISING PARTICIPATION AND COLLABORATIVE PRACTICES......................................... 170 6.3 'SEEING' AND 'DOING' MODES OF ENGAGEMENT IN PRACTICE .................................................. 172 'Seeing mode': perceived educational value of shadowing clinical practitioners .............. 173 'Doing' medical and nursing work .............................................................................. 178 'Functional visitor' or 'resident hostess' ................................................................... 178 The role of the 'resident hostess' ........................................................................... 180 'Doing nursing', looking busy and learning the rules of engagement.......................... 181 Responses to the 'functional visitor' role and impact on learning ............................... 184 6.4 'BEING' MODE OF ENGAGEMENT IN PRACTICE ..................................................................... 187 Participation and marginalisation in the clinical team ................................................... 188 'Invisibility' of medical students.............................................................................. 190 Medical student responses to their marginalised team role ....................................... 192 Nursing students' exclusion by medical staff ........................................................... 193 Feeling valued and valuable as a person .................................................................... 194 Contrasting 'participation' in the medical and nursing student role ............................ 194 'Busyness' and feeling valued ................................................................................ 196 6.5 SUMMARY ............................................................................................................... 198
CHAPTER 7: THE CLINICAL TEAM: PARTICIPATION, HIERARCHY AND MEMBERSHIP ................................................................................... 199 7.1 INTRODUCTION......................................................................................................... 199 7.2 OVERVIEW OF THE DOCTOR-NURSE RELATIONSHIP .............................................................. 199 The 'doctor-nurse game'........................................................................................... 200 Negotiating doctor-nurse boundaries ......................................................................... 201 Hierarchy, gender and the professional relationship................................................. 203 Power and the doctor-nurse relationship................................................................. 204 7.3 NATURE OF THE CLINICAL TEAM .................................................................................... 207 ‘The team’ and the non-professional .......................................................................... 208 Seniority and hierarchy in the clinical team ................................................................ 210 Ward round roles ..................................................................................................... 213 Doctors as leaders ................................................................................................ 215 Changing doctor-nurse relationships and current social order ...................................... 217 The ‘resident hostess’ follows doctor’s orders .......................................................... 217 Technical competence and nursing status ............................................................... 219 Changing roles, continuity of care and learning opportunities ................................... 220 Discontinuity of Care and Patient Exclusion ................................................................ 223 7.4 SUMMARY ............................................................................................................... 226
- iv -
CHAPTER 8: MAKING CONTACT: BUSYNESS, 'PROFESSIONAL SPACES' AND PERSONAL KNOWLEDGE .......................................................... 229 8.1 INTRODUCTION......................................................................................................... 229 8.2 THE ‘BUSYNESS’ FACTOR .............................................................................................. 229 'Busyness' of the clinical arena .................................................................................. 230 Prioritising medical work and patient care in busy situations..................................... 233 ‘Busyness’ as an inhibitor of team-building.............................................................. 235 Advantage conferred by ‘busyness’ ........................................................................ 236 ‘Clinical blinkering’: a response to busyness ............................................................... 238 'Clinical blinkering' and student 'invisibility'.............................................................. 238 Explaining ‘clinical blinkering’ ................................................................................. 240 8.3 'PROFESSIONAL SPACES' IN CLINICAL PRACTICE .................................................................. 241 Working patterns, conflict and collaborative relationships ............................................ 241 Doctors’ and nurses’ ‘spaces’ ................................................................................. 244 Differing medical and nursing patterns of practice ................................................... 246 The power of local knowledge ............................................................................... 247 Collaboration and communication .............................................................................. 248 8.4 CONTACT BETWEEN PARTICIPANTS ................................................................................. 251 Supportive and combative medical and nursing student contacts ................................. 252 Differences between medical and nursing student knowledge................................... 253 Educational lessons for collaborative development ...................................................... 254 Medical students’ ‘rite of passage’ .......................................................................... 257 8.5 'EXPERIENTIAL BIOGRAPHIES'........................................................................................ 258 8.6 SUMMARY ............................................................................................................... 261
CHAPTER 9: CONCLUSIONS, LIMITATIONS AND IMPLICATIONS.... 263 9.1 INTRODUCTION......................................................................................................... 263 9.2 MAIN FINDINGS ........................................................................................................ 264 Collaboration as a dynamic construct ......................................................................... 264 Learning to collaborate............................................................................................. 265 The analytical utility of participation and engagement in practice ................................. 266 Participation, engagements in medical and nursing student roles ................................. 267 Teaching curriculum: maximising collaborative preparation.......................................... 268 Learning curriculum: maximising collaborative preparation .......................................... 271 9.5 METHODOLOGICAL CONCLUSIONS................................................................................... 273 9.3 IMPLICATIONS AND RECOMMENDATIONS ........................................................................... 275 A model for education and practice ........................................................................... 276 ‘Teaching curriculum’: implications and recommendations ........................................... 278 ‘Learning curriculum’: implications recommendations .................................................. 283 Patient care : implications and recommendations........................................................ 285 Research method: implications and recommendations................................................. 287 9.4 SUMMARY ............................................................................................................... 288
REFERENCES .................................................................................... 290
-v-
APPENDICES .................................................................................... 308 APPENDIX 1: OVERVIEW OF MEDICAL AND NURSING PROGRAMME ................................................. 308 APPENDIX 2: ADDITIONAL EVIDENCE SUPPORTIVE OF THE VALUE OF COLLABORATION ......................... 314 APPENDIX 3: ‘KEYS’ TO COLLABORATION ............................................................................... 315 APPENDIX 4: DIFFERENCES BETWEEN STUDENTSHIP AND APPRENTICESHIP ...................................... 316 APPENDIX 5: THE CONDITIONAL MATRIX USED TO ANALYSE THE LEARNING CONTEXT .......................... 317 APPENDIX 6: CRITICAL INCIDENT INTERVIEW FRAMEWORK ......................................................... 318 APPENDIX 7: UNSTRUCTURED INTERVIEW GUIDE ..................................................................... 319 APPENDIX 8: STRATEGIES FOR RECORDING OBSERVED DATA IN THE FIELD....................................... 320 APPENDIX 9: EXEMPLAR OF OBSERVATIONAL FIELD NOTES .......................................................... 321 APPENDIX 10: EXTRACT FROM FIELD NOTES FOLLOWING TRANSCRIPTION AND GROUPING .................... 322 APPENDIX 11 CATEGORIES GENERATED FROM EARLY ANALYSIS OF DATA ......................................... 323 APPENDIX 12: STEPS OF MULTIPROFESSIONAL EDUCATION ......................................................... 324 APPENDIX 13: EXAMPLES OF ‘CORE CLINICAL PROBLEMS’ IN THE MEDICAL PROGRAMME ....................... 325 APPENDIX 14: OUTLINE OF ‘PARTNERSHIPS IN LEARNING’ MODULE ............................................... 326 APPENDIX 15: EXEMPLAR OF STUDY GUIDE FROM MEDICAL PROGRAMME ......................................... 327 APPENDIX 16: EXTRACT FROM COMPETENCY ASSESSMENT BOOKLET IN NURSING PROGRAMME ............... 330 APPENDIX 17: BONDY’S LEVELS OF COMPETENCE AS USED IN NURSING PROGRAMME .......................... 331 APPENDIX 18: TYPES OF MULTIPROFESSIONAL TEAMWORKING ..................................................... 332 APPENDIX 19: PUBLICATIONS, PRESENTATIONS AND AWARDS ..................................................... 333
- vi -
ACKNOWLEDGEMENTS In an endeavour of this size there are so many people to thank for their advice, support, kind words and friendship. Whilst my gratitude is to all who have contributed to the journey, I give particular thanks to the following:
Harriet Mowat, for exemplifying collaborative supervision and friendship, a model from which I have learned so much and will always be grateful.
Sally Glen, for staying with the project when others fell away and for giving me the freedom to pursue my own goals
Julie Taylor and Heather Whitford, my compatriots on the research journey, who have suffered the pains along the way and always provided sympathetic ears and wise counsel.
Jon Dowell and Mo McElroy, for their efforts in reading drafts as the project neared its end.
Special thanks also go to the students, patients and staff who tolerated my presence and shared their experiences. I hope I have done your stories justice.
- vii -
TABLES Table 1: Details of methods of data collection and sources of data .........................................3 Table 2: Framework for analysis of data based on teaching-learning curriculum dyad...............6 Table 3: Outcomes of organisational individualism .............................................................. 18 Table 4: Competencies required for collaboration between professional practitioners ............ 31 Table 5: Aims of the medical curriculum ............................................................................. 36 Table 6: Stages in the analysis of qualitative data ............................................................... 97 Table 7: Contrasting characteristics of collaborative and authoritarian teacher-learner relationships............................................................................................................ 142 Table 8: Sources of conflict between nursing and medical staff in general hospitals ............. 243 Table 9: Six aspects underpinning the philosophy of the new Dundee Medical Curriculum..... 308 Table 10: Learning outcomes of the Adult Nursing Curriculum............................................ 311 Table 11 : Principles of Nursing Multiprofessional Education Strategy.................................. 313
FIGURES Figure 1 Problem-solving model......................................................................................... 30 Figure 2: Levels of 'concreteness' of educational strategies ................................................. 48 Figure 3: Concurrent data collection process and details of data sources ............................... 64 Figure 4: The centripetal participatory learning trajectory. ................................................. 277 Figure 5: Spiral curriculum model adopted for Medical Programme ..................................... 309 Figure 6: Development of student learning experiences ..................................................... 312
- viii -
DEDICATION
This thesis is dedicated to a number of important people:
Mum and Dad, and Bill and Mary, for doing all you could and for just being there, it made a big difference;
- and -
Lorna, for your love, support, forbearance and understanding;
- and -
Archie and Iona, for reminding me of the important things in life and always keeping my feet firmly rooted to the ground.
- ix -
INSPIRATION A typed sheet has remained on my wall throughout the process of developing this thesis. These words have also played their part in keeping me going, and realising the importance of the journey as much as the destination:
Recall the face of the poorest and the most helpless man whom you may have seen and ask yourself if the step you contemplate is going to be of any use to him. Will he be able to gain anything by it? Will it restore him to control over his own life and destiny? In other words, will it lead to swaraj or self-rule for the hungry and also spiritually starved millions of our countrymen? Then you will find your doubts and yourself melting away. Mohandas Gandhi
I have walked the long road to freedom. I have tried not to falter; I have made missteps along the way. But I have discovered the secret that after climbing a great hill, one only finds that there are many more hills to climb. I have taken a moment to rest, to steal a view of the glorious vista that surrounds me, to look back on the distance I have come. But I can only rest for a moment, for with freedom comes responsibilities, and I dare not linger, for my long walk is not ended. Nelson Mandela
In the beginning I took the teacher as teacher In the middle I took the scriptures as teacher In the end I took my own mind as teacher Lama Shabkar
-x-
DECLARATION
THESIS:
Clinical Experience: Preparation of Medical and Nursing Students for Collaborative Practices
Stuart Cable
I declare that I am the sole author of this thesis and that all the references cited have been consulted by me personally; that the work, of which this thesis is a record, has been done by myself, and that it has not previously been accepted for a higher degree
Signed: …………………………………. `
Stuart Cable
- xi -
SUMMARY One of the over-riding challenges of modern health care is to create systems which function in a coherent and seamless manner in order to address the complex emotional, social, psychological and pathological problems with which patients present. Whilst demand is creating a need for organisational reform, considerable attention is being given to educational methods that can develop professionals who can productively co-exist in the delivery of effective health care. This thesis explores the clinical experience of medical and nursing students as a preparation for collaborative practices. It is founded on an interpretation of collaboration as a 'situated activity' (Lave and Wenger 1991), in which 'learning' and 'doing' are conceived as intimately and inseparably intertwined. Within this interpretation learning is conceived as an integral characteristic of social practice and learning to collaborate provides an example of a dynamic construct of working, subject to constant interpretation and reinterpretation. Consequently, learning to collaborate is not founded simply on a traditional, cognitive construct of learning but has social, moral and emotional dimensions. Using a grounded theory method and data derived from interview, observation and documentation, in a single Faculty in which medicine and nursing pre-registration programmes are taught, this study compares and contrasts models of clinical preparation of newcomers to medicine and nursing. The analytical framework is founded on the concept of ‘participation’. The study identifies three modes of engagement in practice, 'seeing', 'doing' and 'being', which are interpreted as a learning trajectory, along which the student should be assisted to progress. Only the 'being mode' of engagement, it is argued, enables the student to realise collaboration directly. Recognition of the importance of participation for collaborative development raises questions about the social organisation of medical and nursing education in relation to the professions and clinical domains for which students are being prepared. These questions are explored in relation to the ‘teaching curriculum’ and the ‘learning curriculum’, both of which influence the practical and personal resources available to students to experience collaboration in action and consequently to deliver appropriate and effective care to patients.
- xii -
TRANSCRIPT CODES
Italics are used for interview transcript, field note and reflective diary material.
All-tape-recorded materials and documents are verbatim transcriptions.
[…] words, phrases or sentences of the extract omitted.
[xxx] information added to make the context or meaning clearer.
… conversational pauses
Data has been coded and edited in order to preserve the anonymity of respondents
-1-
CHAPTER 1: INTRODUCTION: CONTEXTUAL AND CONTENT OVERVIEW 1.1 Introduction This chapter aims to set the scene for this study, which explores the clinical experience of medical and nursing students and how it prepares, or does not prepare them for collaborative practices. In so doing it outlines the broad aims, methods and findings of the study and describes the context within which the study was undertaken. The need for such a study is also explained with reference to a political context that demands collaboration, a health care context that requires collaboration and educational context which seeks methods to facilitate collaboration.
1.2 Overview of the study One of the over-riding challenges of modern health care is to create systems which function in a coherent or 'seamless' manner in order to address the complex emotional, social, psychological and pathological problems with which patients present. Whilst demand is creating a need for organisational reform it has also thrown into the spotlight the traditional relationship between two pivotal professional groups, namely medicine and nursing, that deliver and control access to much of the health care system. More fundamentally it exposes the importance of the personal and professional character of individuals who must co-exist on a daily basis and deliver self-conscious and productive care.
This thesis is about preparation of medical and nursing students for the demands of modern health care practice and focuses on the learning that occurs in the clinical context with particular reference to preparation for working with others, or collaborative practices. Its principal concern is how the hospital clinical experiences of medical and nursing students in one University Faculty prepared them for working with staff from other professions. This was approached partly through review of the formal teaching strategies and programme
-2-
organisation, the 'teaching curriculum', but also through examination of the interpretation and meaning of collaboration arising from participation in practice, the 'learning curriculum' (Lave & Wenger, 1991) 1 .
The selective focus for this study on clinical experiences in hospitals was despite the trend towards delivery of health care in community settings and significant developments in teamworking and multiprofessional practice in such settings (Bezzina et al., 1998, Howkins & Allison, 1997, Poulton, 1996). This choice derived from my own experience of teaching medical and nursing students. The majority of students I encountered continued to conceive their role within an acute, hospital based model of care and a significant proportion of their clinical experience was gained in the hospital setting. Benefits identified as arising from greater levels of collaboration, namely continuity and consistency of care, reduction in ambiguous messages, appropriate referrals, a diversity of knowledge and team-based problem-solving approaches (Miller et al., 1999), are also not peculiar to community settings as this study will demonstrate.
Considerable interest in the educational preparation of students for collaborative practice is evident in the literature (Barr et al., 1999a) 2 , a literature that has grown dramatically during the course of this study. Although a notable proportion of the published research material in this arena has been on shared learning between different groups of health and social care professionals, there has been little attention directed at the effects of current educational processes as a preparation for collaborative practices. In recognition of this fact this study was developed.
Aims of the Study •
To provide a detailed account of the process of clinical learning amongst medical and nursing students within one University Faculty;
1
The 'learning curriculum' refers to learning resources in everyday practice as viewed from the perspective of the learner, in contrast to a 'teaching curriculum' which are the formal process developed for the instruction of the student. 2 Barr et al include an extensive listing of documents relating to interprofessional education evaluated as part of their systematic review
-3-
•
To compare and contrast medical and nursing students' clinical learning experiences, in order to develop an understanding of different forms of clinical learning as a basis for preparation for collaborative practices;
•
To develop a conceptual rationale for future advancement of clinical learning experiences as a preparation for collaborative practices; and
•
To identify pragmatic interventions in order to enhance the effectiveness of clinical learning experience as a preparation for collaborative practices.
Data was collected over a one-year period from a range of different sources and a process of
'constant comparative method', (Glaser & Strauss, 1967), was adopted in which earlier collected data was used to inform subsequent data collection and analysis. Methodology was directed by the primary aim of the study, which was to generate a detailed account of the clinical learning process of medical and nursing students in one Faculty, in order to illuminate preparation for collaborative practices. To this end a qualitative, interpretive method (Denzin & Lincoln, 1994), was employed.
Utilisation of data from a range of different sources (Table 1) enabled triangulation in analysis and therefore increased both the richness of the data and the rigour of the process.
Table 1: Details of methods of data collection and sources of data
Documents
Observations
Interviews
Medical and nursing pre-registration curriculum documents (n=3)
• Teaching hospital:
• Critical incident interviews (n=22, NS= 14, MS=8) 3
• Medical student handbooks (n=2, years 4 & 5) • Medical Study Guides (n=7, years 4 & 5) • Nursing competency assessments booklets (n=3, Years 1-3)
General surgical ward (12 visits) General medical ward (12 visits) Accident & Emergency Department (A & E) (8 visits) • District General Hospital: General surgical ward (8 visits) General medical ward (9 visits) Midwifery unit (5 visits) • Cottage hospital : (3 visits)
• Faculty position papers on multiprofessional education (n=2)
3
NS = nursing students, MS =medical students
• In-depth, unstructured interviews (n= 16, NS=9, MS=7)
-4-
Data was analysed using methods of coding and categorisation, which resulted in the generation of a number of themes that appeared important to the clinical learning process. These areas constitute the analytical chapters, which are broadly organised within the framework of a teaching-learning curricular dyad.
A central feature arising from the data around which the thesis is organised and through which learning is argued to occur, is the nature of participation. Participation is defined in this study as the degree and modes of engagement adopted by students in practice, and was acknowledged by students as a requisite for developing the capacity to collaborate with practitioners from their own and other professions. Participation and collaboration are, therefore, conceived as intimately associated features of practice. What was observed and reported in this study were different models of participation adopted by medical and nursing students, which encouraged greater or lesser opportunities for collaboration. This provided data for comparing the clinical preparation of the two student groups in relation to the roles they were expected to adopt both as students and practitioners and for contrasting their collaborative development. As the analysis is focused on participation as a preparation for collaboration, the findings have more general implications for learning in social settings.
On the basis of evidence presented in the thesis, implications are identified for future development of clinical learning based on a model, the centripetal participatory learning
trajectory (Figure 4, p: 277). This model provides a conceptual rationale for the organisation of clinical education of medical and nursing students as both a general model for clinical learning and more specifically for the promotion of collaborative development.
Organisational Framework The primary aim of the study was to produce a detailed account of the clinical learning process of medical and nursing students in order enhance the understanding of the context in which collaborative development could be facilitated. Melia, (1987) offers two distinct ways of
-5-
handling data based on complex accounts and interpretation. One is to allow a story to unfold as the study progresses saving commentary until the end, though Melia criticises this approach for the necessary circumstantial detail that confronts the reader prior to interpretation. The second is to present the data in 'discrete bites' which, she suggests, has 'a tidy appeal' but is difficult to sustain. Melia opted for a presentation format somewhere between the two and in the preparation of this thesis all three forms were tried. The challenge of presenting a coherent organisational structure was compounded because the study used a number of different data sources and dealt with two contrasting groups. This generated numerous unfolding stories which proved difficult to assimilate in an accessible and meaningful way.
In the process of re-writing a structure did begin to emerge, the clarity and logic of which readers must judge for themselves. It was founded on a framework defined by two forms of coexisting curricula, 'teaching ' and 'learning' as proposed by Lave & Wenger, (1991) and the interface between the two, which derived from the student, their perceived experiences and their engagement in practice.
The 'teaching curriculum' is defined as the construction of resources for learning, for the instruction of students, by which the meaning of what is learned 'is mediated through an
instructor's 4 participation, by an external view of what knowing is about' (p: 97). Such a curriculum may intensify defined learning experiences but, in doing so, may also result in their fragmentation and limitation as they will be unavoidably founded on needs defined by generalised, external objectives rather than the needs of an individual student. In contrast the
'learning curriculum' is defined as the 'field of resources in everyday practice viewed from the perspective of learners' (p: 97) and, therefore, is unmediated by any external source. Rather, the 'learning curriculum' evolves from being present in a specific 'community of practice' and, as such, is described as a 'situated' concept. This conceptualisation of 'situatedness' means that the 'learning curriculum' cannot be considered in an isolated way, but is a characteristic of the
4
'Instructor' might refer to a number of different roles e.g. curriculum designer, teacher, or clinical supervisor
-6-
community in which it is practised and the social relations that are experienced through participation 5 in that community.
Analyses within the curricular dyad created a representation of preparation for practice founded upon both externally and internally generated resources 6 available for learning. This dyadic framework undoubtedly over-simplifies the structures and processes of learning. It seems hard to conceive that the two could be separated absolutely and do not influence each other through their impact on individual students. For example, the 'teaching curriculum' is likely to sensitise students to learning opportunities and resources made available through participation in practice. It allows a degree of conceptual differentiation between learning as mediated by formal educational processes, learning that occurs by virtue of being present in an unpredictable practice environment, and ways that students engage in practice as the interface between the two curriculum forms. It also allows examination of the coherence of the externally defined 'teaching curriculum' and internally conceived 'learning curriculum'. The chapters and a brief outline of content are presented within the dyadic curricular framework (Table 2).
Table 2: Framework for analysis of data based on teaching-learning curriculum dyad
Teaching Curriculum Chapter 4: Clinical experiences: effect of nature, location, pattern and duration and assessment of clinical allocations on role and relationships Chapter 5: Learning relationships: supervision of students, teaching approaches and student negotiation of practice experiences
Curriculum Interface
Learning Curriculum
Chapter 6: Participation and modes of engagement if practice: increasing participation in practice by 'seeing', 'doing' and 'being' in the 'community of practice'.
Chapter 7: Clinical team: social, historical and cultural context of doctornurse roles and relationships, the influence of changing practice environments and the relationship between the patient in the clinical team Chapter 8: Making contact: professional working patterns and conflict, the value and experience of interprofessional contact and the utility of knowing others and being known.
Each of these chapters contains an integrated narrative based on a compilation of the literature, data generated from the study and interpretation of these findings. 5
Lave and Wenger acknowledge different degrees of participation and these will be discussed and explicated in subsequent chapters. 6 Resources may refer to a range of structures and activities including curricular organisation, teaching strategies, observed practice or participative interactions
-7-
1.3 Context of the Study This study was undertaken with medical and nursing students in a Faculty delivering medical and nursing education programmes in a single Scottish University (Appendix 1). The Faculty currently provides education for annual intakes of over 150 undergraduate medical students and 400 pre-registration nursing students.
The Faculty has also made a commitment through a Steering Group comprised of senior academics to pursue strategies for the preparation of students for collaborative practice,
'…to develop multiprofessional education as a way of enriching the learning environment of students and better preparing them for the challenges of interdisciplinary practice' (Steering Group for Multiprofessional Education, 1998: 2)
A number of multiprofessional education strategies between medical and nursing and midwifery students within the Faculty are in place including shared learning in ethics (Edward et al., in press) and labour (Mires et al., 1999, McCarey & Mires, in press).
Students undertaking preparatory courses in medicine and nursing experience a diverse range of clinical areas in both hospital and community settings. Whilst these are almost exclusively located within local regions for the nursing students, medical students may move over a wide geographical area.
The clinical data was collected on two sites. A 703 bedded teaching hospital, based on the same site as the medical school and one of the campuses of the school of nursing, and a 361 bedded district general hospital (Financial Times Business, 1999) which provided clinical experience for large numbers of medical and nursing students.
-8-
1.4 Need for this study The need for such a study arises from a range of sources. Not least of these is the wealth of policy documentation, both governmental (Department of Health, 1999b, 1998a, 1997, Scottish Executive, 1999) and professional, (UKCC, 1999, GMC, 1993) 7 , which advocates greater collaboration between the professions and the need for appropriate education to facilitate this development.
The specific focus of this study developed from the increasing realisation of the distance that existed between numerous interprofessional learning initiatives and any evidence that this might result in collaborative practice (Zwarenstein et al., 1999). Learning in the clinical context creates particular challenges. Barr, (1996) for example, acknowledged the problems of the time required to negotiate and supervise joint learning in practice settings. Freeth & Reeves, (1999) also identified logistics as a significant issue in developing a joint training ward. However clinical learning provides the only circumstances in which collaboration in the delivery of care can be directly realised through its performance in actual care delivery.
The aim of this study was not to manipulate or manufacture learning experiences of medical and nursing students in the clinical arena but to attempt to understand them within the context of preparation for collaborative practice.
The logistical complexities alone indicate that before making major organisational and curricular changes it is worth exploring what the current structures have to offer in order to evaluate whether these could be enhanced without radical curricular reform and the mass movement or re-organisation of large groups of students. This approach is also consistent with the recommendations proposed by Gelmon et al., (2000) for 'constant quality improvement'. They argue for identifying small changes that might be explicitly evaluated in order to identify improved outcomes as a result. Thus this study provides detailed description of learning in
7
UKCC, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting and the GMC, the General Medical Council are the UK professional bodies for nursing and medicine respectively.
-9-
practice in one university faculty, highlighting areas that appear to be facilitative or inhibitory of the promotion of cultures, organisations and relationships which enhance both collaborative working and the preparation of students for collaboration.
Comparison of the clinical experiences of medical and nursing students provides data of the processes, to which they are exposed, which may influence the outcome in terms of the roles performed by practitioners in the two professional groups. Consequently this study informs the debate on the type of practitioner that the current clinical learning culture is designed to develop. This provides information that can then be contrasted against requirements for progressive and responsive health care services. The findings and implications of this study can then be used to inform other faculties of the likely manifestations of learning in clinical settings.
Although the methodological approach adopted was selected on the grounds of appropriateness to the problem addressed, work produced by Cribb & Bignold, (1999) on medical education suggests an additional utility. They argue that the 'hidden curriculum' encourages the alienation of students from patients and advocate 'the fostering of more interpretative and reflexive
research paradigms' within medical schools. Their argument is that the evidence on the socialisation of medical students highlights a tension between 'objectifying' and 'humanising', the former currently and traditionally being favoured by institutional and epistemological norms of medicine. Cribb and Bignold argue that the research emphasis on positivism supports rationalism and objectification, whilst reflexive and interpretative research highlights the utility of self-understanding, subjectivity and the interpretations of the different social players, namely colleagues and patients. Thus the approach adopted for this study and its epistemological underpinnings may, within the bounds of this argument at least, play a small part in the
'humanising' of health care.
- 10 -
1.6 Writing in the first person Rogers, (1992) in a discussion of the nature of feminist writing and qualitative data presentation explains,
'I invite my students to write candidly in the first person, to place the voice of 'I' in the center of
the page, and in this way, to enter academic discourse through the authority of their knowledge as women.'
This idea is based on the overt recognition of the importance of the self in qualitative research process. Beyond simply presenting findings as if from a personal perspective Wolcott, (1990) writes of the value of bringing into the analysis reflections from your own life because, he argues, you as the writer are the researcher on your own experience.
Ely et al., (1997) propose that the conventions of academic discourse inhibit the inclusion of self, and they argue that breech of this convention allows findings to be shared with a wider, non-academic audience. However Ely et al acknowledge that such a breech requires a measure of trust in others, as one exposes oneself through personal reflections rather than hiding behind the façade of objectivity 8 . As will be discussed subsequently a similar requirement of trust is required in the development of the capacity to collaborate.
Although I would argue that taken to extreme over-personalisation of research writing may result in simply an unsubstantiated personal narrative or novel, this study adopts a degree of personalisation. Consequently, the study is written in the first person as an acknowledgement of my intimate involvement in the development, data collection and analysis process. It also reflects on findings that support my own experiences as a clinical nurse and educator.
8
This is discussed further in Chapter 3 'Data avoidance strategy', p:93
- 11 -
Perhaps, most importantly, the personalisation of presentation frees me to reflect on the parallels that I identified between the student experience of learning in the clinical domain and my own experience of student-supervisor relationship and as visitor, in the process of data collection, to the clinical arena 9 .
1.7 Summary This chapter has provided an introduction to the study designed to understand the clinical learning experiences as a preparation for collaborative practice. The purpose of the study, which has been to inform future educational direction in the clinical arena and provide a conceptual rationale for the proposed developments, has also been made explicit.
The context of the study, within a school of nursing and medical school has been briefly described. And a resumé of the chapter contents has provided a brief guide through the study, with particular attention to presenting, in a logical and systematic way, the analysis of the participative process by which students learn and their collaborative development might be promoted or facilitated. This is founded on a dyadic structure defined by the teaching and
learning curricula.
The need for this study has been presented on the basis of the political demand for collaboration in health care but also of the lack of conceptual and pragmatic clarity for the most appropriate educational strategies to facilitate this process.
Finally the linguistic style of the thesis has been discussed in relation to writing in the first person, a style consistent with the qualitative, interpretive method adopted for the study.
9
It is perhaps worth noting that I am a novice in the process of writing in the first person, to the extent that as I wrote this section I had to revisit it and convert it from third to first person. Personal limitations in this sphere highlight the challenge required to present from a personal perspective, a capacity that I have evidenced is present in new students, who we gradually dissuade in an attempt to academise their writing.
- 12 -
The next chapter will provide background material to subsequent data, although a considerable amount of the literature reviewed in the preparation of this thesis will be included in the analytical chapters so that it is presented directly within the context of the findings of the study.
- 13 -
CHAPTER 2: LITERATURE REVIEW: CLINICAL LEARNING AND COLLABORATIVE PRACTICES 2.1 Introduction This chapter provides background material for the study and comprises three main parts, which aim to provide a context for, and understanding of, the purposes and processes of clinical learning and collaboration.
Firstly, it examines the meaning and utility of collaboration and collaborative practices in health care, as a background to subsequent data analysis. It also outlines the political, organisational and educational context in which the current promotion of collaboration is taking place. Secondly, it provides a brief overview of medical and nursing education in order to provide a basic understanding of the similarities and differences in the educational processes and cultures. Finally, it explores the purpose of the clinical experience in undergraduate medical and pre-registration nursing programmes and outlines different perspectives on learning in social settings described as learning as 'individual cognition' and learning as 'situated activity'. Each perspective contributes to an understanding of the learning process the latter perspective provides the conceptual framework for this study and the rationale for this selection is discussed.
2.2 Understanding collaboration and collaborative practices This section elicits the meaning and the value of collaboration in order to illuminate what is required in order to witness the realisation of more collaborative approaches to practice. It also provides evidence from literature and policy documentation to demonstrate a context within which collaboration and collaborative practices are in the ascendancy. Thus it provides a foundation for understanding the educational and organisational influences on the facilitation of collaboration against which the characteristics of the learning context can be understood or evaluated in subsequent chapters.
- 14 -
Nature and meaning of collaboration Collaboration and collaborative practice are complex concepts defined by notions of working jointly with others, deriving from the Latin col - jointly and laborare- to work (Hawkins, 1986). Collaboration is usually described as a process rather than a single event (Henneman et al., 1995, Leathard, 1994) and, therefore, its operationalisation involves managing organisational, professional and interpersonal relationships for a particular purpose. (Evans, 1994) proposes a useful definition, because it encompasses both process and recognition of potential outcome or consequence of the process,
'Collaboration is significantly more complex than simply working in close proximity to one
another. It implies a bond, a joining together, a union and a degree of caring about one another and the relationship. A collaborative relationship is not merely the sum of its parts, but is a synergistic alliance that maximises the contributions of each participant, resulting in action that is greater than the sum of individual works.' (p: 23)
In an introduction to a series of articles on the nature of collaboration, Davies et al., (2000) propose that each author offers a similar message, of the existential nature of collaboration,
'Collaboration is an attitude, a way of being. Genuine collaboration involves a relationship
between equals - one where others are respected and valued. Quality and equality should go hand in hand.' (p: 144)
Specifically in relation to health care, Coluccio & Macguire, (1983) make explicit reference to the purpose of collaboration, based on patient centrality in process and outcome,
'…the joint communicating and decision-making process with the expressed goal of satisfying
the patient's wellness and illness needs while respecting the unique qualities and abilities of each professional.' (p: 59)
- 15 -
What is, perhaps, important to recognise is that inherent within these definitions is that collaboration is not an end in itself but rather a way of being, a relationship, or process that if effective, should result in outcomes such as improved quality of patient care. Collaboration represents a challenge to health care professionals for two reasons. Firstly because it requires sharing of information, knowledge and responsibility, amongst professions that have traditionally worked independently. Secondly it demands a sharing of power based on expertise and knowledge rather than role or title (Henneman, 1995).
Henneman et al., (1995) in an analysis of the concept of collaboration suggests that the complexity of its definition has resulted in the term often being used interchangeably with concepts such as co-operation and compromise. This lack of clear definition, these authors propose, has limited the utility of the concept because of subsequent difficulties of evaluation. As Fowkes, (1982) comments in relation to audit of practice,
'If you don't know what you're doing, you can hardly be expected to know if you are doing it
well.' (p: 228)
The lack of definition may be associated with the ambiguity over the amount of collaboration in the clinical setting reported by health care practitioners (Baggs et al., 1992). Underlying these contentions is the idea that collaboration and collaborative practice are definable in some empirical sense. This is an attractive notion in a health care climate in which evidence-based practice is strongly advocated as it would enable collaboration to be measured and may allow generalisation to other areas and comparisons to be made. However, the reification or definition of collaboration in some empirically definable way may be untenable. The term 'collaborative
practice' used as a noun, appears to imply that it is a fixed procedure, a strategy or mode of practice or organisational design achieved by 'right' attitudes and management structures. Collaborative practice takes many forms dependent on the problem that it is dealing with, the players who are involved, the context within which it occurs and the constructed reality of the different players.
- 16 -
It is also important to recognise that collaboration may in some instances not be the most appropriate mode of action. A more appropriate term might therefore be 'collaborative
practices' as encompassed within this is the recognition of the processual character of the concept and the complexity and multiple facets that comprise collaboration. The goal of learning is to develop these different 'practices', which may be defined as attitudes, knowledge or skills, and not simply 'doing' activities. This is not to imply that collaboration and collaborative practice are not useful goals for service, encouraging, as will be considered in the subsequent sections, exploration of such issues as power differentials, interprofessional relationships or change management. The problems appear to arise if it is assumed that the goal of collaboration, or collaborative practice is somehow ultimately achievable and sanctions are brought to bear for failure to do so, an action that is alluded to in government and policy documents 10 . Additionally perceiving it as some absolute goal may result in a lack of reflection on appropriate approaches to and goals for practice, in which collaboration may not be the most appropriate strategy to adopt.
The value of collaboration This study is founded on the premise that it is appropriate to promote collaborative development of medical and nursing students and aims to explore how clinical learning influences the process of preparation. It would, though, be inappropriate not to provide at least some evidence of the benefits that collaborative practices can confer on both patient care, and to those delivering care and recognise some of the contextual challenges this goal presents.
Questioning the value of collaboration is important if it is to be promoted as an educational goal, because what is noteworthy in the abundant literature on collaboration, is that despite limited supportive empirical data, there is an apparent assumption that it is inherently a good thing (Atkins & Walsh, 1997). Although numerous authors identify barriers to collaboration e.g. (Soothill et al., 1995, Mathias et al., 1997), few are critical of its aspiration or intent (Ross &
10
This assertion is explored further in this Chapter 2, 'The policy context' p: 20
- 17 -
Mackenzie, 1996). Instead, most analytical discussion focuses on calls for clarification of terminology and identification of the most appropriate modes of implementation and levels of collaboration for organisations, professions and individuals rather than its value and conceptual basis (Zwarenstein & Reeves, 2000, Howkins, 1995).
Horder, (1995) acknowledges that there is limited evidence to support the value of collaboration. He argues that evidence for him arises from his everyday encounters, which demonstrate that collaboration benefits patients and clients whilst failures can cause harm,
'… by the volume of day-to-day experience that harm arises from failure to inform, failure to
explain, contradictory advice given to patient by different people, gaps in responsibility.' (p: 157)
Barr, (2000) cites Hudson, (1999) as one of the few cautionary voices, who warns of the dangers of,
'… over-collaboration' that can become over-complex and over costly, raising unrealistic
expectations with correspondingly low attainments as collaboration fatigue sets in.' (p: 81). 11
In response to such warnings some of the evidence for and against collaboration in clinical practice will be considered.
Evidence of the benefits and problems of collaboration Huxham & MacDonald, (1992) provide a list of potential outcomes that arise from organisational individualism (Table 3), and it seems reasonable to assume that these might equally well apply to individual working relationships, as evidence from this study will support.
11
See Hudson (2000) for expansion of his refreshingly 'sceptical' perspective on collaboration
- 18 -
Table 3: Outcomes of organisational individualism (Huxham and MacDonald, 1992: 52) •
Repetition - two or more organisations carrying out tasks that can be done by one
•
Omission - failure to undertake an activity because not identified as organisationally important, not
•
Divergence - actions of various organisations become diluted across a range of activities , rather than
•
Counterproduction - organisations working in isolation may be in conflict with activities of other
present in any organisations remit or omitted because each organisations assumes it to be the responsibility of another used towards common goals
organisations
Review of a range of studies on the value of collaboration appears to identify two key benefits. These relate to positive patient outcomes associated with improved quality and co-ordination of care, and improved staff relationships and support.
Miller et al., (1999) for example, in a series of case study reviews of different teams, conclude that collaboration results in improved continuity and consistency of care, reduction in ambiguous messages, more appropriate referral, wide ranges of knowledge being used to make decisions and team problem-solving approaches being adopted. Baggs & Schmitt, (1988) undertook a review of a series of studies relating to care in the critical care environment which generated a series of statements regarding the value of collaborative practices specifically between doctors and nurses. These statements supported the improvements in patient care, collegiality and increased job satisfaction arising from collaboration. This contrasted with poorer clinical performance and higher levels of stress in areas where collaboration and interprofessional communication were poor (Appendix 2). Whilst Baggs and Schmitt provide evidence that patients may benefit from collaborative practices, these practices are likely to require change in the relationships between different professional groups.
Other sources of evidence regarding the benefits of collaborative practices appear to be mixed. Styles, (1984), for example, suggests that doctors feel threatened by nurses who discuss collaboration because they view it as an invasion of their territory. Nurses feel threatened by collaboration because of the increased responsibility and accountability associated with it
- 19 -
(Prescott et al., 1987). Adamson et al., (1995) also reported that nurses were dissatisfied with the power differences that were built into their relationships, which they felt detracted from the development of collegiality.
Baggs & Schmitt, (1988) propose that deference to other professions, evident in the doctornurse relationship, may actually detract from the retention of the centrality of the patient in the care process. They argue that there is a danger that 'low status collaborators' will defer to those of higher status resulting in conflict between the desire to be accepted (by high status colleagues) and the duty to advocate for the patient.
Finlay, (2000b) presents a qualitative study of collaboration in a team context, based on observation and interviews with a sample of 12 occupational therapists working in a range of different clinical environments. She identified collaboration within a team to be a complex venture, however generally it was reported as positive, respondents identifying issues of identity, support and esteem as benefits of collaborative relationships within the team. She also identified the on-going process that appears to define collaboration, that collaboration, in this context within a team, is not something that is consistently present but, rather, something that emerges and fades,
'It [the team] offers the opportunities for collaboration and participation in decision-making […]
[but] it can be experienced as a battleground. Team members may see themselves in competition with others. They may jostle for recognition or struggle to defend role boundaries. In their different ways, the therapists seem caught up in a never-ending battle to be respected and valued by other members of the team.' (p: 161)
Evidence suggests that collaborative practices can confer benefits upon both patients and practitioners, and the promotion of collaborative development is a worthwhile pursuit for medical student and nursing students. The promotion of collaborative practices appear to be subject to a number of tensions inherent within the current health care and educational context. These contextual factors may have implications for the development and
- 20 -
implementation of collaborative practices and, therefore, trends in the policy, education and practice context will be briefly reviewed.
Context for collaboration; the rhetoric and reality Policy documentation and organisational restructuring appear to demand change towards more collaborative working practices in health care, but Miller et al., (1999) identify inconsistencies and tensions existent within current systems,
‘In the acute sector, organisational policies have driven working practices towards greater
patient throughput by filling as many beds as possible, and staff turnover is high. Despite good intentions, therefore, the development of highly collaborative working practices may be practically impossible […] Putting individuals together and calling them a team does not necessarily lead to collaborative teamworking'. (p: 222)
Their conclusion identifies potential challenges to the aspirations set out in a recent health workforce planning consultation document (Department of Health, 2000: 5) which emphasises the need for teamworking, flexibility and the maximisation of the contribution of all staff to patient care. Miller et al (1999) recognising the complexity of achieving collaboration in practice argue that it requires consistency in government targets and strategy, organisational policies and group structures in hospital care. The contexts within which collaborative learning and practices are advocated will, therefore, be reviewed.
The policy context Pittilo & Ross, (1998) in a review of health and social care policy identify an 'unstoppable
enthusiasm and momentum' in current UK policy to promote multiprofessional working in health and social care. Similarly, Hudson, (2000) reports that although collaboration has been advocated in a range of guises since the inception of the NHS in 1948, it has been fundamental to health and social care policy since the election of the Labour Government in 1997,
- 21 -
'collaboration was not simply back on the agenda, it was at the very heart of new policies in the
shape of 'partnership'. (p: 264)
This movement involved not only developing closer working relationships between health and social services, but recognised the importance of consistency in other areas such as housing, education and employment policy (Department of Health, 1997). Subsequently further health care policy has promoted interprofessional collaboration as a means of enhancing the efficacy of the NHS (Department of Health, 1999b, 1998a), and the emphasis on 'partnership' has been mirrored through policy documentation across the UK (Hudson, 2000).
In an editorial titled 'Collaboration in the new NHS' Gillam & Irvine, (2000) acknowledge the changes in health care policy and structures designed to facilitate closer working relationships. However they are cautionary as to the degree of influence that policy might have,
'The tendencies to control from above, policy overload and impatience with what is, after all,
supposed to be a 10 year agenda could destroy more than it creates. Raising public expectations of improvement in advance of the robust processes required to underpin professional and service development could paradoxically compromise quality of care'. (p: 6).
Hudson, (2000) however proposes that the problem of linking policy to the achievement of collaboration and consequent improvement in care is more fundamental than one of excessive zeal or inflated expectation. The problem Hudson argues is that the development of public policy is 'a-theoretical' in that it has rarely been based on sustainable assumptions about the individual or organisation, or on empirical findings. The direction of past policy, Hudson contends, has been based on an assumption that organisations would collaborate for the benefit of individuals and communities that they serve. He proposes that current legislation is adopting a more sceptical approach based on sanctions and incentives to bring agencies into to closer working relationships (Department of Health, 1998b). Hudson argues that underlying this development is an 'acceptance that exhortation alone is insufficient' (p: 272), however this approach conflicts with assertions that at team level, ineffectiveness in collaboration is the
- 22 -
product of externally enforced goals (Barr, 1997, Øvretveit, 1993). Thus it is questionable whether collaboration can be achieved by governmental or managerial enforcement rather than nurtured through education and organisational support.
The education context Whilst both professional bodies and educational establishments appear to have recognised and responded to recent political and service demands for a workforce better prepared for collaboration this movement has a relatively long history in health care education. Szasz, (1969) for example was an advocate of integrated education for health professionals expressing his concern about the separatist and competitive cultures that arose from academically and often geographically distinct health care education programmes. Szasz argued that traditional education methods, 'encouraged and reinforced individual achievements at the expense of
collaboration and co-operation.'.
Mason & Parascondola, (1972) suggested the need for the redesign of the whole educational structure. They proposed that students of different professions should work together at the commencement of their careers undertaking initial stages of educational preparation through a core curriculum. They based their strategy on the assumptions that students would learn to function as team members and sharing learning would support this, that this mode of learning would be more economically efficient and that interprofessional learning would increase interprofessional collaboration. However, as with much of the literature on educational development around this period and subsequently, little supportive data is provided to support their assumptions. Indeed the converse view is put forward by Mazur et al., (1979) who argue that students should not be integrated in the early stages of their educational development but rather should develop a role identity of their own which they can then contextualise within the wider multiprofessional arena.
- 23 -
Evidence of collaborative development through integrated teaching Evidence regarding the value of integrated teaching in promoting collaborative practice is recognised to be complex and frequently contradictory (Barr, 1996). Howard & Byl, (1971), for example, undertook a three-year study of integrated educational programmes including students of medicine and other health care professions. They found that whilst satisfaction with the educational process of all other groups went up, those of medical students went down. Similar findings of dissatisfaction with integrated teaching have been found amongst qualified medical staff (Goldfracht et al., 2000). Whilst attitudes to such forms of learning are unpopular with medical staff this provided little evidence of their future collaborative practice subsequent to such teaching.
An extensive study of attitude change among teachers, social workers and community workers at the Moray Institute in Edinburgh (McMichael & Gilloran, 1984, McMichael et al., 1984) highlighted a more positive perception of social workers and community workers, by teachers. This was not reciprocated. Similarly, Carpenter, (1995) undertook one of the few pre-test, posttest evaluation studies of attitude change in medical, nursing and social work students following a one week integrated course of study and found a generally positive trend, but this was by no means universal. There is also a paucity of data to support the implicit notion that interprofessional education will have a long-term impact on practice (Zwarenstein et al., 1999).
A systematic review of evidence of the effectiveness of interprofessional education based on the Cochrane Collaboration criteria (Mulrow & Oxman, 1994), found no studies eligible for inclusion and consequently concluded that 'no rigorous quantitative evidence exists' of its effects (Zwarenstein et al., 1999: 417). Barr et al., (1999a) report on a complementary review based on UK data using more inclusive criteria in which the question is not whether interprofessional education cultivates collaborative practice but in what ways and in what circumstances it can contribute to collaboration. They highlight the importance of their evaluations by noting,
- 24 -
'The hypothesis that interprofessional education cultivates collaboration has been restated so
often that it is in danger of being treated as a self-evident truth.' (p: 11)
Indeed in considering the literature there appears to be a danger that interprofessional education might be seen not only as self-evident, but as the only route to cultivating collaboration.
Collaborative development through other educational trends A lesser number of publications, few of which are research based, do describe other educational factors that might influence the development of collaborative practice. Beattie, (1995) for example, proposes that changes in curriculum design may decrease interprofessional tribalism, whilst Parsell & Bligh, (1998) suggest that adult education approaches and small group methods of teaching may prepare students for working with others.
Other studies have suggested that whilst outcome measures may provide some benefit in evaluating educational interventions, emphasis must be placed on educational process. These should include consideration of joint planning, participant commitment and clarity of objectives (Davidson & Lucas, 1995), thus collaboration becomes inherently a process issue rather than a definable outcome.
Tope, (1996) in a feasibility study, collating data from 1500 students, contends that the process of learning about 'interprofessional working' is best achieved when students interact in ‘real-life’ situations i.e. in the direct provision of patient care. Freeth & Nicol, (1998) adopt this position and describe a study in which they attempt to simulate practice. Mixed groups of newly qualified staff nurses and fifth year medical students were brought together in a clinical context to work through patient scenarios. This study whilst described as a ‘success’ also highlights a common problem, that of delivering resource intensive learning methods to large numbers of students.
- 25 -
Harden, (1998a) has called for more explicit focus on the most appropriate modes of educational delivery. He proposes utilising a three-dimensional model, which makes explicit the relationship between particular learning contexts, curriculum goals and 'multiprofessional
education strategies'. Freeth et al., (1999) argue that numerous confounding variables between educational intervention and patient outcome make the effects of 'interprofessional education' difficult to isolate and predict. They propose that rather than a simple 'Yes/No' answer to the question of whether it works it is more appropriate to focus on how it might produce user benefit within specific environments. They propose that the action research model based on problem-solving in specific contexts provides a more appropriate model than one based on technical-rationality in which generalisable evidence of benefit is demonstrable. This perspective grounds collaboration in a specific context rather than considering it as a general and abstract conception, a perspective that is adopted in this thesis 12 .
The practice context Changes in the policy and education contexts have been reviewed in relation to collaborative development. Reform is also required in practice if more collaborative environments are to be created. Whilst some of these will be considered in relation to the observations of practice undertaken in this study some of the broad practice trends, with particular reference to clinical teams and teamwork, will be briefly outlined.
Teamwork as rhetoric or reality Miller et al (1999) in an extensive study of clinical teams based on case studies, surveys and telephone interviews described an organisational context in the acute sector of health care in which greater throughput of patients and rapid staff turnover have made the 'reality' of a stable team an exception. This finding mirrors a familiar historical legacy. Brown, (1982) in a review of health care teams identified that although the need for teams has been well recognised, this
12
See Chapter 2, ‘Learning as a 'situated activity' p: 56.
- 26 -
talk of teams has been dominant in health care for at least thirty years. Banta & Fox, (1972) asserted that the reality of health care teams was largely 'high sounding rhetoric', because participants were too diverse and unfamiliar with each other to function as such. More recent studies suggest that this situation is still largely the case (West & Slater, 1996). Headrick et al., (1998) assigned the problem to inconsistencies in an organisational context which espouses the need for and value of teams, whilst failing to create systems to support them,
'… the reality of practice is that the professionals with whom one must collaborate are the people who happen to be there.' (p: 771-772).
Field & West, (1995) appointed the cause of the imbalance between rhetoric and reality of teamworking to a prevailing organisational climate. This is based on frequent failures to set aside time for regular meetings, to define objectives and clarify roles, to apportion tasks, to encourage participation and to manage change. While structures for team-building may be frequently lacking, the Audit Commission, (1992) acknowledged that other differentials also undermine the unity of teams,
'Separate lines of control, different payment systems…diverse objectives, professional barriers and perceived inequalities of status, all play a part in limiting the potential of multi-professional, multi-agency teamwork…for those working under such circumstances efficient teamwork remains elusive.'(p: 20)
Some of the literature sounds a sceptical note on teamworking, suggesting that teams can be a forum for destructive or defensive inter- and intra-group dynamics as individuals clash on the basis of differing values or levels of understanding (Finlay, 2000). Loxley, (1997: 57) for example, suggests that in interprofessional exchanges, where anxieties are provoked, defence mechanisms of 'suspicion, avoidance, scapegoating, stereotyping, denial, blaming, self-
idealisation' may all be adopted.
- 27 -
Cott, (2000) in analysis of structure and meaning of teamwork in long-stay care teams also identified an unanticipated outcome. Cott proposed that teamwork can actually promote alienation of lower level staff, by higher status professionals. Support for this contention was identified by Cable et al., (1999) in an analysis of multiprofessional working in a range of different teams. Cable et al found evidence that although non-professionals e.g. porters, domestic staff and receptionists were not considered to be part of 'the multiprofessional team', they were essential in the promotion of continuity of care. Similarly, Young, (1981) recognised the importance of non-professionals e.g. clerical and secretarial staff in the smooth functioning of social work services. Cott, (2000) acknowledges that as health care diversifies and cheaper more subordinate staff are brought in to deliver highly specific, or 'basic' functions under the authority of high status professionals this form of team exclusion must be considered. Otherwise he predicts that decisions made by professionals will fail to be translated into practice by their subordinates.
West (1999) suggests that in order to address the problems of teamworking identified and remain effective and responsive to the changing health care context, a fundamental requirement of clinical teams is 'reflexivity'.
'Reflexivity involves the members of the team standing back and critically examining themselves, their processes and their performance to communicate about these issues and to make appropriate changes.' (p: 13).
West acknowledges that 'reflexivity' does not come naturally and suggests a number of ways of improving the reflexivity of the team. Although West does not refer to learners as team members his propositions for reflexivity, if adapted to creating a clinical learning environment, could be extrapolated to be comprised of the following elements:-
•
leadership that acknowledges the needs of students,
•
making students feel part of the team with ideas and experiences to share,
- 28 -
•
creation of a safe environment in which errors can be acknowledged and successes are celebrated
•
an awareness of the multiple demands of the clinical workplace that might detract from attention on creating a learning environment
•
and the capacity to respond to organisational objectives, both educational and clinical
These factors appear to have important implications for students learning in the clinical context and the role adopted by the 'community of practice'. As such these factors will be referred to again in subsequent data analysis.
This section has outlined the context in which collaborative practices are being developed, but as Henneman et al (1995) suggest whatever the policy directive or organisational structure the fundamental building block of collaboration relies on the relationship between two people,
'Collaboration is a process which occurs between individuals, not institutions, and only the
persons involved ultimately determine whether or not collaboration occurs.' (p: 106).
This process Henneman et al (1995) argue requires individuals to perceive themselves as members of a team contributing to some common product or goal, offering expertise, sharing responsibility and acknowledging and valuing the contribution of others. This requires the identification of the necessary skills attitudes and knowledge to support this process. Some of the 'collaborative practices' that are important for the development of a 'seamless' health care service and upon which clinical learning might be identified, developed and evaluated are considered as background to understanding the preparation of students for such practices.
Identifying collaborative practices Exploration of collaborative practices provides a useful focus for considering the clinical learning of medical and nursing students. These practices comprise individual attributes and competencies that students acquire but also they highlight the processual and developmental
- 29 -
nature of working towards a notional goal of collaboration. Some of the different collaborative practices that might have a bearing on clinical learning of students will be considered.
Braye & Preston-Shoot, (2000) identify a number ‘keys’ to collaborative practices that they suggest are required when attempting to facilitate more integrated working relationships. These include the vision to value different perspectives on problems, acknowledgement of the effects of power differentials within groups and the recognition of the ever-changing nature of health care (Appendix 3).
The facilitation of collaborative development is, therefore, evidently a complex arena within which a number of interpersonal, interprofessional and contextual factors need to be addressed. A number of other authors have focused more specifically on the attributes that individual practitioners need to develop in order to facilitate closer working relationships. These provide a benchmark against which the participative process of students in practice might be evaluated.
A frequently cited model of collaboration in health care literature is that of Weiss and Davis (1985) 13 , which identified two parameters, assertiveness and co-operativeness, as key characteristics of the individual collaborative process. High levels of each of these conflictsolving behaviours it was proposed, defined collaboration (Figure 1), as opposed to other interpersonal practices.
13
This model is a development of a conflict-solving model proposed by Kilmann & Thomas, (1977)
- 30 -
Figure 1 Problem-solving model
- 31 -
Weiss and Davis propose that collaboration contrasts with competitive behaviour which involves high levels of assertiveness but little co-operation, accommodation involving low levels of assertiveness but high co-operation, avoidance involving low levels of assertiveness and cooperation and compromise being moderately assertive and co-operative. Although it may be a useful academic exercise to differentiate these different forms of practice, the utility of such a differentiation appears difficult to conceive for practitioners on the ground. Indeed it may simply create new challenges of defining the meaning of assertiveness and co-operativeness in order to create the conceptual map whilst failing to acknowledge the individual meaning of the relationship for the individuals involved.
Barr (1998: 185) identifies a range of individual competencies that might be required to enable practitioners to collaborate which emphasise the importance of process (Table 4), with many of the competencies based on interpersonal relationships and ways of being. Barr acknowledges that many of these skills are not exclusive to collaboration.
Table 4: Competencies required for collaboration between professional practitioners (Barr 1998: 185) •
Describe one's role and responsibilities clearly to other professions and discharge them to satisfaction of those others
•
Recognise and observe the constraints on one's own roles, responsibilities and competence, yet perceive needs in a wider framework
•
Recognise and respect the roles, responsibilities, competence and constraints of other professions in relation to one's own , knowing when, where and how to involve those others through agreed channels
•
Work with other professions to review services, effect change, improve standards, solve problems and resolve conflicts in the provision of care and treatment
•
Work with other professions to assess, plan, provide and review care for individual patients, and support carers
•
Tolerate differences, misunderstandings, ambiguities, shortcomings and unilateral change in other professions
•
Enter into interdependent relationships, teaching and sustaining other professions and learning from being sustained by those other professions
•
Facilitate interprofessional case conferences, meetings, teamworking and networking
- 32 -
Goleman, (1997) also recognises the importance of what he describes as 'emotional' skills in a detailed analysis of what it means to be 'intelligent'. Goleman postulates that the ability to be sensitive to the display and context of emotions, 'emotional intelligence', may indicate more effective characteristics for achievement than traditional IQ measures of intelligence because of the efficacy of factors, such as self-awareness, self-discipline and empathy, in developing productive relationships with others. Goleman, (1997: 43-44) discusses five domains of
'emotional intelligence':
•
Knowing one's emotions - or self-awareness, monitoring feelings from moment to moment is crucial to psychological insight and self-understanding
•
Managing emotions - or self-discipline, handling emotions so they are appropriate, to a situation allows a degree of perspective or insight to be retained. (Smith, (1992) exemplifies the importance of this factor in what she describes as the 'emotional labour of nursing', the ability to subsume personal feelings to support others)
•
Motivating oneself - being capable of rising to occasions, but also of remaining mindful of situations or relationships in which one is involved
• •
Recognising emotions in others - displaying empathy and developing an awareness of subtle social
signals
Handling relationships - developing social competence and specific skills in order to act 'smoothly' with
others
Goleman outlines in some depth the value of each of these domains to developing successful relationships. He identifies a series of fairly specific 'skills' that can enhance the potential for more effective working with, or management of, other people. These skills may define useful attributes or collaborative practices that might be developed within the learning relationship. However taking a more sceptical or critical stance this framework for 'emotional intelligence' might also be viewed as a method of manipulating relationships with others in order to achieve personal success.
Other authors appear to identify more holistic or fundamental conceptual frames that might be useful for the consideration of the individual capacity for collaboration. Hudson, (1997: 2-3), for example, identifies the importance of spiritual maturity and uses the analogy of Peck's, (1987: 188) stages of spiritual development to describe the process of collaborative growth. Peck describes four stages:
- 33 -
• •
STAGE I Chaotic, antisocial - recognises the power of individualism in which relationships are manipulative and self-serving STAGE 2: Formal, institutional - involves the development of attachment to institutions, rules or
structures and value stability
•
STAGE 3: Sceptic, individual - no longer dependent on rules or institutions but highly committed to social causes and the intellectual analysis of truth
•
STAGE IV: Mystic, communal - involves a 'connectedness' to the whole, in which collaboration is 'lived' because the individual perceives themselves as part of something bigger.
Mowat (neé Hudson) & Mowat, (2000) propose that the value of this understanding of spiritual growth towards a more communal form of being is that it provides a framework for identifying both the stage of development and the barriers that inhibit movement through the different stages. Mowat and Mowat argue that fear in a range of guises is the primary inhibitor of development and consequently a barrier to collaboration. They identify fears around nonconformity, of losing power or status, of taking risks and of litigation and argues that recognition of these fears enables them to be addressed, allowing us to feel safer to take risks, take on responsibilities and in turn create a more supportive environment. However Mowat and Mowat also acknowledge that individuals can move backward and forwards through these different stages dependent on particular contexts or situations.
Fromm, (1993, 1976) offers another conceptualisation on human relationships and personal development that might illuminate a process for promoting collaborative development. He describes two modes of existence, 'having', and 'being'. Fromm (1993) proposes that individuals oriented towards a 'having' mode of existence define themselves and their position in relation to others in terms of what they possess. This may comprise a diverse range of things, not only material goods but also knowledge, power, responsibility or social standing. Thus the person defines themselves in relation to external objects or symbols and their primary motivator in life is acquisition. Thus collaboration with others within this mode would be on the basis of what advantage or status the collaborative relationship might confer for the particular individual.
- 34 -
This analysis of a range of issues, identified as central to the understanding and realisation of collaboration, offers an introduction to the conditions within which collaborative practices can develop and begin to influence practice. It has highlighted the challenges for educators, practitioners and students in developing such processes. These processes have to be developed in medical and nursing education contexts, which have different social, professional and historical cultures. The next section will therefore review these cultures in order to explicate further an understanding of the complexity of promoting collaborative development.
2.3 Overview of medical and nursing education
Structure and aims of the undergraduate medical programme Lowry, (1993: 2) outlines the traditional British medical programme, which was divided into three parts. The first part of one-year duration comprised the pre-clinical sciences; chemistry, biology and physics (1st MB). The second part was a further two years of more applied preclinical sciences; biochemistry, physiology and anatomy (2nd MB). The final three years comprised the clinical component (MB BS). The pre-clinical years were taught by university staff, (often not medically qualified), whilst the clinical component was largely in hospitals taught by clinicians with honorary academic appointments. Following completion of the undergraduate programme (five years) a further year was spent in 'apprenticeship' in approved posts prior to gaining full registration, known as junior or pre-registration house officer posts.
In 1993 the General Medical Council (GMC) recommended radical reform of undergraduate medical education (GMC, 1993). Acknowledging the failure of earlier Council recommendations published in 1980, 1967, 1957 to address a number of issues they stated,
'…there remains gross overcrowding of most undergraduate curricula, acknowledged by teachers and deplored by students. The scarcely tolerable burden of information that is imposed taxes the memory but not the intellect. The emphasis is on passive acquisition of knowledge, much of it to become outdated or forgotten, rather than on its discovery through curiosity and experiment.' (p: 5).
- 35 -
The GMC document, 'Tomorrow's doctors', (GMC 1993) proposed that the cause of these problems was largely historical. The medical education structure was based on an original apprenticeship model that was gradually supplemented by medical sciences as they became relevant. The consequence was that the two components developed separately creating a preclinical/ clinical divide. A second problem was the historical legacy that prior to 1953, newly qualified doctors could practice unsupervised following full registration, thus it was considered necessary that a doctor on graduating should have a knowledge sufficiently comprehensive for all contingencies.
The GMC proposals recommended that new curriculum designs should comprise two elements. A 'core curriculum', to introduce 'a degree of uniformity' (p: 8) to a medical programme, and special study modules that students could elect to take, in order to 'enable students to explore
critically and master comprehensively subjects that excite their curiosity. (p: 10).
The GMC recommendations also encouraged two other important reforms. These were increased use of problem-based methods of learning and early clinical contact. Thus methods through which students could become familiar with small group, interactive styles of learning and early clinical contact were designed to make overt the clinical relevance of non-clinical education.
Towle, (1991), in analysis of the specific needs of undergraduate medical education that predated the GMC report, identified a range of curriculum aims (Table 5), that reflected the problems that had existed in traditional medical curricula and still represent the current broad direction of curriculum design. However as Towle, (1998: 7) acknowledges, most of these ideas, 'have proved relatively uncontroversial, but difficult to implement.'
- 36 -
Table 5: Aims of the medical curriculum (Towle 1991: 8) 1.
Reduction in factual information
2.
Active learning
3.
Principles of medicine (core knowledge, skills and attitudes)
4.
Development of general competence e.g. critical thing, problem-solving, communication
5.
Integration (vertical and horizontal)
6.
Early clinical contact
7.
Balance between hospital/community; curative/preventative
8.
Wider aspects of health care e.g. medico-legal/ ethical issues, health economics, medical audit
9.
Interprofessional collaboration
10. Methods of learning/teaching to support aims of curriculum 11. Methods of assessment to support aims
However in considering these aims a number of principles relevant to collaborative development appear to have been adopted. Though these may not have been intended solely for the purpose of collaborative development their inclusion might have the potential for positive effect:
•
Methods of learning that actively involve the student in the pursuit of knowledge (Aim 2) if founded on adult-learning principles are postulated to promote self-direction and lifelong learning upon which shared learning should be founded (Parsell & Bligh, 1998)
•
Development of general competence (Aim 4) identifies skills required by all health professional and therefore may provide focus for shared learning
•
The aim of curricular integration (Aim 5) is consistent with the development of integrated curricula described by Bernstein which may reduce disciplinary separation and subsequently
'tribalism' (Beattie, 1995)
•
Early clinical contact (Aim 6), creates the opportunity to see how others work and even, in principle, begin to establish relationships with other staff
- 37 -
•
Overt inclusion of the aim interprofessional collaboration (Aim 9) makes a strong statement of the requirement to develop educational strategies that might develop and promote collaboration.
•
Strategies of learning, teaching and assessment supportive of the aims of the curriculum (Aims 10 and 11) require the promotion of interprofessional collaboration to be woven throughout the organisation, delivery and evaluation of the programme. This acknowledges Harden's, (1986) call for consistency with aims in all elements of the curriculum planning process.
Although these aims appear positive for collaborative development, Towle (1998) recognises the problems of implementation of the aims that have been encountered. Considering the culture of medical education might facilitate some understanding of these problems.
Culture of medical education and practice The curriculum aims presented by Towle (1991)(Table 5, p: 36) were analysed in respect of their capacity to develop collaborative practices. Cribb and Bignold, (1999) suggest that many recent medical education reforms were actually aimed to counteract the tendency of traditional curricula to create a professional socialisation process for doctors which 'objectifies' patients. The new curriculum aims favoured creating a more 'humanising' culture, but in doing so may make more vulnerable young doctors who will require their armour of objectivity in order to survive.
Cribb and Bignold suggest there has been a culture of 'alienation' of doctors from the everyday world, that was recognised by Becker et al., (1961) and by Atkinson, (1977). The contention that medical socialisation and organisation results in both professional and social segregation is supported by Dumelow et al., (2000) who present interview data from hospital consultants.
- 38 -
Interviewees describe the alienating character of medicine both professionally and personally due to service demands and hospital culture.
This alienation Cribb and Bignold (1995) propose follows an identifiable pattern from an early stage in the professionalisation process,
' a loss of idealism amongst medical students as they move from articulating humanistic ideals
upon entry to an increased pragmatism and sometimes cynicism. This might alternatively be described as a 'transformation' of idealism as increasingly 'real world' values are adopted.' (p: 197-198).
This loss of idealism in the undergraduate phase, is argued in part, to be a product of the need to 'survive' when faced with the sheer quantity of information comprising a medical curriculum. Towle, (1998) observes that most of the curricular changes have involved reform of process i.e. from didactic-lecture format to small-group interactive methods, rather than content. Thus the burden of factual knowledge remains high. That this should be a cause for concern is reflected in findings by Fox, (1979), who identified that the response to the heavy and multiple demands placed on medical students was to adopt 'affective neutrality' or 'detached concern'. Haas & Shaffir, (1984) further elaborated this view describing the process and subsequent outcomes as,
'alienation and separation from lay society that characterises professionalization and lies at the
heart of the loss of idealism and objectification of clients. The process of isolation, separation and elevation provides the context for personal change, so that the move towards authoritativeness in serious or fateful matters is accompanied by external (symbolic) and internal (psychosocial) changes.'(p: 77).
This capacity for individual students to become alienated as they move towards becoming doctors is argued to be increased by ritual elements of daily encounters experienced by medical students. For example Davies, (2000a) and Peckham, (1998) both acknowledge the allegiance to 'education by humiliation' which has prevailed in medical education and in the face of this is
- 39 -
the requirement for students to provide displays of confidence and competence that they may not actually possess (Haas & Shaffir, 1982).
Peckham, (1998) reflecting on the future of medicine recognises the importance of fundamental cultural reform from an almost exclusive allegiance to the scientific paradigm. He argues for a greater inclusion of the arts in the curriculum, in order to provide insight and new ways of viewing, and in turn coming to understand human problems.
Recognition of the effects of the current process of education has evident implications for collaborative practice in highlighting tensions between a call for interprofessional collaboration whilst sustaining a practice role that creates and requires professional detachment and the capacity to function in isolation.
Changing medical education Acknowledgement of the problems of medical education would suggest the need for change to more supportive and inclusive methods and structures. Harden, (1998b) recognises the challenges faced by educators,
'Sclerotic bureaucracy, territorial warfare, raw incompetence and ignorance about the process
have been enemies of change in education. Despite much talk, medical schools, universities and postgraduate institutions have been slow to change.' (p: 189).
Leinster & Dangerfield, (1996) ascribe an inherent conservatism in the process of change to a number of obstacles. These include resource distribution to departments on a full-time equivalent student basis, therefore making large group didactic financially preferable, and an ethos, which favours research over education in terms of career advancement, despite lip service being paid to the importance of teaching. Also there is an issue of ownership of the curriculum by those teaching the programme, what Coles, (1993) recognised as the division
- 40 -
between the planned, delivered and learned curricula. Thus, whilst the documentation is reformed the delivery, learning and student-teacher relationship remain unchanged.
Dacre (1998) for example, in highlighting the variability of teaching methods provides some explanation for the slow pace of change. She acknowledges the fact that few doctors have been taught how to impart their knowledge of their subject and as a consequence tend to rely on methods that were adopted when they were taught themselves. Towle (1998) supports the view of insufficiency of staff development in the area of teaching. She suggests that staff development is a new idea in UK medical schools. Until recently it was considered that professional qualifications and personal experience were adequate to guarantee a satisfactory level of ability as a teacher. The problem Towle suggests was compounded by the acceptance that as medical students were amongst the brightest undergraduates they would be able to cope with parts of the course that were inadequately taught.
Cribb and Bignold (1999) propose that if changes in medical education are to be achieved then there is a need for a greater understanding of the 'hidden curriculum'. In other words understanding why the professional-scientific paradigm has dominated for so long and why little change has been achieved despite recurrent recommendations from the GMC. This, they argue, might best be achieved by more 'interpretive and reflexive research', research into the nature of medical education establishments and a liberalisation of medical education research paradigms. Cribb and Bignold (1999) propose that the traditional professional-scientific discourse that dominates medical education research emphasises distance and 'objectification' and they contrast this with more reflexive-interpretive research paradigms,
'the former approach is more likely to lead to educational interventions being treated as 'natural
experiments' and an emphasis on identifying correlations between, and making causal inferences about, variables. The sheer complexity of the broader social and educational contexts means that they are likely to be 'bracketed out' of consideration, or 'controlled for' by use of statistical techniques. The huge number of potential variables means that these broader contexts are unlikely to be incorporated in any depth in to such research. By contrast
- 41 -
interpretive research assumes that connections between social phenomena are not necessarily (or only) causal; and that subjectivities and cultures are constituted by frameworks of meanings which can be elicited and analysed in ways which are analogous to normal processes of mutual understanding.' (p: 203-204)
Interestingly, after presenting a convincing case on the need for understanding of the 'hidden
curriculum' and for a more reflexive and interpretive culture in medical education Cribb and Bignold appear to falter. The conclusion to their paper proposes,
'There are hazards in reforming both professional socialisation and medical education research.
If we accept that detachment plays an important role in the survival of young doctors - and it would be dangerously cavalier to dismiss this idea completely - then we will want to proceed cautiously with the introduction of certain forms of reflexive learning.' (p: 207)
This then calls into question whether a change to a more supportive, communal, or inclusive form of education is appropriate for the demands of current medical practice. One might argue that the conservative curriculum and resistance to change actually acts as a protective device for newcomers to the profession.
Structure and aims of the pre-registration nursing programme Student nurses were traditionally closely linked to delivery of service, comprising part of the nursing establishment figures and spent most of their period of training in the clinical area. Despite the view cited in the Platt Report on Nurse Education (Royal College of Nursing, 1964) that the more structured education process was better for both students and patients, not until 1986 were proposals put forward by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) for reform (UKCC, 1986). These reforms proposed, in the document
'Project 2000 A New Preparation for Practice' (UKCC, 1986), the Project 2000 pre-registration schemes. The key features of these schemes were a common foundation course followed by a number of specialist branches, a move of the education programme into higher education
- 42 -
institutions and the introduction of supernumerary status for students with respect to service delivery. However, as Dolan, (1993) pointed out, the differences between studentship and apprenticeship indicated the need, not for simply restructuring of nurses education, but a paradigmatic shift in the way student nurses were viewed and viewed themselves. This shift was from one of ‘passive doers’ to ‘questioning thinkers’ (Appendix 4).
Gough et al., (1993) reported that whilst the shift was resisted by some within the nursing profession, doctors were the group most challenged by, and critical of, increased academic credibility of nurses. This criticism was condemned as a double standard by Orr, (1987), due to its implication that
'…while the education of nurses is best carried out as part of giving nursing care, the same
criteria do not apply to the teaching of medicine.' (p: 24)
However Christman, (1988) in more conciliatory tones suggested that the move to an academic tradition in nursing would create a greater common ground and therefore reduce the culture of territoriality.
Whilst interprofessional skirmishes accompanied the introduction of Project 2000 nursing, Macleod Clark et al., (1997b), identified that the change had a positive outcome. In a longitudinal study of 498 student nurses, they identified that the introduction of a more academic approach to nurse education had produced a 'different type' of nurse to those described in pre-Project 2000 studies (Melia, 1987, Gerrish, 1986) 14 . Macleod Clark et al argued that following the new programme there was a shift in perspective away from the traditional view of nursing based on rules, rituals and tasks and closely allied to undertaking or supporting medical functions. This was in favour of more patient-centred, research-based practitioners who were prepared to question colleagues and act as patient advocates.
14 Gerrish, (1986) described nursing work based on the demands of medical colleagues rather than the patients condition, whilst Melia, (1987) identified the importance of 'getting through the work', focusing on tasks rather than patients.
- 43 -
Macleod Clark et al., (1997a) found that Project 2000 diplomates were generally positive about their educational experience although there were a number of criticisms. A mixture of perceptions were reported with regard to the extent of self-directed learning, with some students feeling insufficiently supported by the college, whilst others considered it up to the individual to get as much from the course as possible. The programme was also criticised for lack of practical skills, e.g. in managing intravenous infusions, nasogastric tubes and catheters, although this was tempered by the recognition of many respondents that they could not be fully prepared for their role through an initial training course. Managers interviewed in the study proposed that lack of time to consolidate practice in the pre-registration programme resulted in a lack of 'realism' and a possible increased sense of frustration that students could not do everything for which they had been trained on qualifying.
Jasper, (1996) in a qualitative study with eight staff nurses in their first post-qualification year identified similar issues. Jasper argued that the new programme of education was going to create views that were contrary to those that had existed in the field therefore students would need support and open debate about the problems they encountered if they were not to simply conform to observed clinical behaviours. In her cohort of staff nurses she identified that they perceived that their educational process had equipped them with the confidence and ability to challenge others within the workplace and maintain a viewpoint under pressure. Kyle, (1995), and Weiss & Davis, (1985), have argued that assertiveness is a pre-requisite for collaboration. On the basis of Jasper's evidence the programme would appear to be delivering appropriate skills for collaborative practice, whilst creating tensions for new staff nurses in 'established' clinical areas
Although evidence suggested that there was general satisfaction with Project 2000 courses there was also substantial agreement that the pendulum had swung too far in favour of theory at the expense of practice (Macleod Clark et al., 1997a). In response to the changing health care climate and a number of criticisms the UKCC, (1999) commissioned the report, 'Fitness to
- 44 -
Practice' with the terms of reference 'to prepare a way for pre-registration nursing and midwifery education that enables fitness for practice based on health care need.'.
The Report's recommendations were extensive. Of overt relevance to the clinical experience and preparation for collaborative practice were recommendations to improve integration between higher education institutions and clinical areas, improve support, teaching and learning in practice placements and include interprofessional teaching and learning in programmes.
The potential changes for curricular reform following this report could be significant for nursing, demanding changes in curriculum, organisational relationships and staff and student roles. There is a clear emphasis on interprofessional education and strategies such as problem-based learning which encourage group working and shared responsibility. There is also a focus on improvement of the quality of clinical education and wider educational and practice trends, which have the potential to develop a better-educated and more collaborative nurse.
Culture of nurse education One of the driving forces for educational reform was the recognition of the culture that prevailed in nursing for many years. The World Health Organization (WHO, 1986), for example, identified
'The nursing culture is heavy with insubordination without influence. It is burdened with obligation without power even in directing, heading and controlling its own education and practice, research and management. Such an ethos militates against the emergence of positive initiative.' (p: 5)
Spence, (1994) proposed that rather than recognising the powerful influence of the institutions in which they practice and learn, nurses interpret their lack of power at a personal level. This she suggests relates to an insidious shaping of their professional socialisation by those who have been traditionally dominant in society, namely doctors and administrators.
- 45 -
Beattie, (1995) contrasted the different medical and nursing education institutional cultures,
‘...we can characterize the traditional pattern of medical school as one dominated by ‘partition’, associated with the development of high social distance, and cosmopolitan loyalties; while the traditional pattern of training in schools of nursing has been dominated by ‘patronage’, associated with a strong focus on task completion (‘getting through the work’) and local loyalties.' (p: 16).
This description reinforces a passivity or domination that Mackay, (1990) proposed nurses learn early in their training, a requirement not to speak out. Taylor, (1993) similarly argued that to the detriment of the nursing profession the, 'the image of the white, young, middle class female
nurse remains […] and media images of nurses as angels or whores often remain unchallenged.' (p: 69). Taylor argued that whilst nurse teachers have a responsibility to change such images a culture exists of passivity, conservatism and hierarchy based on the selection of students who conform to their (nurse teachers) own image, or on the traits desired by teachers (Raya, 1990). The consequence of this situation is proposed to be that the 'hidden curriculum' created by values and beliefs inherent within the nursing education institution continue to be largely conservative (Wondrak, 1989) and resistant to educational reform (Field, 1989).
Freire's, (1994, 1970) analysis of oppression provides a useful framework within which to consider the culture of nursing. Freire argued that education is for ‘domestication’ or ‘liberation’, the former accepting the values of the cultural norms, whilst the latter encourages power over one's own destiny. Whilst the latter may appear an admirable goal, consistent with a dynamic professional ethos, Freire argued that many prefer the security of the former state in which the situation, or the 'oppressors' may be criticised, but responsibility for one's actions or condition can be blamed on others. One might contend that this state therefore provides safety in conformity and may explain the criticisms that clinical staff often make of students who are too questioning of established practice whilst lacking skills to 'do' nursing (Taylor, 1993).
- 46 -
Melia, (1987) offers a similar picture of conformity in her analysis of the occupational socialisation of student nurses. However she proposes that nurses are not simply a homogenous, professional mass who all conform to the same values and interests but rather comprise 'loose amalgamations of segments' who pursue different objectives in different ways. The two main segments that Melia identifies are 'service' and 'education'. Students are presented with two different nursing cultures. The college presents 'idealised' or 'professional' views of nursing whilst the ward focuses more on workload. The outcome of the tensions created by the two cultures is that students learn to 'fit in' and 'move on' rather than to expose the differences, with a consequential difficulty for becoming a part of either culture, and adoption of a passive response to the diverse cultures that they experience.
Thus two key concepts appear to be prevalent in the academic discussion of the culture of nursing. There is a focus on power or the lack of it and a tension between the education nurses receive and the practice they observe, which might be argued to create a professional response based on passive acceptance of situations. Both have implications for collaborative development, which will be addressed in the analysis of the data.
2.4 Understanding clinical learning This section explores the literature on the purpose of the clinical learning experience in preparatory programmes for medical and nursing students. It also considers a range of perspectives on learning in social settings in order to provide a conceptual foundation for analysing the role of students in the clinical work place and its relationship to collaborative development through participation in practice.
- 47 -
The purpose of the clinical learning experience Recommendations on the development of programmes for medical and nursing student education which have influenced, or are currently influencing, curricular developments emphasise the importance of the clinical learning experience (GMC, 1993, UKCC, 1999, 1986).
The document 'Tomorrow's Doctors' (GMC 1993) advocates early clinical contact for medical students in order to address the proposed curriculum theme of 'clinical method, practical skills
and patient care'. It is recommended that clinical teaching is adaptive to changing patterns of health care and provides experience of both primary health care and hospital-based services. The reference point for achievement is defined as the equipping of medical students with the skills, attitudes and knowledge to perform as a pre-registration house officer on completion of the programme. The explicit value of different clinical learning experiences is unstated in the document beyond general preparation for practice.
The document 'Fitness to Practice' (UKCC, 1999) acknowledges the 'symbiotic relationship
between understanding and doing' (p: 36), whilst highlighting problems associated with preregistration nursing programmes relating to competence to practice at the point of registration. The document cites evidence from the House of Commons Health Committee, (1999: 31) that Project 2000 programmes 'have resulted in nurses' direct experience with patients being
delayed.' In response to these criticisms it recommends an outcomes-based competency approach for both classroom and practice-based learning with clear direction for practice placements in which students, assessors and mentors know what is expected of them (Recommendation 13). It also recommends that placements should provide experience of 'the
full 24 hour per day and seven day per week nature of health care' (Recommendation 18: 41).
These documents clarify the purpose of the clinical experience as providing the opportunity to practice skills in 'real-life' settings and to develop an understanding of the role for which they are being prepared and the workings of the clinical context. However no clarification of the relationship between specific learning experiences and defined practice outcomes is made.
- 48 -
Coles, (1998) proposes that 'actual experience'. the direct personal experience of a situation provided by the participation in a context creates the highest level of 'concreteness' in learning (See Figure 2). This he proposes is an important consideration in assessing the learner's level of development because, 'as a rule of thumb the newer the learner to a subject, the higher on the
scale of concreteness should be the presentation of any example or illustration.' (p: 75)
Highest Actual Experience Simulated Experience Role Play Demonstration Video recording Audio recording Paper and pencil case Reported case Diagrams Concepts Lowest Figure 2: Levels of 'concreteness' of educational strategies (Coles, 1998: 74)
Thus the clinical component of the educational programme should provide 'concrete' examples or experiences from which the student can learn. These experiences can therefore perform a powerful educational function.
Jolly, (1998) recognises the importance of considering the purpose of the clinical experience in more detail suggesting that its importance has not always been acknowledged. Jolly provides a historical overview of clinical education in medicine and identifies that for four hundred years up to the seventeenth century almost all medical preparation was carried out by reading and not by clinical contact. He suggests that even at the beginning of the twentieth century criticism of the level of scientific rigour resulted in the highly disease-oriented approach to medicine resulting in brief functional/technical learning visits that is only now shifting with the moves back towards the needs of patient and community.
- 49 -
Jolly also identifies that despite the emphasis now placed on clinical education the goals or outcomes required of such learning environments are unclear. For example, in a study using observation and questionnaires distributed to 51 senior clinicians on the purpose of the clinical experience twenty different objectives were identified, the only area of consensus being physical examination and the detection of physical signs (Towle, 1992).
Atkinson, (1981, 1974, 1973) undertook an extensive sociological evaluation, using an ethnographic methodology, of the educational objective of the clinical experience in hospital contexts. He recognised that this experience is an essential part of the training and socialisation process, describing it as a 'rite of passage' based on,
'an assumption that the trainee is to gain 'practical' knowledge and experience through some
form of exposure to, immersion in, and some sort of 'practice' on 'real' settings.' (Atkinson, 1981: 115). Whilst Atkinson acknowledges that students gain certain practical skills in the clinical arena, he suggests that rather than being exposed to 'reality' they encounter a 'dramatic enactment of a
particular form or version of medical work.' (p: 115). He describes a process of creating 'mock ups' whereby students are presented with stage-managed situations or problems in controlled situations in such a way that leads to requisite answers based on the students' investigations (Atkinson & Delamont, 1977). This approach to achieving identified and controlled outcomes, Atkinson and Delamont argue, supports an approach based on logical method of enquiry resulting in an affirmation of the credibility of 'factual knowledge'. In other words, the process supports the notion of an objective truth that confirms the professional-scientific discourse upon which medicine has developed.
In contrast to clinical medical experience that has focused largely on fact-finding and taskdefined approaches, Melia, (1987) identified the reality of clinical nursing experiences preProject 2000 where the factor of primary importance appeared to be on the student 'doing
nursing work'. This involved the student in delivering direct patient care and was emphasised
- 50 -
over a systematic or structured approach to learning. This finding continues to be a recognised reality despite the move of nurse education into higher education establishments, a more theoretically based nursing programme and supernumerary status of students in the clinical area (Bjork, 1997).
Fish & Purr, (1991) propose that the role and purpose of clinical practice placements in nurse education also remains unclear, although the emphasis is often on narrow training outcomes e.g. the learning of specific skills. Woolley & Costello, (1988) argue that the purpose of clinical placements in nurse education is to enable students to integrate skills and knowledge acquired from a range of sources and to ensure that the students can deliver safe nursing care. Barnard & Dunn, (1994) propose that whilst some of the placement objectives may be prescribed some should be determined in part by the individual influences of the area and in part by the student, thus acknowledging the student as an active participant in learning.
This proposal is consistent with the development of a learning culture based on principles of adult education that is topical in both medical and nursing education (Parsell & Bligh, 1998). Learners should act as self-directed and self-motivated participants in care in the clinical arena and are not be used to supplement the staffing requirements of the clinical area.
The purpose of clinical education should therefore be more than functional task acquisition or observation of other practitioners in action. Its purpose is well encapsulated, in the perspective adopted for this study, by Barnard and Dunn (1994: 420) who argue that clinical experiences should move students beyond simple 'hands on' tasks, rather, students 'need to engage their
compassion, thoughts, and judgement in all experiences.' This provides a useful benchmark against which the student experiences identified in this study might be contrasted.
- 51 -
How people learn In order to understand the preparation of students for collaborative practice it is important to understand how people learn. Currently there are a number of prevailing educational theories that influence professional preparation. These might be summarised as those based on psychological nature, of individual cognition, in which the individual is central to the learning process, and those based on the relationship existent between learner and the learning environment, the so-called 'situated' view (Elkjaer, 1999).
This review of two broad perspectives provides a frame within which the development of the student, as a participant and collaborator in practice can be evaluated. The first perspective identifies that knowledge needs to be acquired in a structured and systematic way and the student requires the capacity for reflection on that knowledge. It also identifies the importance of the learning relationship and the role models that students encounter in practice. The second perspective moves the locus of learning from one in which only the individual learns to an interpretation in which it is the 'community of practice' that is perceived to learn. This has implications for all the participants who are transformed by the social engagements in which they participate.
These will be briefly reviewed and whilst each theoretical construct provides insight into the issues related to clinical learning the latter perspective provides a particular conceptual framework within which the data collected in this study is discussed.
Learning as individual cognition Perhaps the most prominent theoretical perspective of learning in health care education involves exploration of the complex mental events that characterise learning. These might best be understood using the computer as a metaphor considering the way that information is acquired, stored, retrieved and used (McKenna, 1995). Such a perspective encompasses theories of cognition (Bruner, 1966), action and reflection (Schon, 1987), modelling (Bandura,
- 52 -
1972) and adult learning (Kolb, 1984), all of which place the individual at the centre of the learning process.
Within this perspective, Bruner (1966) proposed a theory of learning in which he argued that this involved an active process in which knowledge was constructed by relating incoming information to previously acquired frames of reference. Bruner advocated the use of a spiral curriculum for learning the essence of which is that important concepts are introduced in simple form at an early stage of the programme and built upon with more complex concepts 15 . In light of Coles' analysis of the utility of different levels of 'concreteness' 16 an argument might also be made that professional education should occur 'upside down' with clinical experiences preceding more theoretical constructs underlying professional practice (Kriel & Hewson, 1986). Currently models of practice involve students entering professional schools being expected to learn considerable amounts of new information in one setting (the classroom) and apply it in another (the clinic). Advocating early clinical contact therefore provides examples or illustrations that can provide a reference frame for learning theoretical principles (Coles 1998).
Kolb (1984), a leading exponent of adult-oriented education, argues the importance of experiential learning to preparation for practice,
'…adults learn best when the topic at hand is geared loosely to their interests… they learn best
experientially, deriving for themselves abstract concepts from their own concrete experience and then testing these concepts in new situations.'
Cognitive psychology research similarly supports the need for contextualised learning that is explicitly related, though need not necessarily be situated, in practice, in order to facilitate understanding and integration of basic concepts (Coles, 1990; Patel et al., 1990). Coles (1990) outlines a 'contextual learning theory' in which the context needs to be established prior to the presentation of the 'to be learnt', which must be 'concrete' rather than 'abstract' . The
15 16
For an example of a spiral curriculum see Figure 5 p: 309 See Figure 2, p: 48
- 53 -
challenge, therefore, for the educator is to assure learning contexts in which both content and experience have relevance and meaning (Patel et al 1990, Coles 1990).
The evidence for this assessment of contextualised learning has been well demonstrated by Marton & Saljo, (1976) in experiments using both qualitative and quantitative experimental designs. Their studies demonstrated two distinct patterns of learning - those of 'surface' level and 'deep' level processing of knowledge. The 'deep' approach is characterised by an active search for meaning in which students try to understand, question the arguments and conclusions and relate ideas to previous knowledge and experience. Alternatively the 'surface' learners aim to memorise facts.
Bandura (1972) describes similar ideas in practice settings through his studies of 'modelling', the practice portrayed by field experts,
'…when modelling is purposefully used to teach people how to communicate verbally, how to
behave socially, how to drive automobiles, to swim, how to perform surgical operations, and to conduct psychological research, the more talented are likely to derive the greatest benefit from exemplary models.'
Bandura however differentiated 'modelling' from simply copying the behaviours of those they observed. Rather the subjects of his experiments developed novel responses representing,
'amalgams of elements from different models', that in some instances, bore little resemblance to the behaviours exhibited by the original models. Bandura proposed that dependent on their usage, modelling influences may produce not only specific mimicry but also generative and innovative behaviour. This re-interpretive view of modelled action is supported by management theory. Belbin, (1993) has extensively studied team processes and similarly states the idea that modelling is more than simply witnessing and copying others. Rather, Belbin argues, it derives from self-assessment and from assessment of others in order to create a view of what self can and cannot do and how this compares with others.
- 54 -
Understanding this assessment and reassessment process, is explained by Schon, (1987) in terms of 'reflective practice'. Schon recognises a significant problem for educators,
'What aspiring practitioners need most to learn, professional schools are least able to teach.
And the school's version of the dilemma is rooted in an underlying and unexamined epistemology of professional practice' (p: 8).'
Argyris & Schon, (1974) explain this problem in terms of the discrepancies that exist between
'espoused theory', the theory of action which is usually communicated, and 'theory in use' that actually governs the action (Schon, 1987, 1983). Schon argues that reflection creates the bridge between knowledge, learning and ultimately action.
In an appropriately designed curriculum students should have the opportunity to learn both
'espoused theory' and 'theory in use' however they require the capacity for reflective practice in order to realise, manage and learn from the gap that exists between the two. Schon, (1983) argued that this required a fundamental re-evaluation of the relationship between theory and practice in the preparation of professionals and the development of professional knowledge. He differentiated practical professional knowledge, 'knowledge in action' and the process of developing underlying theory as 'reflection in action'. Within Schon's interpretation 'knowing in
action' referred to 'tacit knowledge', the ability to do things without being able to explain them and inability to do them from theoretical understanding of task (Polanyi, 1967), that drives our actions. 'Reflection in action' refers to the professional management of uncertainty, instability, uniqueness or value conflicts. Reflection is therefore the means, Schon proposes, by which
'knowing' and 'doing' are connected - thus within the context of this study, knowing about collaboration does not mean that one necessarily will collaborate, unless reflexivity can create an effective bridge (West, 1999).
One other differentiation that Schon, (1987) makes of utility to the professional educational process is between 'reflection in action' and 'reflection on action'. The former involves reflection in the midst of action, 'during which we can still make a difference to the situation at hand' (p:
- 55 -
26). The latter involves reflection after the event, which may provide a useful learning tool (Henson, 1991), in which we may learn from, but cannot alter, the situation.
Whilst this section has briefly presented the primary ideas underlying a range of different learning theories in which the individual is central, detailed analysis of these theories is beyond the scope of this thesis. However a number of common principles might be derived from them that are of relevance to the clinical learning context (modified from Coles, 1998: 72-73) and, therefore, provide a frame against which to evaluate student's clinical learning experiences:-
•
Newcomers to professions should have early exposure to concrete examples and illustrations, in order to create conceptual frames within which the relevance of more theoretical or abstract ideas can be identified. This in turn is more likely to motivate the student to learn.
•
Students should be enabled to actively engage in the process of learning in order to promote 'deeper' learning that is perceived as relevant to their practice. Articulation of learning by the student might help students to clarify and integrate such learning.
•
Learners should be treated as adults and recognise that they have responsibility to learn. This should be promoted by encouraging students to set their own learning objectives so that the experiences are personally relevant and therefore given priority amidst all the other demands upon them.
•
Learning needs to be individualised and to start where the learner is at rather than at a teacher imposed level.
•
Teaching and encouraging personal responsibility should not be inconsistent. Therefore the former should be supportive and facilitative, rather than directive and imposed.
•
Planned curriculum should be consistent with these principles. Thus strategies which promote reflection e.g. portfolios of evidence (Snadden & Thomas, 1998, Jasper, 1995) encourage reflection, involvement and relevance, whilst examinations restrict learning to what is perceived to be needed to pass and, therefore, promotes perceptions of external control of learning and passivity (Coles, 1998, Foucault, 1975).
- 56 -
The challenges for effective clinical education against these principles are numerous. However, these ideas have largely been based on education in formal or institutional settings. A further theoretical perspective that sheds light on the clinical learning process involves learning described as 'situated' in social practice, that is where little formal teaching is evident (Elkjaer, 1999). This field of educational research provides some useful conceptual ideas that aid the understanding of participation, which is postulated as a requirement of preparation for collaborative practices. This will therefore be reviewed.
Learning as a 'situated activity' Lave & Wenger, (1991) offer an analysis of learning which takes as its focus the relationship between learning and the social situations in which it occurs. It differs most radically from the previous perspectives in that the locus of learning rather than being situated in the individual mind takes place within a framework of social participation (Elkjaer, 1999). This interpretation of learning is based on a perspective in which the reification of social processes and structures is untenable, as these are constantly changing and being changed by the process of performance, or social engagements. Thus learning and performance cannot be separated because learning is performance and the meaning of the activities that occur are a constantly negotiated and re-negotiated interpretation of those held by all the participants of the world in which they practice.
Lave and Wenger adopt the term 'situated learning' to explain this learning in action that occurs through social performance. This, they propose, is a concept that attempts to take as its focus not simply a geographical perspective i.e. a student learning in a particular location, but the nature of the relationship between the learning that occurs and the social situation (Hanks, 1991). Rather than attempting to understand the cognitive processes that occur, what is of interest to this study are the forms of social engagement or co-participation that enable learning to take place and create meaning. As collaboration is a concept that can only be realised in practice this seems to provide an appropriate conceptual frame for analysis of the
- 57 -
engagements in which students are involved and their interpretation of the meaning of these engagements and hence the constructed meaning of collaboration. The participative role of students in practice therefore becomes an important focal point in analysing preparation for collaboration in practice.
Lave and Wenger develop the concept of 'legitimate peripheral participation', to explain the role of the learner in practice,
'This central concept denotes the particular mode of engagement of a learner who participates
in the actual practice of an expert, but only to a limited degree and with limited responsibility for the ultimate product as a whole.' (Hanks 1991: 14).
This concept they suggest is not a an educational strategy or teaching technique but rather an analytical viewpoint which connotes: (i) 'legitimacy' of presence which confers a sense of belonging, (ii) 'peripherality' involving ideas of changing location, learning trajectories and power 17 and therefore movement towards a more central (although Lave and Wenger do not recognise the idea of a single centre in a social context) and powerful position, and; (iii)
'participation' indicating both different degrees of engagement and acknowledging the diversity of relations involved in varying forms of community membership 18 .
In contrast to perspectives founded upon individual cognition Lave and Wenger argue that there are no mental representations that are fixed following learning but rather learning requires constant re-interpretation of meaning not only by the individual but amongst all the participants involved in generating learning. Thus within Lave and Wenger's definition it is the
'community of practice', and not simply an individual who learns. Lave and Wenger do not exclude the individual from their interpretation but view them as part of the 'community' who
17 Lave and Wenger suggest this issue of 'peripherality' involves notions of positve and negative empowerment; as one moves closer to a notional centre one becomes more powerful but ‘peripherality’ is also disempowering, as an important protective device for society, from the newcomer 18 Thus in uniprofessional context a student may be full' participant but in multiprofessional context the role may be more peripheral
- 58 -
construct working practices not through action, but through interpretation of action through the construction of a social context narration and story-telling (Orr, 1990).
Elkjaer (1999: 80-81) criticises Lave and Wengers' situated learning model suggesting that it over-emphasises context of learning over the individual learning by presenting 'communities of
practice' as interactional contexts rather than groups of individuals,
'I simply find it hard to envision an interactional context of learning that somehow is not based
on the actions, interactions, experiences, emotions and thoughts of individuals - but socially shaped and shaping individuals.'
Elkjaer suggest that his criticism is resolved by combining Lave and Wengers' concept of
'communities of practice' with Strauss', (1993) concept of 'social worlds' and his 'conditional matrix'. The 'social worlds' concept proposes that the individual is not an 'isolated entity', for example an individual learner, who encounters society, but rather is 'a social being, shaped by
and shaping society.'' (Elkjaer, 1999: 82). It also recognises the dynamic nature of activities that should not simply be viewed as individual actions or interactions, but have meanings dependent on time and the multiple perspectives of the interactants.
Strauss & Corbin, (1998, 1990) enhance the utility of this conceptualisation through the use of an analytical tool, the conditional matrix (Appendix 5). This instrument grounds the individual in a conditional context, or 'social world', which may have bearing on their actions and interactions. Thus social life, and learning as an example, cannot simply be defined in structural terms but must also consider shared commitments, shared resources, shared ideologies and shared meaning, thus learning is a collective rather than individual action. Consequently learning cannot simply be viewed as a container 'filling up' i.e. a more is better perspective, but rather involves meaning and understandings defined directly in relation to the context of action or practice (Elkjaer, 1999)
- 59 -
Such a view has implications for the utility of knowledge. Within this construct the idea of general knowledge is a misnomer. Knowledge only has utility and meaning if it can be made specific to a particular context. Thus a 'general' knowledge of collaboration, or collaborative practices must be realised in practice if the knowledge is to be of value. Abstract knowledge is meaningless unless it can be transformed into practice.
Implications of learning as a ‘situated activity’ for the clinical learning arena Arising from this interpretation of learning a number of implications for the clinical role and preparation of students are evident:
•
Learning is not necessarily a product of formal teaching but occurs as a consequence of practice. There is arguably no differentiation between participating in practice and learning. Within this interpretation attention needs to be given to the participative role of student in social practice, who must gradually move towards full participation in the socio-cultural practices of the professional community.
•
Learning as participation is not simply a way of acquiring skills, but also of developing an identity and sense of belonging in the community. The activities in which they participate will construct meaning and reality for the student. Thus a functional orientation to clinical education may develop a reality based on mechanistic function and objectification, of knowledge and even of relationships.
•
Differences in perspective among co-participants are instrumental in the generation of learning, therefore it is not simply encounters with clinical supervisors or mentors but all engagements that are important. Responsibility for learning cannot therefore simply be devolved to a small group of 'teachers' but is the responsibility of all participants in the social context including the student.
•
Students participating in a social context are not transformed exclusively by the engagements in which they participate, although their transformation may be most dramatic. Practitioners as co-participants also learn and therefore it is important to consider
- 60 -
what impact the encounters experienced by practitioners as colleagues, mentors or teachers may have on their own interpretation of reality.
This section has provided a broad framework within which student development as a participant and collaborator in practice, can be evaluated. The first perspective identified the need for structured and systematic knowledge acquisition, the importance of reflection, the learning relationship and the role models that students encounter in practice.
The second perspective considers the locus of learning residing in the 'community of practice' which is perceived to be a learning community, rather than in the individual. This has implications for all the participants who are transformed by the social engagements in which they participate. Overall, the review has tried to emphasise the implications of different theoretical perspectives on the student's role and learning in practice that in turn may influence the collaborative practices adopted.
2.5 Summary This chapter has provided context to the subsequent evaluation of data arising from the study. The first section of this review focused on the concept of collaboration and considered the meaning of collaboration. It was proposed that the concept was best described as a process by which outcomes might be achieved, particularly in terms of improved patient care. The review also touched on the debate between technical-rationality and more interpretive and evaluative methods of understanding collaborative practices, the former being consistent with current trends in evidence-based practice, but being based on the questionable assumption that collaboration is an empirically definable concept. The latter approach emphasised the specific nature of collaboration that is part of a process in which it will be more or less evident, over time, dependent on the problems needing to be addressed, the individual relationships and the context in which it occurs. A brief and selective review of evidence to demonstrate the value and problems of collaborative practices for patient care and collegial support was also included.
- 61 -
This section also reviewed the context within which collaboration is emerging in order to demonstrate current political value. It described education and practice developments, which might influence the collaborative process to provide context to the analysis of students' experiences in medicine and nursing.
The second part reviewed the different professional and organisational cultures of medicine and nursing. It also acknowledged the evidence that collaborative development is being promoted by the respective professional bodies and identified some of the challenges to promoting change within medical and nursing education institutions.
The final part explored the concept and purpose of clinical learning and discussed the lack of clarity that exists as to what different experiences of clinical learning propose explicitly to achieve. It acknowledged the importance of providing concrete illustrations and examples of collaborative practices and recognised the value of participation in practice as a route to both understanding and performing collaborative practices. A range of different educational theories was also considered to illustrate some of the conceptual ideas that may facilitate the understanding of the evidence emerging from this study. In particular it recognised the utility of the concept of 'legitimate peripheral participation' as a construct for analysing and contrasting the role of medical and nursing students.
The next chapter will provide a reflective account of the methodology that was adopted for collecting data on the nature of preparation of medical and nursing students for collaborative practices and demonstrate its appropriateness to this study.
- 62 -
CHAPTER 3: METHODOLOGY AND FIELDWORK DESIGN 3.1 Introduction The methodological orientation of this study is designed to deal with the clinical learning experiences in a holistic rather than fragmented form. It aims to try to understand the complexities of medical and nursing student learning in the clinical work place, with particular reference to factors influencing their collaborative development, in order to provide both conceptual and pragmatic frameworks for creation of more effective learning environments.
In order to deal with the complexity of concepts and contexts it adopts a qualitative interpretive form of design and utilises a range of different data collection methods in order to build up a detailed picture of practice experiences and to enhance the rigour of the study
Data was collected using three field methods: (i) documentary analysis, (ii) interviews and (iii) observation, these being supplemented by a reflective diary that I kept throughout the research process. A qualitative, interpretive approach was adopted to explain the relationship and potential influences of the organisation and experience of the clinical context, the preparation for working with others in practice and also to reflect my own learning.
3.2 Overview of data collection and analytical methods The study was undertaken in a single university faculty, which provided pre-registration programmes for medical and nursing students. The main aim was to understand the experiences of these students when allocated to clinical contexts in order to gain insight into the preparation, both intentional and serendipitous, that might promote their collaborative development. This aim resulted in collection of data on the planned component of respective programmes, (through documentary analysis), the teaching and learning component (through, in-depth and critical incident interviews) and the environmental or contextual component (through observation).
- 63 -
Data collection took place over the period of one year with different strategies occurring concurrently (Figure 3), so that each in turn informed subsequent data analysis. Thus, for example, discussions with students influenced the focus on the planned component e.g. in the area of assessment, which sensitised me to observe for particular factors e.g. relationships in the clinical areas. Alternatively data observed in the clinical areas could be introduced into interviews in order to encourage explanation or illumination of issues or to validate observed findings. Early interviews also informed the selection of observation sites which took place in general wards in a district general hospital and in general wards and one specialist unit, an accident and emergency department (A & E), in a teaching hospital (Figure 3).
Students and sites were not considered to be representative or typical in any statistical sense. Students were selected because of their seniority and consequently wide experience in a range of clinical settings and because professional recommendations identified that students should be fit for practice and prepared to work in collaboration with colleagues. Thus their readiness for such working practices was of interest and relevance to this study. Sites were on the basis of convenience for me in terms of accessibility, but also represented a diversity of learning environments based on general trends identified by student interviewees.
Whilst concern about representative sample size is not consistent with a qualitative study the quantifiable characteristics of the data collection process are given as an indication of the range of sources from which the data was derived (Figure 3). Reflections on process were recorded in a personal, reflective diary.
- 64 -
Figure 3: Concurrent data collection process and details of data sources
- 65 -
The method employed for data analysis comes closest to the 'constant comparative method' described by Glaser and Strauss (1967). The data collected were coded and categorised, resulting in a number of different categories (Appendix 11), however different forms of coding were adopted in order to immerse myself in the data and as seemed appropriate given the different forms of data collected. This analytical process will be discussed in more detail later in this chapter.
The result of the categorisation process was to produce five different theme areas, which subsequently formed the basis for discussion in the analytical chapters in this study. These areas are (i) the organisation of clinical experiences, (ii) the facilitation of learning, (iii) the modes of engagement in practice, (iv) the nature of the clinical team, and (v) influences on contact between qualified staff and students.
Having outlined the key elements of the data collection and analytical process this chapter will review the methodological process, indicating the rationale for strategies adopted and lessons learned. It will also indicate some of the parallels in the relationship I experienced, both in practice and with supervisors, that provided insights into the learning relationships experienced by students and the impact of their role on their participation in practice.
3.3 The qualitative methodology In an introduction to a textbook on qualitative research, Silverman (2000) recognises that,
'… the choice between different research methods should depend on what you are trying to find out'. (p: 1)
Such a statement provides the premise against which this selection of methodology should be evaluated. This study was designed to develop a deep understanding rather than prove relationships and the qualitative research approach is proposed to be facilitative of such a goal for a number of reasons :-
- 66 -
•
Understanding is best achieved by analysis of words and observations rather than numbers;
•
Data is 'naturally' occurring i.e. unstructured rather than structured allowing the informants to provide their own accounts;
•
Understanding is based on meaning rather than behaviour i.e. the approach is interpretive, attempting to document conceptions from other peoples’ rather than one's own perspective (Hammersley, 1992: 160-172).
This study is allied to the grounded theory methodology (Glaser & Strauss, 1967) accepting the
'constant comparative method', which compares collected data against generated categories to ultimately suggest a 'theory' of clinical learning. The 'constant comparative method' seemed appropriate because I had a generalised interest in the understanding of the students' world and recognised a need to generate a conceptual frame in which to develop clinical learning. I was not proposing to establish proof of certain facts or test a hypothesis but rather to generate them.
However I also identified closely with the 'loose, working definition' of qualitative research provided by Mason (1996: 4) in developing and reflecting on fieldwork design and analytical process. Mason describes the common elements of a qualitative study thus,
•
its philosophical position is broadly 'interpretivist' in the sense that it is concerned with how the world is interpreted, understood, experienced or produced
•
it is based on methods of data generation which are flexible and sensitive to the social context in which data are produced
•
it is based on methods of data generation which involve understandings of complexity, detail and context.
Rather than defining methodology in terms of following a pre-defined blueprint,
- 67 -
'Qualitative researchers need to be able to think and act strategically in ways which combine
intellectual, philosophical, technical and practical concerns rather than compartmentalizing these in separate boxes.' (Mason 1996: 2). What has been outlined are broad directives of the process of qualitative research. More explicitly the sensitivity of the approach was founded upon what Benner, (1994) might define as
'interpretive inquiry'. As such, it took as its focus the understanding of concerns, habits and skills and experiences presented through 'participant narratives and situated actions' (p:xiv-xv). Rather than explanation or prediction of behaviour through causal laws and formal theoretical propositions the aim of the approach was to utilise the power of understanding to become more effectively or humanly engaged with practice.
3.3 Selecting a methodological approach Grounded theory provided the primary framework within which the methodological approach to the study was developed, however a number of other methodologists were influential as will be discussed subsequently. Some of the issues associated with the approach adopted will therefore briefly be discussed.
The case for using a grounded theory method Grounded theory is a method of theory generation in which the theory develops from and is grounded in the collected data (Glaser and Strauss, 1967). The theory is developed, not using the more traditional logical-deductive approach whereby hypotheses are derived from preexisting theories with data collection and analysis working towards verification or refutation of hypotheses. Rather, with grounded theory method constructs and concepts are 'grounded' in the data and hypotheses are tested as they arise from the research (Field & Morse, 1985). As Charmaz, (1990) points out,
The 'groundedness' of this approach fundamentally results from these researchers' commitment to analyse what they actually observe in the field or data.' (p: 1162)
- 68 -
More traditional research methods begin with either specific questions and problems, or tightly framed, preconceived ideas but this study was concerned with developing an understanding of student experiences. The grounded theorist therefore adopts a different approach,
'… the purpose of the study is to identify problems and discover what the actors themselves, see as solutions. Problem identification cannot take place prior to the study; therefore, a problem statement is impossible to make, and a truly accurate research question is impossible to ask prior to the study.' (Stern, 1985: 153)
Nevertheless in setting out to study the clinical experience as a preparation for collaborative practices I needed some structure both for personal security and to provide some direction to the proceedings. However, it is important to emphasise that the order of developing the research question is different to the logical-positivist method,
'The final refined research question comes at the end of the study, when you have discovered the factors with which the problem is involved and perhaps related those factors to solutions.' (Stern 1985: 153).
This reversal of developing theory from data, rather than verifying theory from data, raises a misconception about grounded theory that it is 'atheoretical' in nature (Chenitz, 1986). The outcome of this misunderstanding Chenitz suggests, is that some researchers are hesitant to use the grounded theory regardless of the fit between method and problem. Chenitz ascribes this hesitance to a traditional adherence to a need for a conceptual framework to guide a study. The unsatisfactory alternative Chenitz proclaims is for researchers to use an unrelated framework that they try, often unsuccessfully, to shape to fit the study. Thus to return to Silverman's earlier point, methodology should be selected on the basis of suitability to the problem in hand.
- 69 -
The process of the grounded theory method Any discussion of grounded theory methodology is necessarily complex because 'the processes
of grounded theory research occur simultaneously rather than in a linear fashion' (May, 1986: 149). These processes which involve the process of ‘constant comparative analysis’ are outlined below:
•
Data collection for grounded theory study i.e. interview, observation, documentary analysis
•
Concept formation: coding and categorising i.e. labelling, hypothesising on and grouping data
•
Concept development: reduction i.e. selection of categories arising form the data down to a manageable size : literature review i.e. extraction of relevant material from literature : selective sampling i.e. focusing data collection until all categories become saturated : emergence of core variables i.e. emergence of major ideas and processes which describe what is happening
•
Concept modification and integration: theoretical coding i.e. evaluation of empirical data to conceptual groups and theory development : memoing i.e. ideas sparked off whilst coding data
•
The research report i.e. final analysis and discussion of the developed theoretical framework (modified from Coulter, 1988: 39).
This structure provides a basic framework for the research process adopted in a grounded theory method, to which a number of modifications were made. These will be discussed in subsequent sections.
- 70 -
The case for introduction of other methodological approaches Grounded theory was the primary influence on methodological approach but the qualitative researcher is confronted by the challenge of adopting approaches which remain sensitive to the subject or topic under scrutiny which may change or develop as the study progresses. This highlights a need to choose between sensitivity to the subject, therefore letting the data or research problem drive the method, and adhering to what Harding and Gantley, (1998) describe as a technical 'methodological cookbook', in which each action is clearly prescribed in advance. I opted for the former approach whilst recognising the risk that this entailed. Baker et al., (1992: 1355) for example criticise the tendency for 'method slurring', what they describe as,
'a tendency […] to blur distinctions between the various qualitative approaches and to combine methodological prescriptions eclectically.'
This criticism is supported by Morse, (1999), although she goes on to make a plea for researchers who can demonstrate 'methodological versatility' and argues the utility of
'methodological pluralism' in which she proposes single problems can be explored in a number of different ways. She illustrates her viewpoint by presenting a study on comfort of trauma patients that incorporated three different projects:
•
A phenomenological study to explore the meaning of comfort,
•
An ethnographic study to explore the context of comfort, and
•
A grounded theory to examine the process of comfort (p: 394).
Whilst Morse's study undoubtedly generated a plethora of rich data and used a range of data collection and analytical strategies, the underlying assumption of her argument is that the methods are clearly distinct. Such a perspective is somewhat undermined by briefly considering the example of the ‘grounded theory’ method co-originated by Glaser and Strauss (1967). Glaser, (1992) writes to his colleague Strauss, who had recently published a re-interpretation of their methodology (Strauss and Corbin, 1990),
- 71 -
'It (Basics of Qualitative Research) distorts and misconceives grounded theory, while engaging
in gross neglect of 90% of its important ideas (…). You wrote a whole different method so why call it 'grounded theory'? It indicates that you never have grasped what we did, nor studied it carefully to extend it.' 19 (p: 2)
This now famous disagreement indicates that qualitative research methods are not absolutely definable. Rather they describe dynamic processes influenced by both individual interpretation and also historical 'moments' (Denzin & Lincoln, 1998: 13-22), or phases through which Annells, (1997a) argues philosophical perspectives, paradigm of inquiry, intended product, theoretical underpinnings, procedural steps and claims of rigour have all changed.
The novice researcher may find it expedient to adhere to a single methodological approach or rule book in order to collect and present data and construct theory in a seemingly coherent manner. This also might provide protection from having to delve deeply into the numerous techniques and philosophies that define, (or arguably make indefinable) the nature of qualitative research. However my experience of the research process suggests that strict allegiance inhibits wider thought on methodological, observational and particularly theoretical data. Rather a more honest approach to data collection is less definable and coherent and involves reflection on process, or what I term 'active thinking'. This term was coined as whilst much reflection took place in situ i.e. while collecting data or during the act of analysis, numerous insights were achieved whilst undertaking the other part of my professional role as a lecturer working with medical and nursing students and also in non-work related activities. This has parallels with similar descriptions by Glaser, (1978) in which he describes the importance of intuition and 'the personal and temperamental bent' of the researcher in developing 'theoretical
sensitivity'.
19
This argument is further explicated beyond the scope of this study by Melia, (1996), Annells, 1997a & b)
- 72 -
Assuring quality in the study Despite the argument for a flexible approach to research a fundamental point which the researcher in setting out the methodological stall needs to consider is the issue of quality 20 . Silverman, (1998) suggests that evaluation of quality resides in four criteria; conceptual depth, rigour, thoughtful research design and practical relevance. An alternative term adopted by Lincoln and Guba (1985) is that of 'trustworthiness', that is,
'How can an inquirer persuade his or her audiences (including self) that the findings of an inquiry are worth paying attention to, worth taking account of? What arguments can be mounted, what criteria invoked, what questions asked, that would be persuasive on this issue?' (p: 290)
This study utilised a range of different strategies, which will be explicated in more detail at relevant points, however the first criterion against which the study might be judged is a claim that I make of openness. Krathwohl, (1985) argues that the process of undertaking research is rarely as coherent or logical as it appears in its final presentation. For the purpose of reader comprehension the actuality of the process is not presented as it happened, although I opted for a 'warts and all' submission of method identifying strengths and limitations of the method and lessons learned in the process.
Other strategies that support the 'trustworthiness' of both my method and analysis included triangulation within and between data collection methods (Lincoln and Guba, 1985, Denzin, 1970), annotated transcript return to interviewees for comment, and informal discussion with players in the clinical areas to corroborate evidence (Greenwood, 1984, Dey, 1993). Further opportunistic validation was available through my role as a lecturer to medical and nursing students. Thus ideas, issues, incidents and themes could be explored with students in the 20 This is arguably with more vigour than if one has allied oneself to a pre-defined methodological school, in which strategies are built into the process.
- 73 -
course of teaching, generating comments, interpretations and re-interpretations, and contradictions, a strategy of using 'member checks' to increase believability and credibility (Hall & Stevens, 1991). Furthermore I kept a reflective diary of my role and influence on both data collection and analysis process and utilised the supervisory process for independent inspection of the coherence and clarity of the assertions being made in the analysis of the data.
Last, but not least, I am married to a doctor and quantitative researcher, a factor that provided numerous occasions upon which data was shared and interpretations different to my own were provided. This provided a useful countercheck in light of my own background in nursing and consequent greater understanding of background, experiences and process to which nurses are exposed. The processes of quantitative and qualitative research in terms of personal commitment, periods of doubt and occasional exuberance were also identified through this relationship as strikingly similar.
3.4 The Role of the Researcher
Being a nurse researching medicine and nursing Burgess, (1984) recognises that there are both advantages and disadvantages to the researcher researching settings with which they are already familiar. I am a nurse who has practised in the accident and emergency field for a number of years. I have also subsequently held a range of lecturing posts and have current responsibilities teaching both medical and nursing students. The product of this background is that I am well versed in the language of the medical and nursing professions.
The fact that I was a nurse also created a degree of connection with staff when collecting data on the ward, who on occasions would share results, problems or diagnoses in a manner that suggested that they recognised that I knew what it was like to work clinically. Below is an extract from one such encounter whilst observing practice,
- 74 -
Observation Note: Nurse was taking a patient's blood pressure very close to me and speaking
to the patient. The blood pressure machine alarmed and she turned the machine towards me so that I could read it. The blood pressure reading was very low and the staff nurse mouthed to me, 'That's normal'.
Other studies e.g. Allen (1996) suggest that familiarity with the setting may disadvantage the researcher in that they may fail to recognise common cultural patterns. The method adopted to address this factor was copious note taking of all that went on in the clinical setting 21 . Conversely, my extensive knowledge of practice in the A & E environment resulted in a familiarity that meant that certain issues could be explored in detail starting from a highly informed foundation. It was acknowledged however that this position meant that I could not adopt the role of 'naïve learner' that Lofland & Lofland, (1995) suggest can often provide a useful tool for encouraging rich description.
At a practical level my background as a nurse may have been influential in terms of understanding of witnessed behaviours, but what may be less overtly recognisable are the ideological biases that this might have introduced into the research process. In this study this is potentially based on my greater understanding of, and subsequent greater affinity for, a nursing over a medical perspective. This may be of significance in relation to selected methodology, as the literature recognises a paradigmatic difference between the two professions in relation to research and evaluation.
Campbell & Johnson, (1999: 1274) propose that medical education and evaluation has historically founded itself on 'common sense' and 'hard science' approaches that are based on the assumption, 'that knowledge exists outside of people and is waiting to be discovered'. This has some resonance with the 'objectification' created by institutional and epistemological norms of medicine that result in 'alienation from the everyday world' (Cribb and Bignold 1999: 195) discussed in the previous chapter. This contrasts with nursing which as a relatively young discipline in terms of its research portfolio and academic tradition has largely embraced the 21
See this Chapter, 'Limited interaction’ observation' p: 90.
- 75 -
interpretive, qualitative paradigm (Mason, 1996), with a focus on understanding the social world of the patient.
This study evidently defines itself in the latter paradigm, a situation that could be argued to underlie my allegiance or bias towards a nursing perspective. However medicine is increasingly demonstrating a paradigmatic shift that encompasses interpretive, methodological approaches (Mays & Pope, 2000, Pope et al., 2000, Harding & Gantley, 1998). This in turn is in line with wider educational trends, Jones et al., (1997) in a review of approaches to researching student learning in higher education identify that,
'Within education there has been a shift from respect for models of research based on the scientific tradition of experimental and quasi-experimental research methods, towards qualitative, descriptive methods within naturalistic settings.' (p: 13)
One might argue that my choice of methodological paradigm is tied to my own professional, epistemological background, however the selection is in line with wider trends in educational research and evaluation.
Researcher impact on context The descriptions of data presented are within a context of reflexive researcher, taking account of the impact of my presence and role and the intuitive development of analytical constructs. The effect of my presence is emphasised because as Hammersley and Atkinson (1983) observe, the social researcher must recognise that, 'we are part of the social world we study … This is
not a matter of methodological commitment, it is an existential fact.' (p: 14-15)
On a number of occasions I evidently overtly influenced the process of data collection and clinical behaviour as the following example from observational field notes demonstrates,
- 76 -
Observation Note: [I am seated outside staff office with view down the ward] One of the
charge nurses brings a registrar over. She says to him, 'This is how friendly we are', and kisses him on the cheek. The registrar laughs introduces himself and shakes my hand and says, 'See how well we all work together.'
Whilst an argument may therefore be made that I unduly affected behavioural patterns, the interpretive nature of this study goes beyond simple description. It begins to present an argument on the relationship between staff that this behaviour demonstrates i.e. the symbolism of the interaction. In this instance this might be based on notions of flirtation, humour and diminished hierarchy and the apparent interpretation of what working well together means is shown in this example in terms of seniority and gender. It is possible to tie oneself in interpretative knots in analysing a single situation but what is important is that the researcher should become aware of and begin to explore possible explanations of witnessed actions and start to integrate these into the matrix of other data sources. So for example, one may question whether junior nurses are so familiar with senior medical staff, whether senior nurses are so informal with junior doctors. In other words, developing an interpretation of the 'rules' and influences on such engagements in a wider context exploring whether such behaviour is the exception or the norm.
The above point emphasises the importance of reflection on process, rather than the objectification of the observational activity and therefore recognises that the researcher’s role is a part of the creation of a reality and must be considered in the methodological process.
3.5 The process of data collection In order to emphasise the rigour of the study and outline key elements in the process of carrying out this study the situations in which data was collected, the subjects from whom data was collected and the instruments and procedures by which data was collected, are all discussed.
- 77 -
Situation This required decisions to be made regarding the two field approaches to data collection in which context and relationship with informants were considered to be of particular significance i.e. informal interviews and observations.
Central to the informal interview is the requirement to engage the student in conversation allowing students to introduce topics that they considered to be relevant rather than the interviewer dictating the content of the interview (Melia 1987). To this end I considered it important to try to equalise the relationships between the interviewees and myself as far as possible. Students recruited were given a choice of where they wished to meet, either whilst on placement, in a university setting or in their own homes. In the event all students appeared to be influenced more by convenience of the organisation of the interview and opted to be interviewed during clinical allocations in practice contexts, usually in an office or staff room. Both, on occasions, resulted in interruptions either through telephones ringing or other staff entering and whilst this was not ideal I considered it appropriate that choice of venue should be elected by the student. I also made efforts to disassociate myself from being seen as part of the university 'establishment'. Time was spent at the start of the interview introducing myself by first name, describing myself as a research student within the university, outlining broadly the purpose of the study and explaining the procedure for taping, anonymising and allowing the opportunity for student feedback on the interview transcripts.
In essence the focus of this approach was to inform but also to attempt to develop a rapport with the student prior to the taped interview beginning and continue the interview in such a way that the student felt unconstrained by my needs or position (Benney & Hughes, 1984). The basis on which my approach was essentially founded was a view presented by Schatzman & Strauss, (1973) in which they suggest that,
- 78 -
'There is no more important tactic…than to communicate the idea that the informant's views
are acceptable and important.' (p: 7)
In spite of the efforts made students frequently looked to me for approval for the issues they were discussing, a typical comment on closure of the interview being 'I hope that was some use
and you can make sense of it all'.
Students generally seemed quite relaxed in their discussions and were often openly critical of the educational programmes or experiences to which they had been exposed. Some however did look for acknowledgement of their views or descriptions. One student for example alluded to her experiences of working with a range of other staff in a third world health clinic on a number of occasions, but frequently prefaced her descriptions with the phrase, 'I don't know if
this is relevant but …'. Whilst I evidently had my own agenda for the interviews 22 the format of the unstructured interview method adopted allowed the flexibility for topics to be exposed as students considered appropriate. I therefore attempted, as far as possible, to allow the student to indulge in open discussion of the topics they raised introducing ideas from the literature, earlier interviews or other sources of data as seemed relevant to the flow of the conversation and consistent with the 'constant comparative method'.
Observational data collection sites arose from some of the findings of the early interviews. Students identified that their experiences of working with practitioners from their own and other professions broadly differed between teaching and district general hospitals and between general and specialist areas within the teaching hospital. This is similar to Atkinson's (1973) findings in Edinburgh Medical School. I therefore elected to collect observational data that might provide a useful source for comparison or contextualisation of other data sources, enhancing the richness of the interpretations and counter-interpretations of the nature of working and learning with others in a range of clinical contexts.
22
See this Chapter ‘Subjects’, p: 80
- 79 -
Some of the areas were elected for geographical convenience due to my intention to carry out observations at different times of the day and because of my other lecturing commitments. One district general hospital was identified by medical students as being particularly good in demonstrating close working relationships between staff and involving them in the delivery of care. However it's geography, some one hundred and fifty miles distant in a relatively remote location, made its inclusion prohibitive. However this highlights an advantage of utilising different methods for data collection to understand better the range of experiences to which students were exposed 23 . The specific ward areas selected were on a first approach basis. i.e. wards were contacted following general agreement from the Directors of Nursing and Medicine and charge nurses were then contacted directly on the specific wards. No charge nurse refused to be involved and it was those first approached that were utilised. As no general wards had been identified by students as particularly noteworthy exemplars of collaborative working practices or student inclusion, I considered this an acceptable method.
The accident and emergency department was selected as an alternative model for comparison with the ward areas. I was familiar with similar areas from my clinical career and recognised that it provided a very different model of teamworking and different spatial relationships 24 and therefore I considered this area to provide a useful contrasting context. However I also recognised that my familiarity with the area could have limited my ability to stand outside the cultural context in a more objective fashion than was possible in other areas. I attempted to over-ride this by recording in detail all my observations in as full a way as the constraints of the method made feasible 25 .
23 24 25
See this Chapter, ‘Instruments and procedures’, p: 83 See Chapter 8 See ‘Instruments and procedures’ p: 83.
- 80 -
Subjects Data for this study relied on three key informant sources, medical students, nursing students, and practitioners, each of whom will be considered.
Medical and nursing students Selection of students as subjects/informants in this study was based primarily on the desire to understand the process of learning to work with others as experienced by students in the clinical context. Senior students were selected as it was aniticiapted that they would have extensive experience of a range of clinical areas. These interviewees were encouraged to express opinions and describe experiences which in turn informed subsequent lines of enquiry. To this end despite interview data being collected only from medical and nursing students my subject selection was based on the assumptions of 'theoretical sampling' described by Glaser and Strauss (1967). This sampling technique proposes that subjects should be selected who will most facilitate the development of the emerging theory. Whilst restriction to student interviewees might be argued to have limited the diversity of perspective it was the student experience that was of central interest in this study. The claim to have adopted 'theoretical
sampling' is based on an interpretation of the concept made by Melia (1987) in which,
' ideas the interviews produced in the early stage of the study served to shape the line of enquiry, and in this way the data collection was directed by the theoretical notions which emerged.' (p: 190)
The realities of selection were also influenced by access. Medical students in particular were spread over a wide geographical location and rarely came together in small groups in fourth and fifth years 26 . As I wished to access students prior to making individual contact in order to outline the project and secure their general agreement to participate, suitable points of contact had to be identified. Student nurses had periodic blocks in the School, medical students only came together in small groups prior to their general practice attachment. Subsequently twelve
- 81 -
visits to these medical student groups had to be arranged over a one-year period. The result was that student nurses were generally interviewed in hospital environments and medical students on their general practice placements. The advantage of meeting with small groups prior to interviews allowed general information dissemination on the project. However more important from my perspective, it provided students with an opportunity to exclude themselves at this stage thus respecting their voluntary status as interviewees. Only a small number requested not to be contacted although others were excluded due to their geographical distance from the medical school whilst on attachments.
In selecting subjects for the study it is perhaps worth considering the motivations of the respondents for participating in the study (Denzin, 1978). Richardson et al., (1965) refer to altruism as a motivator, that is giving of information because the respondent wanted to help the interviewer and/or because they felt it would benefit others. Richardson et al (1965) suggests reasons of intellectual satisfaction brought about by exchange of ideas and the perception of tangible rewards. Although no reward could be or was overtly offered by me all interviews were designed to take place in a positive and constructive atmosphere and at a place and time convenient to the interviewee. Many students also appeared to value the opportunity to talk about their experiences, a response that may be an indicator of lack of support or opportunity for guided reflection, or may hint at the value of catharsis when confronted by the educational, interpersonal and logistical challenges that they face.
Students subsequently recruited were selected on an ad hoc basis from those agreeing to participate however they were again given an opportunity to withdraw from the study. No students availed themselves of this offer.
Students as subjects of the observational data were included in the data on a 'happen to be there' basis i.e. wards were not selected for presence of particular students but rather to inform the emerging themes from earlier data. Observational data was collected on any students who 26
This finding was noteworthy in itself as discussed in Chapter 4, 'Location of medical student attachments' p: 109
- 82 -
were on the ward during the observation period. However as far as possible I informed staff of my purpose, made efforts to anonymise data and offered to exclude individuals from field notes on request. No such requests were received.
Practitioners Practitioners were also included in the observational data on a 'happen to be there basis'. This consequently included a wide range of disciplines 27 . These informants were observed in order to develop a picture of staff working relationships within the clinical context and in order to confirm or provide counter-data to that provided in the student interviews. Practitioners were on occasions also approached to clarify meaning of events or to illuminate observations further. An example of one such contact is outlined in the example below,
Observation note: [Discussion with nurse in charge prior to leaving the ward following three hours of observation] I raised my observation of the lack of contact between medical and
nursing students. She found this unsurprising as trained nurses also have little to do with medical students. At best this might involve asking fifth year medical students to take a blood sample. She added that if medical students approached the nursing team for information then that would be okay but they were overloaded with student nurse teaching and would not want to get involved with medics.
Practitioners were not interviewed as part of this study as the focus was on understanding the clinical experience from a student perspective. This may prove useful data in subsequent studies of the clinical learning relationship. Some practitioners also approached me to discuss the purpose of my visit and this resulted in conversations on the nature of student experiences, teaching and learning
27
See Chapter 8 'The busyness factor' p: 229
- 83 -
Instruments and procedures Some of the previous sections have highlighted issues relating to the particular instruments and data collection processes selected, but a little more detail is worthwhile in justifying their selection and operationalisation. This section will therefore briefly consider both the literature and the data collection procedures adopted for documentary analysis, critical incident interviews, informal interviews and observations. Each data collection method is presented as a separate strand of the study but in reality each occurred concurrently and subsequently informed and developed the lines of enquiry in the others.
Documentary analysis This study utilised a range of curriculum documents, student study guides and competency handbooks from the medical and nursing programmes to illuminate the planned, taught and learned elements of the clinical experience 28 . (Lincoln & Guba, 1985) suggest that documents are a useful source of information that have often been ignored in both research and evaluation. Hutchinson & Webb, (1989) propose that rather than a sole source of data they may provide additional slices of evidence that may ‘confirm, extend, or contradict other findings’
(p: 313). This was the rationale for their inclusion as a source of data.
Lincoln and Guba (1985: 276) are particularly pragmatic in their choice of documents as a data source:
•
They are available at low cost (mostly of investigator time),
•
They are a stable source of information in that they reflect past situations that can be analysed and reanalysed
•
They are a rich source of information, contextually relevant and grounded in the contexts they represent
28
See Table 1, p: 3 and Figure 3, p: 64, for more complete listing
- 84 -
•
They are often legally unassailable providing statements that satisfy some accountability requirement
•
They, unlike human respondents, are non-reactive
Hammersley & Atkinson, (1983) suggest that attention should be given not only to the actual written material but also to number of broader issues. These include how the documents are written, how and by whom they are read, who writes them, their purpose, their outcomes, what the writer takes for granted about the readers and what the readers need to know to make sense of them?
Silverman, (1993) recognises the distinction between the utility of documents, which may be different for different people. He suggests that the people who generate and use them are concerned with how accurately they represent reality. Alternatively, Silverman proposes that documents highlight the social organisation under scrutiny regardless of their accuracy or inaccuracy, truth or bias. In short documents reflect a dominant social construction.
Once appropriate documents have been identified the researcher then requires a system for arranging and analysing them. Kerlinger, (1986) proposes this approach to be more than simply a method of analysis but a source of further investigation in which ‘the investigator takes the
communications that people have produced and asks questions of the communications’. The approach to content analysis may be quantitative, measuring the frequency and variety of the messages, or qualitative when the goal of the research is oriented more towards discovery rather than verification alone (Altheide, 1987). In this study I considered issues of educational models, organisational structures and language to contrast medical and nursing experiences and to reflect on the nature of the learning process facilitated by the paperwork and the assumptions behind the documents.
Guba & Lincoln, (1981) argue that analysis of documentary evidence, ‘lends contextual richness
and helps to ground an inquiry in the milieu of the writer.’ Conversely, Allport, (1942) criticised
- 85 -
documents as being possibly unrepresentative, lacking objectivity, being of unknown validity and possibly being deliberately deceiving or self-deceptive. Lincoln and Guba, (1985) counter these damning claims as being founded upon a conventional research paradigm i.e. positivism, in which representativeness and objectivity are more fundamental than in a naturalistic paradigm. They also propose that the possibility of deception exists in all data and therefore should remain a constant consideration, whilst validity may be tested by triangulating the data against other known facts for ‘internal consistency and coherence’ (p: 279).
In this study I found that documentation did provide an additional source of data that could be used to further the interpretive process in relation to the clinical learning experience and to generate questions on the student experience. For example different patterns of clinical experiences were evident from looking at timetables within the medical and nursing curriculum documents. This led me to explore the potential impact of this finding in interviews 29 . It also proved valuable in informing the emerging lines of enquiry for consistencies and inconsistencies in planned and delivered curricula.
Critical incident interviews The approach adopted for the critical incident interviews was primarily based on methods utilised by Cormack, (1983) and Dachelet et al., (1981). These studies both built up profiles of effective and ineffective working and learning practices in clinical areas. As such the technique appeared to provide a vehicle for understanding the experiences of students and their exposure to collaborative working and learning practices, through rich and detailed descriptions of practice. Indeed Branch & Pels, (1994) indicated the value of such a method,
‘When we started the critical incident method, we had no idea how powerful it would prove to be, or the difficult material it would unearth.’ (p: 1)
29
See Chapter 4.
- 86 -
Smith & Russell, (1993) cited it as an educationally valuable approach because it provided a means of, ‘... entering into their (nursing students) world, its preoccupations and perceptions...
and as a means of strengthening teacher-student relationships.’ p: 120)
Retrospective reporting as a means of collecting critical incidents has been used widely in both medical and nursing research. Despite the problems, for example of forgetting details or subconscious editing, they provide a number of advantages, in particular over direct observational techniques (Cormack, 1983). They allow both long and short term retrospection on incidents, allow longer term consequences of activities or incidents to be considered and avoids subjects of observations performing in response to direct observation, therefore experiences are more likely to be true to reality. However the technique investigates perception of roles and events of particular importance to the respondent therefore data collected is likely to be influenced by interpretation of past experiences rather than the 'reality' of them.
Additionally, in using students as data collectors as well as providers, an argument could be made that the process encourages the use of observational and reflective skills on practice, thus their involvement in the research process might enhance the educational experience.
The critical incident interviews were piloted with twelve student nurses and seven medical students (the imbalance due to holidays and electives of senior medical students) and students were asked to identify incidents that they felt had been productive or counterproductive to their learning about working with those from other professions (Appendix 6).
Both during and following these interviews i.e. in the collection and analysis stages, it became apparent that useful, or even meaningful, categories were difficult to ascertain. Almost exclusively interviewees were speaking in general terms about particular wards in which teamwork or ‘the atmosphere’ was particularly good, rather than exposing specific incidents in the detail that (Flanagan, 1954) proposed as central to utility of the technique. The tendency was to create narratives about the essence of their learning or working experiences that were
- 87 -
composite pictures of several incidents, based on interpretation rather than the 'objective' and detailed descriptions that had been implied in other studies.
Norman et al., (1992) also found a problem with the definition of a critical incident and described ‘incidentless critical incidents’. Norman et al’s approach argued that a more appropriate unit of analysis than the actual incident was ‘happenings’ i.e. elements of incidents that clearly have significance to the interviewee. From a researcher perspective then it is the
‘meaning’ assigned to such ‘happenings’ that are of greatest significance. This moves the epistemological stance of the student from one of categorisation of incidents to one of interpreting the ‘meaning’ based on activities that happen, as perceived by the interviewee, to occur in practice. This recognition has implications for the analysis of collaboration as a 'situated
activity' 30 in which it is proposed that learning is the product of the multiple and negotiated meanings of different players rather than some objective, definable and measurable concept.
Although I had anticipated detailed descriptions of 'incidents' what I got, and became increasingly frustrated by at the time, was a notable lack of specificity. Only in writing up the data, after the fieldwork period was complete, did I realise that perhaps it was my perspective that was wrong and I was failing to 'deal with the complexity' that I had proposed at the outset. My goal had become mechanistic, a search for specific 'objective' problems that I could single out and therefore solve through a defined and generalisable intervention or learn from and transfer. The actuality was that students created their own reality by deconstruction and reconstruction, filtering and amalgamating incidents based on experiences, perceptions, attitudes and values that generated, for them, 'good' or 'bad' learning contexts or relationships that could not then simply be transferred or transposed onto another person or situation.
During the fieldwork I reviewed the critical incident interview process which I felt indicated the need for a methodological re-evaluation. Firstly, I considered that students were constrained by the approach and appeared to have some difficulty in describing effectively 'effective/ 30
This concept was discussed in Chapter 2, 'Learning as 'situated activity' p: 56
- 88 -
ineffective' or 'productive/counterproductive' learning or working experiences. Secondly students were generalising and reinterpreting situations. Thirdly, as identified in other studies, re-interpretation highlighted that a gap may exist between views expressed in interview and literal descriptions of observed practice (Allen 1997).
These findings provided the framework for future data collection, which comprised of informal interviews, which aimed to facilitate 'conversations' with students. This allowed them to express descriptions of their realities of the clinical situation with less structure and unstructured observations the findings of which could be fed into conversations to prompt between the student and myself. This last point therefore proved a useful mechanism for informing and validating my own interpretations of observed practice.
Informal interviews Sorrell and Edmond (1995) in a review of health discipline research over the last decade revealed an increased use of the interview as a date collection method. Drew, (1993) emphasised that the manner in which interviewers evoke respondents’ recall, information, expression and feelings has a direct impact on the quality of data obtained.
I elected to utilise the informal interview method in order to probe for depth and clarity of information in a mode that carries with it a ‘unique intimacy’ not provided by the other methods of data collection (Sorrell & Redmond, 1995).
Interviews were guided by brief lists of topics and issues collated from literature and other modes of data collection but interviewees were encouraged to express their own views on any issues they considered important (Hallet et al., 1996).
To a degree the student was encouraged to take charge of the direction of the interview and I had a list of headings that I used to prompt conversation (Appendix 7). As an 'icebreaker'
- 89 -
students were asked in the first instance to outline their clinical experience to date. The discussions then generally ranged through positive and negative clinical experiences, expectations of their own education and role in the clinical area. Observed findings from practice were also included as facilitators of discussion and to encourage students to provide their own interpretation of meaning.
Cicourel, (1964) contrasted two different conceptualisations of the interview: a phenomenological approach concerned with the interview situation (Hyman, 1954), and dynamic interpretation based on aspects of the actors’ personalities (Kahn & Cannell, 1957). Issues related to interviewer and respondent characteristics have been addressed and the situations in which the interviews took place were at the discretion of the interviewee. Benney & Hughes, (1984) suggest that more than just the environment, i.e. time and place, the interview situation contains a ‘contractual’ element. The interviewer it is suggested benefits from the respondent’s time and attention and divulgence of information and the respondent also receives time and attention, and the opportunity to explore issues relevant to them and to express frustrations. Students appeared generally to value the opportunity to discuss their clinical experiences. In particular this was when I explained that it was hoped that the data would serve to better inform the organisation of their course. Students also asked me about the nature of the clinical experiences of students of other professions and therefore were 'rewarded' with information.
Tape recording interviews is arguably not the best way for developing a relaxed atmosphere for divulgence of information. Indeed interviewees may request that the interview should not be recorded. Some methodological experts consider this the best way to collect detailed records for conversational analysis (Lofland and Lofland 1995). Recordings may be kept so that future researchers have the data available should subsequent analyses be required, in particular for the facilitation of construct and content validity. Other methodologist argue that the advantages tape-recording confers are offset by respondent distrust (Lincoln and Guba 1985). I tried to remain sensitive to student response to the tape recorder and whilst none of the interviewees
- 90 -
objected to the tape-recording a number of students became notably more talkative after the recorder was switched off. In order to relax students I, therefore, began to switch on the recorder prior to my preamble and did not hurry to switch it off when the interview seemed to be over. This was in recognition of Whyte's, (1982) observation that in the early stages of the interview the recorder may provide an obstacle until a rapport has developed.
I also considered it essential that each interview was carried out in an atmosphere of ‘informed
consent’ as defined by Armiger, (1977). Armiger maintained ‘informed consent’ to be a ‘process’ rather than a single event, involving privacy and confidentiality. Thus, before each interview the conditions that the interviewee could withdraw consent or terminate the interview at any time were emphasised. The student was also provided with the opportunity to comment at the end of the interview and to review the transcripts at a later date.
'Limited interaction' observation Adler & Adler, (1998) define observation as, an approach that, 'consists of gathering
impressions of the surrounding world through all relevant human faculties.' (p: 80). It is not simply what the observer sees but utilisation of all the senses including the mind, which reflects on and interprets actions witnessed. Adler and Adler recognise that as members of society we are constantly observing, but what differentiates the observations of 'everyday-life actors' from those of social scientists is the systematic and purposive nature of the social scientist's observations.
In order to develop a systematic picture of the practice setting, observations were carried out in this study at different times of the day 31 in different sites and on different players i.e. practitioners and students. Although this approach was largely designed on what I considered to be common sense for providing a detailed picture, retrospective support was 31 This was generally in 2- 3 hour blocks and at different times between 7am and 10pm, the timings relating to day shift patterns.
- 91 -
found for the triangulated approach which utilised three types of data source; person, time and space data (Denzin, 1970):
•
Person-data is collected from individuals or groups, using one source to confirm or disconfirm data from another
•
Time-data is collected over different periods to see if relationships between staff changed
•
Space-data from different locations is collected to test consistency between them to develop arguments or counterarguments to theoretical constructs.
Redfern & Norman, (1994) argue that such triangulation enhances the validity of research findings.
My role has been discussed elsewhere however it is important to acknowledge different roles that an observer might adopt. Generally in non-participant observation efforts are made to minimise the impact on the clinical context by only speaking if spoken to. The model I adopted might best fit the description of 'limited interactant' (Schatzman & Strauss, 1973). This role required me not to set myself apart from the participants i.e. a totally passive presence which may be particularly unnerving for staff, but to confine discussions largely to seeking clarification or meaning of events. In such a role Schatzmann and Strauss, (1973: 60) contend,
'the researcher is not only an observer, but is revealed as personable and interested […] The agenda is understandable and appears appropriate, therefore the observer can be thought of as at least "kind of" a member of the group.' (p: 60).
Lofland and Lofland (1995) recommend in logging data that the researcher/ observer whether known or unknown, should as 'a rule of thumb', jot notes inconspicuously. I entered the field with this as an intention. However the reality of this recommendation proved problematic for me as the following early field note indicates,
- 92 -
Observation note: On return to the ward I decided I had become too attached to my chair as
some sort of comfort inducing space. I therefore put away my clipboard [mindful of Lofland and Lofland's recommendation] and wandered around the ward. However, in a very short time I felt
exquisitely uncomfortable and embarrassed at my lack of any overt function in a busy environment. I looked at notices on the wall, looked out of the window and picked up some magazines. Consequently, I found I was no longer observing but rather trying to make myself look inconspicuous or casually pre-occupied. I also found that this brief but intense period of embarrassment made me move to areas where there were no staff in order that I wasn't simply standing and staring. Within ten awkward minutes I had returned to the security of my chair and clipboard.'
I was unable to find any reference to this problem in the data. However I was interested in a study described by Silverman, (2000) in which he indicated that the researcher had to spend several months sitting in the waiting room of a massage parlour before any of the masseuses would agree to undertake unstructured interviews with him. I find it hard to conceive what he did for all that time as simply sitting without any evident purpose would seem untenable.
The final issue of the observation mode of data collection was what to record. Wolcott, (1994) argues that much of the literature talks around this problem rather than dealing with observation skills directly. He identifies four strategies which whilst difficult to demonstrate directly in the data, I found useful in the collection process (Appendix 8). •
Observe and Record Everything
•
Observe and Look for Nothing - That Is Nothing in Particular
•
Look for Paradoxes
•
Identify the Key Problem Confronting the Group
Observation provided a useful tool for triangulating the data and consequently created a fuller picture of the practice experience. Perhaps more importantly for me it proved a valuable lesson in relation to the theoretical or ideological bases of data collection and the challenges and compromises of actually practising the art of observation.
- 93 -
3.6 Analysis of the data The grounded theory method provided the primary analytical frame but this was influenced by a number of factors and authors. Some of these will be discussed in order to illuminate the challenges of the data analysis process.
Data avoidance strategy: writer’s block and fear of complexity In seeking to openly analyse the process by which the data was collected, organised and interpreted I will briefly explore an issue that proved to be a significant challenge to the study. This was a recurrent process of 'data avoidance' in both the collection and analytical phases. This term describes my preoccupation with constantly returning to the literature for conceptual clarity and direction rather than immersing myself in the data (an action that was the cause of some disquiet to one of my research supervisors). This might have been assigned to personal idiosyncrasy on my part but discussion of this practice at a research meeting with fellow researchers indicated that it was not an uncommon occurrence. I therefore considered it to be worthy of further exploration. Furthermore the essential requirement that qualitative researchers ‘immerse’ themselves in the data (Glaser and Strauss 1967), requires that this practice of avoidance is addressed or at least acknowledged.
Schatzmann and Strauss (1973: 117-120) recognised the circumstance of the researcher surrounded by data, ‘at the mercy of whatever form and content they present to him.’ (p: 117), who feels overwhelmed by the realisation that the data does not simply speak for itself. i.e. themes are not explicitly evident. These authors do not overtly acknowledge the idea of
'avoidance' but they present strategies for moving forward with the 'data piles'. This includes telling the story within the data to an imaginary but defined audience and interrogating the data i.e. searching for supporting or negative evidence after having teased ideas out of the data
Ely et al., (1997) explained the problem of qualitative data analysis in terms of a form of
'writer’s block', a response to the complexity of qualitative data,
- 94 -
'The more we work with the writing of qualitative research from the first fledgling field notes
and attempts at making sense of the research, the more we are convinced that the entire endeavour often gets mired in our lack of trust for the process. Part of this probably results from the vestiges of doubt that remain from the positivist mentality that has been drummed into so many of our heads for so long. We can foreground the process and describe various crafting devices and strategies that can bring lifeless reports to life. What is infinitely harder is to help you trust that such writing is valuable and valued, both for you as a researcher and for those reading your reports'. (Ely et al p: 53)
This issue of trust in both the data and self requires what Atkinson (personal communication to Strauss and Corbin 1998: 144) describes as faith, work, creativity and a belief in the value and reality of pluralism,
'Making it all come together...is one of the most difficult things of all...Quite apart from achieving it, it is hard to inject the right mix of (a) faith that it can and will be achieved; (b) recognition that it has to be worked at, and isn’t based on romantic inspiration; (c) that it isn’t like the solution to a puzzle or math problem, but has to be created; (d) that you can’t pack everything into one version, and that any one project could yield several different ways of bringing it together.’
As Ely states and Atkinson implies this may be the product of a prevailing allegiance to positivism in which answers are more definite. The qualitative researcher needs to begin to recognise that in dealing with the data they are not simply working towards a single answer or solution but rather they are trying to expose the complexities that social processes encapsulate. Geertz, (1988) suggests, therefore, that the work required of qualitative researchers is understandably anxiety provoking and avoidance an understandable reaction, to the demand that we 'convince our readers that we have actually penetrated (or been penetrated by)
another form of life, of having one way or another truly 'been there'''. (p:4-5).
Kaplan, (1996) describes that qualitative data analysis may reap many different products or interpretations and the fear is of uncertainty,
- 95 -
‘At the beginning of my journey, I was naive. I didn’t know yet that the answers vanish as one
continues to travel, there is only one further complexity, that there are still more interrelationships and more questions.’ (p: 7)
There may be one further explanation that I would like to offer. Qualitative research is not an emotionally neutral process, it does not contain the objectivity claimed for a positivistic approach, therefore within the data the researcher exposes something of themselves. There is consequently a fear of exposure that requires the researcher to be feeling in a confident frame of mind in order to immerse themselves in the data. To exemplify this point, discussions with my colleagues also undertaking doctoral studies often referred to the issue of being found out. There were fears expressed that they hadn't read or understood all the articles referenced in as much detail as expected, that their method was not as rigorous as it might have been or that their academic ability simply wasn't up to it. I experienced all these fears. I also encountered the fears of presenting ideas that were potentially conceptually or philosophically unacceptable to the audience. To write about collaboration as a form of negotiated meaning rather than an empirically measurable entity 32 to a medical readership rooted in the scientific paradigm 33 made me feel that this interpretation was my intellectual inadequacy rather than a legitimate presentation of the data. To return to the credibility of published material that therefore had
'proven' academic credentials because it was in print provided a security that my own data could not.
Althoough I recognise the problems of immersing oneself in or confronting the data if processes or phenomena are to be illuminated in order to inform practice and learning and unearth deeprooted ideological, social, professional and personal conditions, then a number of tools or systems exist to support this. Those that proved useful to this study are considered in the next section.
32
As expounded in this thesis, particularly in Chapters 2 & 9. I recognised that this might be my prejudicial perception of the medical perspective, however see Chapter 2, 'Culture of medical education and practice' p: 37 33
- 96 -
Dealing with the Data As has been identified in the previous section dealing with the data in some way is integral to the process of developing a qualitative research study as the methods adopted are likely to generate large amounts of complex and often confounding material. Methods for collecting data have been explicated separately but the analysis and subsequent methodological development used was a 'constant comparative method' described by Glaser and Strauss (1967: 101-115) in which method and analysis occur in an interwoven, feedback form.
The practice of analysis included a range of different approaches involving transcription and annotation, various forms and levels of coding, grouping of data sets and categorisation. Ultimately I came to the view that these activities were more about immersion in the data than explicitly providing the framework for presentation of the data in a coherent form.
The final analytical representation arose from the formation of a narrative to illuminate the experiences, circumstances, conditions and meanings of students’ literal or interpreted experiences as preparation for working with others. However the analytical processes recommended by a number of different authors proved useful in informing the management of the data.
Hycner, (1985) contends that there is danger in the phenomenological method of data analysis in that if ‘reified’ then there may be loss of expression. Keen, (1975) supports this contention,
‘...unlike other methodologies, phenomenology cannot be reduced to a ‘cookbook’ set of instructions. It is more an approach. an attitude, an investigative posture with a certain set of goals'. p: 41)
Despite his acknowledgement Hycner goes on to outline steps that might be useful for the researcher to consider. Those marked * proved useful to the process, however I drew on the
- 97 -
work of other methodological authors e.g. Strauss and Corbin 1998, Lofland and Lofland (1984), to inform these stages (Table 6):-
Table 6: Stages in the analysis of qualitative data (Hycner 1985): 1.
Transcribe*
8. Cluster units of relevant meaning*
2.
Bracket and reduce phenomena*
9. Write summary of each interview
3.
Listen to interview for sense of whole*
10. Return to participant with summary and themes: Conduct second interview
4.
Delineate units of general meaning*
11. Modify themes and summary*
5.
Delineate units of meaning relevant to
12. Identify general and unique themes for all
research question 6.
Train independent judges to verify units of
interviews 13. Contextualise themes
relevant meaning 7.
Eliminate redundancies
14. Create composite summary*
One notable feature of Hycner’s stages is the incorporation of stages to increase the rigour of the analysis i.e. stages 6 and 10. These were not adopted due to cost, time and availability of staff but each stage of analytical development was presented and critiqued with and by one supervisor, (HM), and the coherence of the coding and subsequent categorisations agreed.
Over-prescription may be undesirable in a methodology aiming to be sensitive to subject and context although as outlined in the previous section there is a danger that a researcher never becomes intimate with the data due to the enormity and complexity of its mass. A number of strategies were therefore used 34 :
•
The documentary data were analysed in the first instance to contextualise data collected elsewhere. Issues of type e.g. curriculum document, student handbook, etc., and content e.g. educational models, assessment design, programme content and organisation were noted. Increasing familiarity with the material also highlighted useful comparative material between the nursing and medical programmes e.g. differences of language/ terminology for similar practices.
- 98 -
•
The interview data were transcribed by me and annotated throughout this process. Interview transcripts were then read and re-read and I began to code ideas and issues on a line by line or paragraph by paragraph basis as seemed appropriate. This allied closely with what Strauss and Corbin (1998) describe as ‘open coding’, the microanalytic process of conceptualising or abstracting from the data and cross-linking incidents of events which shared some common characteristic e.g. 'student inclusion' and 'coffee times' were described by numerous interviewees within the recorded conversations.
•
The next stage was categorisation, the grouping of particular phenomena around higher order concepts (Strauss and Corbin 1998). I found this was aided by listing all the codes separate from the data and going down the lists, which were extensive, and beginning to group the codes into categories. It was then necessary to cross reference these codes against the original transcripts for greater depth of meaning
•
Two further stages are argued to increase further the abstraction; 'axial coding', linking categories in terms of properties and dimensions and 'selective coding'; a process of integrating and refining the theory around a central ‘grounded’ concept (Strauss and Corbin 1998). However I began to have reservations about limiting this complex data around a single concept but also perceived the danger of no longer telling the story within the data, due to excessive methodological allegiance.
•
The next step I took was therefore to begin to outline a narrative of what was evident within the data. The 'conditional/ consequential matrix' (Strauss & Corbin, 1998) (Appendix 5), proved useful in this respect in considering different levels e.g. policy, organisational, professional, team, individual at which actions and interactions might be influenced. The narrative phase also included observational data therefore the action taken with this will also be considered.
34
Key stages in the process are underlined for emphasis
- 99 -
•
As described earlier the observation process was one of recording as far as possible all the events to which I bore witness. This resulted in extremely episodic, fragmented data that resulted in events rarely flowing from start to finish in any coherent way. This data also included reflections on the data collection method and insights that I had on different observations often relating to ideas arising form the literature. Creating coherency therefore proved more difficult than with the interviews, which had a more evident flow.
Lofland & Lofland, (1984) suggest a method for organising observational data into three groups dependent on the data content, 'observational notes' i.e. direct observations of events,
'methodological notes' e.g. influences of researcher on context, and 'theoretical notes' e.g. conceptual abstractions from observations or links to other data sources. I found that these three forms of organisational notation accommodated the data very well. However this was an extremely time-consuming process requiring transcription of the field notes and a degree of sorting (See Appendix 10). After approximately twenty hours on three sets of observational field notes I reconsidered this method. Although this proved a useful sorting device and might provide a useful cognitive frame within which to consider the data I did not feel the gain was worthy of the time that would be expended to treat all the field notes in a similar manner. The field note data was therefore coded in a similar way to the interview data i.e. 'open coding' and integrated into the lists of codes that were developing.
Consideration of the lists at some length and recurrent grouping and regrouping of data, which was then cross-referenced against the original transcripts resulted into the identification of twelve categories within the data (See Appendix 11). By cutting and pasting from original documents, transcripts (interviews) and field notes (observations) lists of data were organised. Further consideration of these resulted in the grouping surprisingly easily which perhaps suggested the coherence of the categorical relationships. This resulted in the identification of five dimensions within the data from which it was considered there was sufficient data to draw
- 100 -
coherent and well-supported narratives. The five dimensions ultimately defined the five analytical chapters.
3.7 Summary This review of the methodological process has aimed to give an open and reflective account of the research process. It has exposed the methodological challenges that are presented to qualitative researchers and also demonstrated my increasing knowledge of the research process.
The chapter has provided an overview of the approach adopted for collecting data and briefly quantified the amount and sources of data collected. I indicated the appropriateness of a methodological approach which was primarily founded upon 'grounded theory' but incorporates a more pluralistic approach as appeared appropriate to the collection and analytical process. I have also discussed the benefits and risks of both a 'cookbook' and a pluralistic approach. I have tried to reflect on my impact and perspective on the study and explored how qualitative research deals with the more involved researcher role as compared with roles in more positivist traditions.
Sampling issues have been considered through discussion of sites and subjects which provided the data. Instruments and procedures of documentary analysis, interview and observation have been reflected upon utilising literature and experiences from this study.
Finally the analytical processes have been described and I have tried to explain some of the challenges that this created.
The subsequent chapters will discuss the data that this method generated and will draw on appropriate literature to illuminate and support the narrative on the learning experiences of
- 101 -
students and the context in which they learn in relation to preparation for collaborative practices.
- 102 -
CHAPTER 4: CLINICAL EXPERIENCES: 'ATTACHMENTS', 'PLACEMENTS', ORGANISATION AND ASSESSMENT 4.1 Introduction The previous chapters have provided background to the area of clinical learning and the concept of collaboration and collaborative practices and have introduced the idea of participation. They have also discussed the process by which data was collected and compiled. The next five chapters provide the narrative arising from the data and comprise sufficient excerpts from the data to allow the story of the clinical experience to unfold whilst incorporating my interpretive work along the way. This was an approach used by Melia, (1987) to create a convincing account of the world of the student nurse. The data in this study, which considers two students groups, from medicine and nursing, provides the opportunity to contrast the participative roles of students as preparation for collaborative practices.
This chapter describes the organisation and assessment of the clinical experiences for the two groups of students, their resultant lived experiences in the clinical area and identifies and illuminates the impact this has on their participative roles and the model of practice it generates.
Review of the different medical and nursing clinical experiences within the two programmes highlighted differences in the participative role that students adopted. This appeared in part to be influenced by the organisation and patterns of their periods in practice. At a fundamental level this was indicated by differences in terminology to describe the medical and nursing experiences, but also was represented by the location of experiences, their pattern and duration and forms of monitoring and assessment. Each of these is argued to be founded on structures that mirror the model of practice adopted by qualified practitioners. In the case of nursing students this is a relatively participative and communal model in which the student gets to know the staff at least of their own peer group, whilst for medical students this is more individualistic and isolated. However different locations offer different models of practice as will
- 103 -
be illustrated by the data. Whilst the models illustrated may actually be appropriate for the role that students will be called on to perform on qualifying, the differences observed appear to have consequences for collaborative practice which will be explored.
A further feature of the teaching curriculum was the mode of monitoring and assessing both clinical and non-clinical practice. The literature emphasises the importance of assessment and the impact this can have of student behaviour. Students from this study frequently raised the prioritisation of work based on assessment processes, of particular note was the effect of examinations on medical students’ work. This is explored in relation to participation in practice and potential impact on collaborative development.
4.2 'Attachment' or 'placement': a note on terminology Review of the curriculum documents of the medical and nursing schools highlighted a basic terminological difference between the clinical experiences provided. In the former these experiences were referred to as 'attachments' whilst in the latter as 'placements'. This language differentiation became increasingly evident to me following a series of interviews with nursing students in which we discussed their 'placements', a term with which I was familiar and assumed to be generic for clinical allocations.
In the first medical student interview, the student appeared not to understand the term
'placement' and asked for clarification. Further exploration of this terminological difference in subsequent interviews indicated that the different terms used by the two groups represented quite accurately the role adopted by students in practice, a finding substantiated in this study by field observations of patterns of student activity. The medical student was ‘attached to' an area or clinical firm whereas the nurse was ‘placed in' an area.
The significance of this differentiation will become more apparent in subsequent discussion. Its importance appeared to relate to two factors. The first was the degree of involvement the
- 104 -
student had in delivering direct care (low amongst medical students, high in nursing students). The second was the freedom to develop one's own learning experiences and requirement of personal autonomy and direction in the practice area experiences (high amongst medical students, low amongst nursing students). Thus, whilst the medical student is simply 'attached' allowing a high degree of spatial freedom the nurse is 'placed' in a situation and therefore subject to closer scrutiny and working within more defined parameters of practice 35 e.g. specified shift periods. Whilst freedom to learn may be perceived as a valuable commodity, what many medical students described was a lack of inclusion or involvement in care delivery and the clinical team. These show parallels with the respective role descriptions provided for qualified practitioners in the previous section.
Medical ‘attachments’ Whilst medical students were exposed to the clinical arena at an early stage of their training this tended to be on the basis of short visits. These early visits had very defined objectives, e.g. to see a procedure, practice a skill or shadow a particular member of staff, the ''seeing' mode of engagement'
36
. The 'attachments' to firms or clinical areas occurred in years 4 & 5 when the
student was expected to be more involved in care delivery.
The programme for Years 4 and 5 was outlined for students in Course Handbooks (University of Dundee Medical School, 1997a). The major objective of the clinical attachments was described in the Year 4 Handbook as 'the learning and mastery of the competencies relating to the core
symptoms as seen from the perspectives of different disciplines.' (p: 2). This, the Handbook suggested, involved a move from 'the multidisciplinary approach' adopted in the earlier phases of the curriculum, to 'a trans-disciplinary approach'. (p: 3). The distinction that was drawn between the two appeared to be that whilst the former was classroom-based the latter involved
'real world experience'. Consequently, the 'trans-disciplinary approach' required broader aims and goals in which learning was dictated by task, involving integration of knowledge from 35
See previous section for comparable patterns of qualified medical and nursing practice
- 105 -
different attachments and mastery of competencies related to the task. Whilst further elaboration of definition does not appear in the Handbook, Harden, (1998a) differentiates contextually between the two (See Appendix 12) :-
•
Multiprofessional education - 'Each profession (…) looks at the subject from the
perspective of its own discipline and the role or impact, if any, of the different disciplines on the subject'; and •
'Transprofessional education - 'takes place in the context of the clinical practice of medicine
(…) Students function as members of the health care team in the delivery of care'.
Study guides were developed around a series of 'Core Clinical Problems' that students were required to address, a problem-based approach (See Appendix 13), that evidence suggests better prepares students for clinical practice (Woodward & Ferrier, 1983). Hill et al., (1998), for example, compared a traditional i.e. discipline-based curricula, with non-traditional i.e. problembased curricula, and found that graduates felt better prepared for practice in the latter in particular in relation to interpersonal skills, confidences, and collaboration with other health care workers.
The design of the programme was to enable students to constantly relate their teaching and learning to a frame of outcomes (Harden et al., 1999), within which their experiences could be directed to the end-point of training, which was to perform as a pre-registration house officer (GMC, 1997) 37 .
Nursing ‘placements’ Nursing students undertook a range of different clinical placements within both hospital and community settings, some of the requirements for which are prescribed by European Community guidelines (child care, maternity care, mental health and community). Perhaps the 36
This is discussed in more detail in Chapter 5, ‘Seeing’ and ‘doing’ modes of engagement in practice’, p: 172
- 106 -
most notable difference between medical and nursing placements was the level to which the nursing placements were managed. For example, all placement sites were audited for educational suitability, programmes were provided for preparation of preceptors and each area had a designated 'link lecturer', a member of the School staff who liased between School and student placement 38 .
Since the implementation of Project 2000 training for student nurses concerns have been expressed about the distancing of educational and service providers (UKCC, 1999, Gough et al., 1993) and shortages of placements. Gough et al (1993) highlighted the importance of the clinical learning context, however they argued the need for management and support for placements, and 'conscious development of the teaching role of qualified staff'. They argued that,
'Although tacit learning is unimportant, a 'sitting by Nellie' approach is not enough (…) the use of existing role models is insufficient.' (p: 97)
The Nursing Curriculum Document (University of Dundee School of Nursing and Midwifery, 1997) recognised the need to manage the clinical learning, to create a context, which should,
'articulate with the theoretical content of the modules (…). The pattern of clinical placements reflects the amount of resources available within the Trusts (…) as well as in the Independent Sector. The pattern also reflects the appropriateness of those placements to student's level of knowledge and experience.' (p: 81)
My work within the School as a lecturer highlighted the tensions that prevailed between availability and suitability of placements and the variability of support students received in the clinical domain. This was in common with national findings, as the UKCC (1999: 40) 'Fitness to 37
This outcome is also discussed in Chapter 2,’The purpose of the clinical learning experience’, p: 47 However a diverse range of models of link lecturing exist dependent on clinical staff needs, the working practices and locations of particular areas and the preferences/motivations of the individual lecturer. 38
- 107 -
Practice' document indicated problems nationally and of variable, poorly planned and poorly coordinated placements in which students failed to develop even basic skills.
Lloyd-Jones & Akehurst, (1997) also identified a physical separation of the academic and the clinical arenas which caused problems for lecturers and practice staff. They proposed that lecturers had limited current experience in the clinical arena and practice staff were inadequately prepared for their mentorship role.
The design of the nursing programme appears to have attempted to address some of these problems by designating a certain number of hours required of lecturers to allocate to 'linking' duties and a computerised database to monitor delivery. The School also provided a module
'Partnerships in Learning' designed to prepare clinical staff for their mentorship role within a wider framework of learning in clinical contexts (see Appendix 13). The curriculum also preempted a recommendation of the 'Fitness to Practice' document (UKCC 1999) for longer placements,
'By offering some longer practice placements, students will have sufficient time to develop a range of skills , experience work on different shifts (…) and familiarise themselves with working practices in the health care environment.' (p:41)
However emphasis on the duration of the placement is qualified in the literature. Some argue that there is a danger that long unsupported placements could simply recreate the apprenticeship model of learning (Glen, 1999) that existed prior to Project 2000.
The 'Fitness for Practice' document, Recommendation 10 (UKCC, 1999: 37), advocated consistency of clinical supervision in all practice placements towards which systems of audit within the School and clinical areas and staff preparation and support were directed. Thus the design of the clinical programme was to provide students with a flexible experience within which, with the support of the clinical mentor and academic staff, they could address their own learning needs.
- 108 -
The non-inclusion of students in service establishment figures (with the exception of the final six months of the programme in which they were on rostered service i.e. had a service commitment), provided, in theory at least, the opportunity to shadow staff and patients through different patterns of care 39 . Placements of over six weeks in educationally audited areas were considered, according to the curriculum document, to allow students time to develop skills, knowledge of the working environment and to establish relationships with clinical staff.
This outline indicates some initially identifiable differences in clinical experiences in medicine and nursing. Considerably more attention is paid to the organising, monitoring, and support of the nursing programme than is evident in the medical programme. Nursing students have a participative role in delivery of care, which contrasts with the medical student role in which considerable freedom exists to pursue areas of interest and to absent themselves from the clinical area. More evidence of the differences that create 'professional spaces' between the two groups will be provided in subsequent sections.
4.3 Influence of location on the clinical learning experience The data would appear to support the contention that the location of clinical experience has a significant influence on student learning, in terms of the structure and of the degree of participation of the student in practice. The learning and working trajectory followed by the two groups of students provided different models of practice and different spatial relationships with both practitioners and other students.
Whilst medical students’ experiences related largely to variations between diverse geographical locations, the nursing student was located primarily within a single hospital and focused on differences between specialities. Their spatial geography was therefore highly defined within a particular hospital. Factors pertinent to their experience were concerned with institutional size,
39
The student role in practice and relationship with qualified staff is explored further in Chapters 7 & 8
- 109 -
staffing levels, work patterns and the ‘busyness’ of the clinical area 40 . The data supported the idea that rather than professions comprising a defined, homogenous group that in actuality
‘segmentation’ (Melia, 1987, Abbott, 1988) existed between groups of professionals working in different areas 41 and therefore the clinical 'communities of practice' to which students were exposed differed widely. Engagement between students and staff of other professions also varied and thus different locations provided contexts of differing quality in terms of practising the skills of interprofessional collaboration.
Location of medical student attachments Medical students in this study experienced a pattern of placements focusing around the teaching hospital in which the medical school was sited but which took them to a range of other hospitals over an extensive geographical area covering much of Scotland and some hospitals in the north of England. Students in their fourth year had a choice of placements, some choosing a range of peripheral hospitals whilst others selected to remain mostly in the teaching hospital. However in the fifth year students were allocated, ‘names out of a hat’ as one interviewee perceived it, to their attachments. Some of the attachments were influenced by where the students' junior house officer jobs were likely to be, as they undertook, as far as organisationally possible, a period of junior doctor shadowing on these wards.
Teaching and learning in teaching hospitals and district general hospitals Medical students described variability in the quality of attachments in particular making the distinction between the better educational experiences received in district general hospitals as compared to their home teaching hospital, a similar finding to Atkinson (1973). Some of the medical students felt the advantage of the former was that a greater diversity of patients were located within one ward area availing them of a broader clinical experiences. This was
40 41
See Chapter 8, ‘The 'busyness factor’ p: 229. 'Segmentation' is an analytic and organising device for considering the different perspectives on and versions of
profession and role adopted by different 'segments' of the professions for their own purpose.
- 110 -
considered advantageous because of the breadth of knowledge required of the trainee doctor i.e. covering a wide range of specialities,
Medical Student Interview 2: Student: 'It's difficult because you have to cover your medicine,
surgery, your paediatrics and stuff like that. So, that is, it's difficult because you do have to cover them all. But saying that, if you work more in peripheral [hospitals], where they have more diverse patients on the same ward, so you may be see a bit of everything. I mean you may be see your medicine, some surgery, obs and gynae patients
A second student proffered similar comments,
Medical Student Interview 4: Student: (…) you saw everything, you saw like respiratory stuff,
cardiology stuff, but the one consultant (…) you saw a lot of pathology which was good, even though it was a smallish hospital, you saw a lot because it was like the catchment area was huge'.
Student numbers and ‘production line’ learning Most students associated the quality of their location with lower numbers of students. These levels were notably higher, (verified in field observations), in teaching hospitals than district general hospitals. This fact they considered had an impact on staff and student motivation,
Medical Student Interview 3: Student: (…) in district general hospitals don't have as many
students and they're not basically fed up with students, whereas like in A & E in Dundee, they have students every week for the whole year. Four students every week or something like that. Or rheumatology, four students every week for a whole year and sometimes when you get students at the beginning of September or October you're fresh, you're ready for them, everybody's going great, but by the time Christmas comes you do get a little tired of teaching people and maybe things you told some people you don't tell some people. Whereas in district generals there are less, there's definitely less students going through them. They're more eager to teach you.
- 111 -
Another student acknowledged a ‘production line’ of students and supported the contention that there were less learning opportunities and a gradual diminution of enthusiasm for teaching over the academic year in the teaching hospital 42 ,
Medical Student Interview 2: Student: I think in XX [Teaching hospital], (…) there are just so
many students on the ward, tagging along, sitting around, looking for something to do. I think they just get sick of, I can't blame them I think I'd be the same. But everywhere else, they're not, students are kind of a novelty so they like having you around. It's quite nice. I'm only in Dundee for eight weeks this year, deliberately because I don't want to work in XX [Teaching hospital] because you don't learn as much either. It's too busy and you don't get the same
hands on.'
The result of this lack of 'hands on' practical experience was described in a range of different ways. Two male medical students suggested it created a ‘competition’, and ‘struggle’ whilst a female student also expressed her dissatisfaction but described the limitations of the context in less combative terms as ‘compromising’ learning' 43 . The conceptualisation of the educational experience as a 'production line' is also recognised in the literature. Playdon & Goodsman, (1997) in analysing the learning agenda of medicine indicate the problems of such a process,
'We identify training as a learning process, which deals with known outcomes, as exemplified in the production line and production management and its central concern is the same product should be produced identically each time.' (p: 983)
Thus what students appeared to be acting out is a struggle to train themselves in technical skills, undoubtedly central to medical practice, whilst staff recognise a constant stream of students in need of training in ward work. Playdon and Goodsman argue that the emphasis on
'training' rather than 'education' basing itself on a throughput/product system, prepares individuals to follow instructions rather than empowering them to take control of and 42
This are will be explored in more detail in Chapter 8 in relation to the 'busyness' of the clinical environment. This competition for opportunity was also discussed in Chapter 5: ''Seeing mode': perceived educational value of shadowing clinical practitioners', p: 173
43
- 112 -
responsibility for their own learning and develop personal accountability. This model would appear to provide an inappropriate process of clinical learning for 'deep learning', to prepare students for complex and ever-changing dynamics of collaborative practice in which both the personal and professional factors are intertwined (Ash, 1994). In short the ‘production line’ system fails to acknowledge the individual.
Observational data from this study of the 'busyness' of certain locations appeared to result in medical students often becoming 'invisible' to staff. This was most noticeable in the teaching hospital where staff would walk round students and not make eye contact. This behaviour increased even in district general hospital areas when student numbers were high 44 . A different model existed in the A & E department where students were attached to a doctor and tended to shadow them or be sent off to see patients prior to the doctor's intervention. In the A & E department medical students tended to be present singly, more doctors were available and these doctors were attached to the unit i.e. did not move between clinical areas in pursuit of patients or results 45 . Students also sat in a general staff sitting room at break times and thus were able to converse and share coffee with staff, a feature that students in other areas appeared to relate to their feelings of inclusion or exclusion within a situation.
The field notes from the first observational visit to a medical ward in the teaching hospital record the lack of contact 46 between medical and nursing students, a factor that would seem a pre-requisite for collaboration,
Observation note:' I raised my observation of the lack of contact between medical and nursing
students allocated to the same ward. She [a staff nurse] found this unsurprising as trained nurses also had little to do with medical students, at best this might involve asking a fifth year to take a blood sample. She added that if medical students approached the nursing team for information that would be OK but they were overloaded with student nurse teaching and would not want to get involved with the medics.'
44 45
See also Chapter 8 See Chapter 7 for exploration of the different working patterns of doctors and nurses
- 113 -
This picture contrasted with the picture reported by several students in the district general hospitals (particularly the smaller district general hospitals) where students became well known and ‘all’ staff participated in providing learning opportunities for them,
Medical Student Interview 3: Student: …in a district general, you're treated well by all staff. Like
the nurses would sort of say if I wanted to get practice doing Venflons, IV cannulas, I could go round to theatres and see if I could do all those one afternoon just to get the practice (…). The nurse would ring the ward I was on and tell me every time there was another patient instead of me waiting around on my backside sitting for the next one to come in and you could go away and do something else
Effects of clinical presence and absence on student inclusion Observational data highlighted that students in district general hospitals were also on the ward for longer periods than was evident in the teaching hospital. This according to one student interviewee was because they were noticed more, so got more involved. More frequent ward rounds were carried out by consultants in district general hospitals. This provided an opportunity for students to observe clinical decision-making in action and on occasions play a more active role. Consequently there was also an increased opportunity for contact between students and senior members of hospital staff, a factor that would seem to be a necessary prerequisite for developing a relationship and practising the skills of collaboration.
My observation that medical students appeared to stay on wards more in district general hospitals also received an alternative explanation by some students to that of feeling included and noticed. Two students suggested they stayed on the ward because of a lack of available alternative places to go,
Medical Student Interview 3: Student: If we are out of Dundee we are staying in the hospital
most of the time but if we are in Dundee we might go to the library or go to the computers or the lunch time breaks, so we hardly stay on the ward and spend time with staff.
46
See Chapter 8 ‘Contact between participants’ p: 251.
- 114 -
Thus in the teaching hospital the competition from alternative media for learning and stronger social ties appeared for students to reduce the willingness to remain in the clinical areas. This might be explained by the tension that some students reported between being on the ward and getting through exams. The priority students felt in the curriculum lay in exam success and assignment completion.
Medical student inclusion in specialist and generalist areas Whilst comparisons of clinical experiences between teaching and district general hospitals almost exclusively favoured the latter, some positive learning experiences were described in the former. These tended to be in specialist units with well-defined and largely separate organisational structures and a high staff:patient ratio e.g. coronary care, oncology, accident and emergency and intensive care,
Medical Student Interview 6: Student: I’ve just done a month on the oncology wards in XX [Teaching hospital] and I can’t say anything about that, like the nursing staff were very good
but then it’s so secluded and it’s away from everything else and there outpatient clinics are held down on the wards an everything. And the nursing staff, there were three of us doing an attachment, they all knew who we were and like they would have helped you and said like such and such is not in yet, or such and such because the patients were all coming in for chemotherapy. So they would sort of say who to go and see and who’s in. It’s because they know you, whereas if you go to the general outpatients in XX [Teaching hospital] just the general area, 3, 4, 5, whatever area you go to I think they tend to be under a lot of pressure themselves with work and they seem to do so, there’s so few staff and so the last thing they need is to find an extra student coming in. Interviewer: […], you said in the oncology unit they knew you, knew what you needed. How did they get to know you? Is it just by the fact that you are there? Student: Well it’s smaller and they don’t get that many students you see they don’t get students, well they do they get two fourth years a week, but we were there on a month attachment because its a special study module so we chose to do it. You were there every day
- 115 -
for a month at a time. You know you had to go to all the clinics with the Professor so you were there constantly.
Separation from the wider hospital organisation appeared to create a greater sense of ‘community’ 47 , involving not only clinical staff but also support staff. The smaller size of specialist units meant that staff knew each other and therefore recognised 'outsiders' who the students seemed to suggest they welcomed in. The important factors here were that people tended to get to know the student 48 and throughput of students was lower 49 . Both factors appear to have implications for collaborative development amongst students.
Inclusion and geographical diversity A final issue relating to location of medical student attachments was the extensive geographical distance between locations that were typically experienced in the final two years of the undergraduate programme. For most medical students this involved moving between urban and rural locations and through hospitals across Scotland and the North of England. The basis for this at curriculum level appeared to be primarily the pragmatic requirement for hospital placements in a context of rising student numbers, changing patient care patterns and a need amongst students for a diverse clinical experience covering key specialities. A medical student gave an additional perceived rationale not identified in the official documentation, but supportive of the idea of isolationism inherent within medicine (Cribb and Bignold 1999) 50 ,
Medical Student Interviewee 5: Student: I think you’re learning to stand on your own two feet
but I think that's a really good thing. I actually look forward to fourth and fifth year 'cos' you sit in lectures, it's like everyone sits in a huddle, goes to tutorials, everybody's holding everyone's hand, go on the wards in your third year and there's like six or seven people with you. But in your fourth year you have to go by yourself and some people find that hard, 'cos' there's not, the easiest thing on earth whenever you go on a placement (…) when you're by yourself you're looking after yourself all the time, you have to ask everything yourself, you have to go down to 47 48 49 50
Concept of ‘community’ is discussed in Chapter 9, ‘Learning curriculum: implications and recommendations’, p: 283 See Chapter 8, ‘Experiential biographies, p: 258 See Chapter 8’ The busyness factor’ p: 229 See Chapter 2 , ‘Culture of medical education and practice’ p: 37
- 116 -
tutorials by yourself, you have to go to meetings by yourself (…) it learns you a good lesson, you can operate independently which is what you want. There's no point going round all the time with three or four other people from the University and all the support, you get to JHO and you're lost, 'cos' people are, no one's there supporting you, telling you what to do, sometimes you're going to have to do things by yourself and you want to have the confidence to know.
This issue of ‘learning to stand on your own feet’‘, was cited in a number of medical student interviews and conversations. Several students’ comments related the organisation of their attachments to the fact that being a doctor required a high level of autonomy and therefore it was good for them that they could 'survive' all the different types attachments on their own. Thus coping with the isolation created by geographically diverse attachments was considered an important, if for some, hard skill to learn.
In relation to preparation for collaborative practice this section highlights a number of notable findings. One is that different models of collaborative clinical education and learning prevailed in different practice contexts and that these factors were often reportedly influenced by medical student numbers/ throughput. The most cited contrast was between the poorer clinical learning opportunities existing in teaching hospitals as compared to the more, participative and sometimes multiprofessional involvement of a range of staff in DGHs. In light of the increasing centralisation of the acute sector on large hospital sites it is likely that students will have less district general hospital learning opportunities.
Students also recognised movement around diverse hospitals as an isolating experience but one they considered important in recognition of the autonomy required in the role for which they were being prepared.
- 117 -
Location of nursing student placements The most prevalent structure for nursing student placements involved students working in a single, home hospital, which could be a district general or a teaching 51 . Nursing students in discussing placement locations were usually unable to make comparisons between particular hospitals but rather focused on intra-hospital issues.
Data from both the in-depth student nurse interviews and from the critical incident descriptions indicated that certain clinical areas were identified as good learning environments. Selection of a particular hospital was often allied to the student’s place of residence prior to commencing the nurse-training programme as the majority of student nurses were recruited from the local area. This contrasted with medical students who were recruited from a more dispersed geographical catchment and were less likely than nursing students to be long term residents in the area of the medical school or host hospital.
Inclusion and geographical localisation Nursing students' localisation in a single host hospital tended to create a greater familiarity with routines and internal systems and increase the number of interpersonal relationships. Observations of senior nursing students in the staff canteen supported the fact that they had large numbers of acquaintances with different members of staff. Students nurses observed in the canteen areas were always in groups with other nurses. This was unlike their medical student colleagues who were more commonly seen in groups with other medical students or, on two occasions, alone in the district general hospital.
This greater involvement with a collegial group amongst nurses generated an interpretation of role differentiation in which I began to perceive the nurse/nursing student’s role as a ‘resident’
51 However the nursing strategy 'Making a Difference' (Department of Health, 1999a) noted the loss of links between student nurses and 'home hospitals resulting in difficulties of recruitment and retention of staff
- 118 -
of the hospital or clinical area. This compared with a typical the doctor/ medical student profile more accurately defined in the role of ‘visitor’ in the hospital or clinical area. This was more than simply a description of the transient nature of allocations or house officer jobs but described the nature of their activity and availability of peer group support. This idea supports the contention made earlier that student nurses were of the place i.e. on ‘placements’ whilst medical students temporarily attached to the place i.e. on ‘attachments’.
The potential implication of this fact was that student nurses who belonged in a place i.e.
'residents' had less need of skills of self-reliance because they were familiar with the environment and had an extensive social network. This was unlike the medical students who were passing though or dropping in, i.e. 'visitors', and appeared isolated and therefore required greater skills of self-reliance and personal autonomy.
Whilst 'residence' and 'placement' appeared a more supportive situation to be in, one student nurse based in a district general hospital was critical of the residential nature of nurse training, centralised in a single hospital, identifying it as a restriction on the level of experience she had received,
Nursing Student Interview 2: Student: I’ve done most of my training in XX [DGH] and I think
we’ve been deprived. I mean the students working at XX [Teaching hospital], you know, I think you’re seeing a greater number of patients and variety of conditions, so I think it’s a wee bit sheltered’
Another student nurse called for 'greater choice' and 'more electives'. The learning for students with the exception of a single elective placement is prescribed. This contrasts with a medical programme that comprises a core programme and special study modules which provides a degree of choice 52 and enables the student to tailor their learning and experience to their individual interests. Thus student nurses are supported by restriction of placements and
52 Discussion with medical students indicated that this wasn't as open to student choice as course documentation suggested. For example in a session I delivered on collaboration in an optional special study module looking at collaboration I asked students as an icebreaker why they had selected the module. Of fifteen students thirteen had put
- 119 -
prescription of content, a situation that would appear to require a lesser level of autonomy than their medical student peers.
Nursing student inclusion in specialist and generalist areas Since student nurses were largely limited to single hospital sites their understanding and analysis of the location of placements was more restricted. However several made comparisons between specialist and general units similar to medical student colleagues. Comments referred to problems of the busyness of the ward/ clinical environment and on the working atmosphere that existed within a particular unit. One student compared her current experiences of ward organisation and medical-nursing relationships in an oncology ward with earlier experiences of practice on a medical ward,
Nursing Student Interview 8: Student: …it works very differently it does. I mean as opposed to
the medical floor, like say you've got your named nurses which I think works really well if you’re working as part of a team (…) But as for communication with doctors up there [medical ward] its completely different to down here. It's a lot more together between say the nursing staff and the medical staff, it's quite close
However in spite of her praise of the medical nursing relationship she was critical of the relationship between medical staff and patients suggesting that there was 'no direct link between medical staff and patients' with the nurse being used as a bridge to the patient. This might be explained by the role differences of 'residents' and 'visitors' described previously, however the role of nurse as transmitter of medical information is well evidenced in the literature.
Evidence exists of a role and relationship disparity between medical and nursing students that might impact on the common ground or frame of experience upon which collaborative the module as fourth or fifth choice and remainder had left lower choices blank and had therefore been allocated to the module.
- 120 -
relationships are built. The different organisational structures and underlying cultures/ philosophy may be actively precluding closer working relationships between these staff as will be explored in subsequent chapters.
4.4 Duration and pattern of the clinical learning experience The duration and pattern of the clinical experiences also influenced the role adopted by students in practice and the opportunity to engage with qualified staff. Whilst some discussion on optimal times in relation to particular learning outcomes exists in the nursing literature, e.g. Watson & Harris, (1999), no reference to the attachment duration in medical student learning was found. In particular perhaps the most influential report on medical education in the UK in recent years, 'Tomorrow's Doctors' (GMC, 1993), makes no reference to the issue of duration of clinical experiences although it does identify the need for a change in the pattern of attachments and supervision.
In interviews with medical and nursing students the time spent in the clinical areas was identified as a factor which affected the learning opportunities and in particular the opportunity this created for developing collaborative relationships with staff. Allied to the issue of duration in the data were issues of patterns of learning and organisation of time in the clinical area that provided a distinctive difference in clinical activity between medical and nursing students.
Duration and pattern of medical student attachments Prior to Phase 3 of the medical undergraduate programme students had numerous short attachments in a range of different clinical areas for the purpose of specific interventions, or for shadowing identified clinical staff. Students appeared to value the close contact with other professionals that this shadowing experience provided and saw the rationale for it as one of seeing what other professionals did and also as one of developing the interpersonal skills necessary for collaboration,
- 121 -
Medical Student Interview 5: Student: I think for us to see what they do because at some point
you might have to refer a patient to them. There’s no point in referring to someone if you haven’t got a clue what they do as their job. (...) it helps in communication as well. If you get to know them, build up a rapport'.
There appeared to be general agreement that a day or half-day was sufficient. The medical student perspective on their learning appeared to support the contention that this was skewed towards acquisition of knowledge, a "go-and see-and-remember" perspective rather than a more developmental process in which they use the experience to analyse and redefine their own role 53 . Simple observation of practice was considered sufficient to gain an understanding what others do. In fact a number of students felt that shadowing in order to learn about other professional roles had been rather over-played in their programme. This, in part, was explained by students as being due to the lack of involvement in their own role in the particular situation i.e. they were there simply to observe, not to do.
The requirement for participation was a recurrent issue and in years 4 and 5 of the medical programme students frequently reported the short duration of placements in which they were expected to develop their ‘clinical skills’ resulted in lack of involvement with staff. For example although blocks were of four weeks in some blocks this comprised a number of different experiences in both general areas, specialities, hospital and community. Thus time spent getting to know staff was likely to be very limited. This issue was captured by one student who recognised that because of the nature of their clinical role the development of skills underpinning collaboration was unlikely to be achieved whilst a student,
Medical Student Interview 3: Student: (…) you’re a student so people don’t, people don’t really
care what you have to say. I don’t mean that, but what I’m saying is like when you’re a student, fourth year, fifth year on a ward, no-one, I’ll put it like this, no-one will get involved with you enough to get in confrontation with you because you’re not going to do anything that’s going to get you into confrontation with you. ‘Cos’ all your doing is helping out junior house 53
See Chapter 6.
- 122 -
officers, going on ward rounds and basically if you mind your manners and know what you’re about you’re not even going to, odds on you won’t even be speaking to everyone on the ward (...) I don’t think anything is as real as when you get out there because I don’t think you’re in a placement long enough to experience the problems that you’re going to experience.
This lack of participative involvement, suggested by this student, left them ill prepared for the role of junior house officer because of the prolonged and close working relationship that this position required,
Medical Student Interview 4: Student: ...when you become a junior house officer you’reon that
ward for six months and you’re doing things for people and people are doing things for you and there’s more chance of you getting into problems with people, than you are as a medical student.
Other students reported similar feelings that they were just ‘finding their feet' and people were getting to know you when you have to move on’ (Medical Student Interviewee 3). This they considered to inhibit not only the relationship building but also the learning opportunities,
Medical Student Interviewee 2: Student: ‘In some hospitals it gets to the point where you’re
maybe in your third week and the nurses know you and they know your name. They maybe call you to come to take blood maybe before they’d call the JHO, stuff like that and it makes you feel good. It makes you think, ‘I’m actually doing something’, because it’s nice to know you’re helping, not just hanging around looking blank which is what you normally do as a student. So that’s quite nice, so it would be nice to have a longer time and then you could fit in even more, get more and more to do and you’d get a lot more experience that way as well.
This suggests that after a period of time as staff got to know students they actually recognise specific learning needs of individual students. Equally students begin to feel actively engaged in the delivery of care. Elkjaer (1999) describes this as the point at which learning becomes an integral and inseparable part of the process of performance and at which the locus of learning
- 123 -
transfers from being simply in the ‘individual mind’, i.e. a move from collaboration as a professed ideal, to one of social participation (collaboration in action) 54 .
Another student was asked how he felt the clinical placements could be improved,
Medical Student Interview 6: Student: I think the only thing I would think would help would be
longer attachments because a month on a ward is fine but then you’re away again and if you don’t come back to that place people forget you, and I think maybe if you had a couple of months you’d have time to meet and get to know more people and for them to recognise you as being part of the ward.’
However, longer duration placements are only valuable if the student feels they are involved or have some function. One student described the circumstances of their ‘PRHO’ (pre-registration house officer) experience, a block designed to allow them to practice the junior house officer role for 'real',
Medical Student Interview 5: Interviewer: If you're moving every month it's very difficult to
establish the relationships you need to sustain. Would it be preferable to stay longer? Student: I don't think so, 'cos' last year I thought a month's awful short, you're always rushing on, but then we did six week attachments in our PRHO training things and you were bored actually, you know, you wanted to move on because there's only so much you can learn really and then because you've got no responsibility and it's not a job or anything and you do so much hanging around as a student, if you're hanging around on the same ward for six weeks it starts to get quite tiring.
This contrasted with the student’s experiences on a short orthopaedic attachment, in which she did feel involved,
Medical Student Interviewee 5: Student: 'I think the reason why I enjoyed my attachments so
much was 'cos' I was in theatre a lot, and I never thought surgery was something I had a particular interest in. It's not something now I intend to pursue, but I got the opportunity to
54
See Chapter 2 'Learning as a 'situated activity, p: 56
- 124 -
assess so much and I even got the opportunity to operate myself and I just loved it, I really liked it
Thus the duration of placements has to respond to a range of different learning requirements of which collaboration is only one element. It may be that the organisation of some longer placements may fulfil this need. Medical students also recognised the diversity of experience they needed that compromised the potential for prolonged single placements,
Medical Student Interviewee 2: Student: ‘It’s difficult because you have to cover your medicine,
surgery, your paediatrics stuff and all your speciality stuff like that’
Later interviews around the problems of compromise between numbers of placements and frequency of contact with clinical staff led discussions to the notion of a ‘home ward’ 55 . This was described as a ward to which the student was allocated for the duration of their professional programme, to which they could return overtly for procedural experiences e.g. blood taking, but more covertly as an opportunity to develop relationships with staff over a long period. Consistent with the notion of concurrent analysis this concept was explored with subsequent students. Comments were generally favourable,
Medical Student Interviewee 6: Student: I think from the point of view of establishing
relationships with people that would really help.(...) if you did have a base I’m sure it would help’.
The only reservations around this idea related to the potential for overloading already heavily student subscribed wards with an additional student burden as often students from several years were present on the same ward.
Thus the general findings revolved around the need to have longer placements whilst gaining the diversity of experience required of the medical curriculum. In Phase 3 of the medical programme the clinical experience was designed around attachment to particular clinical firms
- 125 -
or clinical areas. The recommendation of the General Medical Council (1993) was for a more flexible supervisory process, thus allowing students to tailor learning to their own needs in a supportive environment. However the pattern of student experience in the clinical area differed between specialities although broadly it was summarised by the example below,
Medical Student Interviewee 5: Student: Well , if it’s a hospital consultant you tend to hang
around the JHOs, go to the postgraduate meetings or the staff meetings if you can, and in the fourth year there were tutorials and they were great; we haven't had many tutorials in fifth year. In psychiatry it was different, there weren't any JHOs, you were very much linked to the consultant, so that was different. You actually sat in their clinics and went and visited with them… and then general practice is different again. You’re given a lot of responsibility in general practice and that's quite nice. I think most days while I'm here I'm seeing patients on my own.
The issue appeared to be one of creating learning that was both relevant to the student and in which the student felt involved in practice 56 . Longer placements may in part deliver this but without more overt inclusion of the student in the health care team, as several students recognised, their role as student will remain distant from the realities of the JHO role for which they are being prepared.
Duration and pattern of nursing student placements. The Nursing Curriculum Document (University of Dundee School of Nursing and Midwifery, 1997) makes explicit reference to the duration of placements as significant change in course structure in response to feedback from a range of parties,
‘Students prefer and derive more educational benefit from longer (6 weeks or more) placements. They find that shorter placements do not allow them time to settle and become comfortable enough in the environment to utilise the learning opportunities available. This area received universal criticism from educational staff, students and preceptors alike.’ (p: 19)
55
In 1999 this was introduced for Dundee medical students from year two onwards but was termed a ‘parent ward’.
- 126 -
Broadly students concurred with the perceived benefit of longer placements. The primary reason for this view appeared to relate to involvement of students in practice and developing relationships with clinical staff. However this was not simply a longer is better policy,
Nursing Student Interviewee 9: Student: I think it's getting a balance, you know, now I think
fifteen weeks or something. Well that's all well and good if you like it, but if you absolutely hate it fifteen weeks is an awful long time. But four weeks tends to be too short. You're really getting into it and it's time to go and you think, 'Well I could do with another three or four weeks here.'
This student also commented that preference for longer placements also related to reducing stress for the student. Each change of placement she suggested was 'like starting a new job' although it was eased if placements were in the same hospital, 'that's helpful because they tend
to do things in a similar way'. This contrasts with the situation of the medical students who were frequently changing attachments less then every four weeks and often moving to geographically disparate hospitals.
One student described the need for longer placements in the branch programmes i.e. the latter eighteen months of training with particular emphasis on the final stages of the education programme as they develop the ward management skills required of a staff nurse. Students moving closer to qualification will be required to fulfil the functions of a staff nurse and achievement of more complex learning objectives
Nursing Student Interviewee 9: Student: I think more time on wards would be a good thing,
rather than three or four weeks. This has been a seven-week placement, which has been better. I think three or four weeks is a bit quick. You're just finding your feet, finding your way around the ward and you're starting all over again in a brand new ward. I think it could be more beneficial to spend a couple of months, may be three months on the one ward rather than do four wards in those three months
56
This will be explored further in subsequent Chapters, particularly 5, 6 & 8.
- 127 -
Although a six week duration for the placement is defined this exemplifies the prescription that is inherent in other elements of the programme. It may be more useful to define the duration of placements in terms of learning objectives. For example if basic orientation to clinical contexts are required then short observational placements may be sufficient. Practice of functional activities i.e. learning of technical skills, may again only require short periods in practice. If the objective is about developing collaborative practice then these longer placements seem more appropriate so that students become known as individuals and have longer to develop contacts with other staff. As one nursing student identified,
Nursing Student Interviewee 3: Student: '…it's important, getting to know the members of the
team and actually participating in the team. 'Cos' it does take a couple of weeks to settle in and feel like you are part of the team.
In addition to the duration of placements a number of students identified the pattern of their placements. Of the unstructured interviews only two of the nursing students identified their future career as being in the community. A heavy hospital orientation appeared to prevail within the student cohort, supported by ad hoc 'straw polls' of a number of different student cohorts at different stages of their training, whom I taught in my capacity as a lecturer. One interviewee identified that order of placements was therefore important, stating that early allocation to community settings was inappropriate due to her view that most nurses wanted to work in hospitals. She proposed that, '…getting a feel for the job that you're going to do', at an early stage was important and suggested that the failure in this respect was a factor contributing to a high early attrition rate from the course. Thus consideration needs to be given not only to duration but also pattern of placements and these may be best designed on an individual basis in order to assure relevance to personal learning goals.
4.5 Monitoring and assessment of clinical practice 'It is impossible to overestimate the importance of assessment. Involvement of teachers in
developing assessment procedures is almost certainly the most important educational tasks
- 128 -
they will undertake. The methods they select and the content they include will have profound effects not only on what students learn but also on how students learn.' (Newble, 1998: 131).
The monitoring and assessment of students in practice, as the above quotation indicates is evidently an important element of defining the teaching curriculum. Rowntree, (1987) defines the purpose under 6 main headings: selection, maintenance of standards, motivation of students, feedback to students, feedback to teacher, and preparation for life. Oliver & Endersby, (1996) identify a range of different tools used in the clinical assessment of nurses including profiles, numerical rating scales, peer and self assessment, portfolios, journals, and case studies. Similarly an extensive range also exist in medicine defined as written e.g. multiple choice, short answer, or essay questions, oral e.g. structured or unstructured viva voces, observation e.g. objective structured clinical examinations (OSCEs), or witnessed problemsolving/ skills demonstration, and combined approaches e.g. projects, logs diaries, presentations and simulations (Harris, 1998).
Assessment as a disciplinary device The importance of considering the mode of assessment is emphasised by Foucault's (1975) analysis of power in which he argues that 'examination' is a disciplinary mechanism used by organisations in the management and control of their workforce. Foucault proposes that examination, or the measurement of competence, knowledge or skills, may act in a way that rather than forging individual practitioners who can perform in specific contexts results in the mechanistic creation of a 'docile body that may be subjected, used transformed and improved.' Whilst it would be extreme to over-emphasise the 'docility’ of the medical and nursing work force, some evidence was found in this study of the influence that assessment has on student behaviour. In particular medical students were highly focused on learning to pass examinations, identifying this as a primary motivator to learning.
Newble & Jaeger, (1983) illustrate the influence of assessment in a study of based on surveys and discussions with medical students on their participation in practice. They identified that
- 129 -
over a one year period senior students' attendance in the clinical areas became less and less. Data from the study indicated that the explanation for this was that the chance of obtaining an unsatisfactory report from the ward areas was minimal, whilst failure of an examination resulted in a pass-fail viva. Consequently students’ attention was focused almost entirely on passing exams. Although this may be a reasonable action in order to survive the educational process, the outcome may be an inhibition of the self-directed learning described as goals of both medical and nursing programmes.
Monitoring and assessment of clinical medical practice In this study students in the medical programme undertook a diverse range of clinical experiences under the supervision of a defined consultant or group of consultants. The aim of these experiences was to give the student, 'An appreciation of diseases […] in addition to an
appreciation of how the same disease influences patients differently. (University of Dundee Medical School 1995: 39). Clinical attachments were selected on the basis of the different experiences and body systems that students were required to study.
A staff development programme to facilitate support of students was available for all academics. The University requirements were that staff should attend 'staff development
activities in one of the medical education subjects for a minimum of six hours per year in order to update their skills in clinical development, teaching methods and approaches to assessment.' (University of Dundee Medical School, 1995: 72). There was no apparent prescription however as to specifically what areas of staff development supervisors should attend. This contrasted with the nursing programme in which a defined programme of study was available to
'preceptors’.' 57 .
57 Preceptors in the nursing programme were the equivalent of supervisors in the medical programme being required to facilitate learning and assess competence in practice. The roles they adopted are considered further in Chapter 5.
- 130 -
Assessment in the undergraduate medical programme comprised both summative and formative components. The detail of this process included: •
Phase 2 58 summative assessment comprised written examinations, multiple choice questions and short answer questions and an OSCE. An 'integrated assessment' devised by the particular block of study organiser, comprised a formative assessment (of which no record of students’ performance was, however this aimed to provide guidance to the individual student on their progress) (University of Dundee Medical School, 1995: 45)
•
Phase 3 summative assessment comprised a series of course assessments at the end of each block of study and an integrated proficiency examination which assessed an individual students ability to carry out different aspects of the work of the pre-registration house officer' (University of Dundee Medical School, 1995: 51) 59 .
'Study guides', check-lists and portfolios for supporting learning In addition to the assessments students were provided with 'Study Guides' for each block of the programme designed to 'integrate the students experience in different attachments' (University of Dundee Medical School, 1997b). These Guides include a list of presenting complaints/ problems that the student should try to observe, a range of anticipated learning outcomes, recommended reading and guides to further resources (including people) to support their learning (See Appendix 15).
The 'Study Guide' provided an outline of what students should expect on their placements in terms of learning opportunities and formative assignments. In some areas the teaching and learning was primarily at the bedside, in others in out-patients and in others based- on students following particular patients through their range of therapies. In two areas there was overt
58 Assessment of Phase 1 is not included, as the clinical component is limited in this stage, however a range of periodic assessments occurs in this Phase. 59 The assessment format was revised in the 1999 curriculum document and included a more diverse range of strategies including a full problem-solving question paper, a full multiple choice question paper, and OSCE of around 30 stations a portfolio assessment and a diagnostic clinical examination. However this methods of assessment post-dated the experiences described by students in the study.
- 131 -
mention of learning to work with other staff. In general practice (p:24) one objective was 'To
further develop knowledge and skills in teamworking', whilst in 'Ageing and Health' it was 'To understand the role of the doctor as a member of a multidisciplinary team, and to be familiar with the roles of remedial therapists, nurses, social workers and other team members' and in specific relation to the ward attachment,
'You should attend, and contribute to, at least one multi-disciplinary team meeting. Ideally, you will feel part of the ward team, and will discuss your patient with nursing and medical staff on a regular basis.' (p:23).
The 'Study Guide' proposed a range of requirements of the students in what some critics might described as a reductionist approach to learning a criticism that has been made of objectives and competency-based forms of assessment (While, 1994, Barr, 1998, Playdon, 1999),
'In Year 4, you will pass in your different attachments through the various contexts in which medicine is practised, building an understanding of each of the tasks from these different perspectives…The major objective of the attachments, however is the learning and mastery of the competencies relating to the core symptoms as seen from the perspective of different disciplines'. (University of Dundee Medical School, 1997a: 2)
The reality expressed by students was that although objectives were defined the pressures on the work place and demand for learning opportunities often meant that students failed to get the experiences required. In such cases the 'Study Guide' provided a framework for learning in these areas,
Medical Student Interviewee 2: Student: (…) you get your study guides, your things like that.
But things don't always go, you're not always going to see everything. Interviewer: How do you get round that? How do you get your expereince? Student: Well you don't get your clinical experience, you get it from text books. There's nothing much you can do about that. If a patient is not coming in, just may be luck you'll see see on another attachment or something. You just have to make the best of it, what you have. Some hopsitals are better than others, you get a different variety.
- 132 -
The 'Study Guide' frequently re-iterates the importance of task as the primary motivator to learning, 'the learner is driven to find out as dictated by the task (p: 3) and sets a final year goal that, 'All students will be required to complete a further 12 clinical attachments in the fifth
year, in which you will, for part of the time, develop the knowledge, skills and attitudes of a house officer' (p: 3). The form in which this goal is written appears to suggest that 'knowledge, skills and attitudes' are adequately definable and can be conferred on to the student, transference of attributes rather than reflection on and development of an individual approach to practice.
One of the requirements of the clinical experience is to develop clinical competence, involving signing off a number of supervised procedures in a book. However one student highlights that competence is not a static state as competence can increase as well as diminish and regular opportunities to practice are not always available
Medical Student Interviewee 5: Student: I suppose for practical procedures you need to keep
practising. Like some, if I've been doing my medical blocks for four weeks by the end of the block I will become more competent, but after GP and things like that where you hardly did any procedures at all your skills will be a bit, you'll feel incompetent and when you actually start to do the procedures again you'll feel incompetent. This is evidently important to the students in light of the warning in the study guide, that defects in 'clinical skills' are 'the commonest cause of failure in the final examinations'.
Another aid to learning available for medical students was the procedure check-list. Students found the procedure checklist particularly useful as there was no ambiguity regarding what was to be achieved and students got these signed off as they completed each - this could be by medical staff or nurses, however how the competence of each of these staff was assured was unclear.
- 133 -
Students were frequently critical of the assessment process. Inn some cases they didn't feel it was relevant to their clinical learning in others it was considered to fail to provide the necessary motivation to learn, which was described to be most powerful when externally imposed,
Medical Student Interviewee 2: Student: I think the worst thing about the course is that they
have less exams. That sounds silly but if you have exams you're more encouraged to study, to learn about things (…) The majority of my year, say about eighty percent crammed in the last couple of weeks and had a really easy year. Whereas it would have been better if they'd given us exams all the way through. Interviewer: So sort of periodic assessment? Student: I reckon we would have got a lot more out of it. If you learn it two weeks before the exam it's in one ear and out the other. There should be, I've met students from Glasgow and Edinburgh in different placements and at the end of their four-week placements they get a clinical exam by the consultant. And they don't do it to Dundee students who are doing the same placement. So they get a long and a short case, where they have to go to a patient and do history and examination, get asked questions and stuff. So, they're more inclined to work in that placement and learn some stuff. So they're more inclined to do some work in that placement. Students were also assessed in part on the quality of the completion of their 'study guides' as part of the portfolio of learning,
Medical Student Interview 6: Student: I suppose all my learning was based on what I'd seen
and if I hadn't seen something it wasn't foremost in my mind and I wasn't learning about it. But then we had structured study guides when it came to the exams I used them to revise from, you know there's 96 presenting symptom and each one had a whole list of stuff you should know about them so I just learned all that (…) Interviewer: Have you referred back to those since? Student: No Interviewer: Right, so primarily it's an exam tool to get you through, not something you're going to use now?
- 134 -
Student: No, every time I have a query now I just look up a text book. Because the study guides that they gave us was a series of questions, you know, 'What's the differential diagnosis?'. 'What are the management options?'. It wasn't information, it was, 'this is what you should know', so you would read it and you would find out what the differential diagnosis was, so it's not something you go back and learn from 'cos' it was never facts, it was learning structure.
This completion of documentation in order to satisfy a specific goal appears to ally more closely with the notion of 'training' rather than 'education' (Playdon, 1999). This contention is reinforced by comments of students in which they appeared to complete a task without being clear of the underlying rationale, as one student commented,
Medical Student Interviewee 6: Student: (…) when we did our PRHO blocks we had these huge
wads of things that we had to fill in, all the learning objectives and what we were supposed to achieve and some of us really struggled to make it fit with what we were doing in our attachment and the consultants certainly thought, 'what is this stuff I've got to wade through?. Though assessment is designed to assure the competence and preparedness of students for practice, most frequently students discussed this in terms of motivation to learn. External imposition of learning e.g. through exams was generally well accepted as useful and appropriate by students, whilst more reflective forms of assessment e.g. portfolio were viewed as less useful. This raises issues of the orientation of students toward their learning in particular the development of lifelong learning and the pre-requisite self-directedness. It highlights the value placed on knowledge and its acquisition, a ‘having’ mode of learning that this thesis argues is less useful for collaborative development than the more reflective 'being' mode of learning.
Monitoring and assessment of clinical nursing practice The pattern of placements for nursing students was proposed in the curriculum documentation to articulate with the theoretical components of the course and utilise a range of assessment methods. Students undertook assignments during each module of the programme and these
- 135 -
often drew on clinical experiences or clinical cases which emphasised, 'the nature and utility of
reflection as a component of professional learning and practice' (University of Dundee School of Nursing and Midwifery, 1997: 81). Learning was directed by a competencies booklet for each year of the programme (Appendix 16) containing a list of required outcomes measured against specified levels of performance These were based on levels identified by Bondy, (1983), of dependent, marginal, assisted, supervised or independent (Appendix 17). Thus similar competencies or outcomes could be achieved at different levels of performance.
The processes and assessments in place were proposed to concentrate in year one on developing 'fundamental aspects of nursing knowledge, skills and attitudes' developing a
'repertoire of core nursing skills' upon which subsequent learning was founded (University of Dundee School of Nursing and Midwifery, 1997: 81). These became more focused as students moved into their branch programmes or adult, child, learning disabilities or mental health.
Student assessment in the clinical arena was designed on a tripartite arrangement between an identified 'preceptor' in the clinical work place, a lecturer from the School and the student. The
'link-teacher', a non-clinical lecturer based in the School of Nursing and Midwifery liased with clinical staff, and in some instances worked alongside students in the clinical area.
The School runs programmes for clinical preceptors in order to update them on course developments and assessment and the link-lecturer acted as resources to support the preceptor preparation programmes. All sites used for the placement of nursing students were also subject to audit prior to their use.
The key differences therefore between the medical and nursing clinical contexts were the degree of management of experiences that were reported to occur. Although in the medical programme the assessment was largely left to the individual supervisor, in theory at least in the
- 136 -
nursing programme assessment occurred in audited areas by preceptors who had a degree of preparation and had the support of a of a link-lecturer.
Nursing students illuminated a situation in which high levels of variability still were prevalent descriptors. Preceptors were inconsistently present and assessment was frequently by preceptors with whom the student had not worked,
Nursing Student Interviewee 4: Student: ...you're meant to have your link teachers and things
like that, where they'd come up and discuss, for example, your objectives that you've got for that placement […] what you want to learn, what you want to get out of that. But often the link teacher doesn't appear, or hasn't been able to come to the placement then, and if you're busy, you're just helping out anyway […] you don't really achieve your objectives. Another student proposed that difficulties related to attitudes of staff to their supervisory responsibilities, 60
Critical Incident Description 20: Nursing Student: 'The preceptor had only worked with me for
six days due to her holidays. Two days before I was due to leave she said, We need to do this' and threw the report at me. She stood near me giggling and whispering with the other staff nurses as they filled in the report and I heard them say things like, 'Don't give her this mark, give her that'. The report said I had no confidence and my patient care was no good. I got D's for both of these. This had never been discussed with me and I had no time to do anything about it.
Another suggested that the shortage of placements meant that the School undertook little monitoring of the placement once it had been approved. One student in criticising a placement added, 'The School can't afford to upset them.'
The comments that nursing students made appeared to focus on processes related to the monitoring of quality of placements and completing assessments. There were almost no comments from students about assessments as motivators or inhibitors of learning. That said, there appeared to a be a high level of consistency in their valuing of assessed skills and getting 60
See Chapter 5 'Supervision of clinical learning' p: 140
- 137 -
them signed for. One student suggested that the methods used by medical students of having to have defined skills signed by different staff would be a very useful tool for them 'making you
feel as if you know something and it means staff have got to watch you'. It is the external recognition of one's skills by the provision of an overt symbol that appears important. This allied with a reflective note I made in my diary,
Reflective diary note: Students seem very keen on getting skills signed for by clinical staff, it
seems that someone is then recognising their worth. This fits with the non-clinical experiences, when you return an assignment it seems to be the mark that is all they are interested in rather than the comments or whether they feel they did a good assignment or not.
This perspective focusing on external definition of what is valuable to learn also fits with Fromm's, (1976) view of the 'having' mode of existence. This contrasts with the 'being' mode in which students do not fit learning into some internal frame of reference, but rather into an externally imposed frame of reference. Thus the teaching curriculum comes to dominate the potential of the learned curriculum in which the individual generates and draws and develops their own perspective. Perhaps one might argue that a degree of loss of individual perspective is a consequence of the process of professionalisation.
4.6 Summary This Chapter has provided an introduction to the organisation of the clinical experience and the resultant lived experience of students in the clinical area. It has identified the different organisation patterns within the medical and nursing programmes, identifying and illuminating the impact this has on the roles performed by different students.
The difference between an 'attachment';' and a 'placement' appeared to relate to the degree of engagement the student had in practice and the opportunity that they had to develop relationships with practitioners, a requisite for practising skills necessary for collaboration and indeed actually collaborating in the delivery of care. The notable difference between an
- 138 -
'attachment' and a 'placement' was also the degree of freedom it conferred on students to present or absent themselves from the clinical area. In the former this was high in the latter it was low, thus arguably developing models of practice that differed in relation to spatial orientation and expectation.
Location, duration and pattern of clinical experiences differed between the two programmes. Medical students were moved more frequently and through more varied geographical locations, whilst student nurses were largely based in single hospitals. The suggested outcome of this situation was that nurses became familiar with routines and environments in a way that medical students did not. This was evidenced in differing degrees of familiarity with hospitals and availability of peer group support. Nursing students were likely to be working with other nursing students whereas medical students often were 'attached’ singly. Medical students consequently required the capacity to cope with a more isolated existence, which mirrors their later anticipated experience as young doctors.
In Chapter 2 the review of undergraduate medical education indicated a culture of alienation, objectification and isolation. The wide geographical distribution of medical students’ attachments requires a high degree of independence and the capacity to work in isolation in a way that nursing students do not because of their 'required' presence in a particular location where they are exposed to a high degree of scrutiny. Thus students are likely to develop different role expectations and have different interpretations and understandings of what it means to work with others. Though nurses may come to see this as based on close physical proximity such a model is unlikely to be familiar to medical students whose pattern of working is more diffuse.
The monitoring and assessment of students both rely heavily on the clinical staff, and students appear to value the development of practical skills. The most notable feature in comparing the two programmes was the degree of control. Whilst nursing had a number of strategies including ward audit, defined preceptor programmes and identified link-lecturers, the medical placements
- 139 -
were not audited and staff were left far more to make their own decisions about the most appropriate way to support students. Variability was a significant theme in the quality of clinical experiences in both programmes. Medical students were also more focused on examinations than their nursing counterparts.
This chapter has given a broad overview of the different participatory roles of medical and nursing students and the influence of a number of organisational parameters. The next chapter will consider the ways in which learning is facilitated and students facilitate their own learning in the 'community of practice'.
- 140 -
CHAPTER 5: FACILITATION OF LEARNING: SUPERVISION, TEACHING STYLES AND NEGOTIATED LEARNING
5.1 Introduction This chapter considers the formal mechanisms to facilitate learning in the clinical arena for supporting learning. This broadly considers (i) the supervisory processes, (ii) the discrepancy between the planned and the delivered teaching curriculum and (iii) the role of the student in this process.
It contrasts the different teaching methods adopted by clinical staff for medical and nursing students and reflects on explanations for these differences. It also explores the impact of the learning relationship on the identity this promotes in different student groups. It describes varying approaches adopted for teaching medical and nursing students and observes how on occasions the same practitioners will adopt very different educational strategies to facilitate learning. This is interpreted as being based on the different role conceptions held by clinical staff of the role and personal and professional resources required by the medical and nursing students. Finally, the chapter considers the role of the student in the learning process by considering their motivation to learn, the need of the capacity for self-direction and the process of negotiation that occurs in delivering care and satisfying individual and 'community
of practice' needs.
5.2 Supervision of clinical learning Much of the discussion that has preceded this chapter has exposed the informal process and contextual resources that are available to students. However formal supervisory resources are available to both medical and nursing students to support their integration and participation in practice and facilitation of their learning. The model adopted in each situation and the reality
- 141 -
of the process described by students and observed in the field demonstrates certain differences and patterns that influence the engagement, learning and perspective on learning.
Supervision of medical students A number of factors identified in the literature are likely to influence the quality of clinical teaching. Firstly, most clinical teaching/supervision of students that occurs in practice is undertaken by staff who have at very least a dual role, of teaching and patient care, (although this is likely to be also combined with administrative, managerial and research commitments). Staff are therefore unable to devote sufficient time to professional education (Wolfhagen et al., 1997). Whilst hospital trusts receive a sum of money, (service increment for teaching, SIFT), career progression in academic medicine is largely on the basis of research merit (Dacre et al., 1996). Secondly, few doctors have teaching qualifications or instruction on how to teach and skills are variable (Dacre, 1998). In recognition of some of these problems the General Medical Council has recently produced a guide 'The Doctor as Teacher' (GMC, 1999), to promote good teaching practice. Thirdly, the teacher must act as a role model as much learning occurs simply by observation (Coles, 1998), as this study also supports. CamposOutcault et al., (1995) identified the positive effect that role models have on students' choice of career speciality and Towle (1998) argues that teaching styles are learned from exposure to role models in undergraduate training.
Role and relationship with the supervisor Westberg and Jason (1993) describe the need for a change in the supervisor-student relationship in medical practice, to create a more collaborative model for learning. They differentiate between two forms of relationship which comprise opposite ends of a spectrum (Table 7):-
- 142 -
Table 7: Contrasting characteristics of collaborative and authoritarian teacher-learner relationships (Westberg & Jason, 1993: 18)
Collaborative •
Learners are treated as valuable contributors
Authoritarian •
to their own and to each other's learning
Learners are treated primarily as recipients of teaching
•
Teacher and learner jointly set the agenda
•
Teacher sets the agenda
•
Learners participate in assessing their learning
•
Teacher presumes to know learner's learning
needs •
Teacher and learner establish individual and
needs •
Teacher determines goals of learning
•
Teacher may develop a learning plan
•
Teacher monitors learner's progress
shared goals of learning •
Teacher and learner develop individual and group learning plans
•
Learner monitors own progress and provides feedback
•
Independence and collaboration are fostered
•
Dependence and competition are fostered
•
Instruction is learner-centred
•
Instruction is teacher centred
Westberg and Jason argue that clinicians who function collaboratively can translate this to any relationships, therefore the relationship with the supervisor in practice provides a frame for relationships with patients.
The Medical Curriculum Document referred to the fact that medical students would be supervised in the clinical arena, however interview data indicated variability in the quality of the supervision that they received,
Medical Student Interviewee 3: Student: (…) some consultants are really good and they'll take
an interest in you. Most consultants will teach you on the ward rounds. (…) There was one consultant I was with in XX [DGH] doing medicine and on the ward round he would ask you everything about the patient as he was going round and he'd explain things to you. He'd keep you thinking all the ward round rather than just going round after a trolley, not having to think, not having to do anything.
- 143 -
Another student described, Medical Student Interviewee 5: Student: Sometimes when we are doing the attachments the
supervisor is away for holidays and things like that. Interviewer: How do they manage to do your assessment then? Student: That's the problem. A lot of the, some of the attachments is not organised in that way because the supervisor is not there and then the rest of the consultants are not sure what to do with the students and things like that. That's what I mean by disorganisation.
This lack of organisation by the supervisor meant that students often were unclear of their learning objectives, despite the use of 'Study Guides' to direct their learning on particular attachments. The outcome was that there was sometimes a conflict in expectations or achievements at the end of the assessment,
Medical Student Interviewee 5: Interviewer: (…) are there any of your attachments that stand
out because they were particularly good or particularly bad? Stud: Right, er I think there are a few that most of the students think are quite good. Ophthalmology, ENT, haematology, 'cos' they are well organised and the supervisors they know, they've set out the things they are expecting from the students and they want the students to do such and such things. So, it's easier for us to fulfil this so that the supervisor assesses us and they know what we will have done and they can ground the evidence on how to assess us. But other attachments they don't have good guidelines of what they are expecting from us so sometimes we thought we'd fulfilled what they want from us but then when you have to assess them and things like that it turns out that they're expecting you to do something that you didn't do
Equally some consultants appeared to be unclear of the learning objectives of students whom they were supervising and were reported on a number of occasions to have little personal knowledge of the students for whom they had responsibility,
Medical Student Interviewee 2: Interviewer: … do you think the consultants know what the
objectives of your placements are?
- 144 -
Student: I don't know if they're given a list, I assume they are given objectives. Interviewer: I mean would they differentiate between if you were, say, a third year student or a fifth year student? Student: No, they may be ask at some point, may be say to you, 'What are you in now?', but no, there's not any sort of different approach depending on which year you are. They don't really get to know you personally.
Students frequently reported two factors that they valued most in a clinical attachment, the relationship with the supervisor and other clinical staff that made them feel included and a clear structure to their learning. Location, as was discussed in the previous chapter was reported to have a bearing on perceptions a significant component of this differentiation appeared to involve the relationship between students and their consultant supervisors,
Medical Student Interviewee 4: Student: (…) the consultants were very friendly and they
weren't sort of intimidating as you get in teaching hospitals. They tend to be more intimidating in teaching hospitals and think they're God.' (…) teaching hospitals are fine at times it's just you tend to get more, it must be the type of, sort of person that wants to go into a big sort of specialised hospital (…) Interviewer: Right. When you said about big hospitals tend to attract a certain type of person, can you expand on that? Student: Well some consultants in teaching hospitals are fine, they're very nice, but you do get the certain ten percent element. I don't know, they seem like dictators and sort of prance around the place. Sort of trying to, I don't know, they just seem to be, they do seem to think they're God and do seem to think they're the most important person on earth.
Though this student had some difficulty in defining specifically what her concerns were regarding the climate most frequently encountered in teaching hospitals, the issue appeared to be around a perceived hierarchy that inhibited the student-consultant relationship and proved a potential inhibitor to a collaborative relationship.
- 145 -
Features of collaborative supervisory contexts Westberg and Jason's (1993) continuum outlining collaborative through to authoritarian supervisory behaviours (Table 7, p: 142) appeared to provide a generalised differentiation between relationships in teaching hospitals and district general hospitals. In the former context students were less likely to feel able to speak up or participate in setting learning objectives, delivery of care or be a member of the team. One student exemplified the difference between the two environments using coffee breaks as an illustrative example,
Medical Student Interviewee 4: Student: (…) like in a district general the consultant would
have made the student cups of coffee after the ward round. Like you'd sit down, (…) everyone would take it in turns to make cups of coffee. Whereas if you go to certain neurosurgery meetings in DRI, because when you do your neurosurgery attachment there's an eight o'clock meeting and you daredn't touch the coffee, the coffee is for consultants and staff only. Students will get shouted at if they touch it. (…) Like I didn't touch the coffee but one of my students, my friends thought the coffee was for everybody. I just didn't want any and they told her to put it down, it's not for you. Like this was cheap NHS hospital coffee, this wasn't percolated you know (laughs).
In addition to the relationship factor outlined, medical students also valued structure in the clinical learning. They appeared to exhibit a greater motivation to learn when objectives were set at the behest of others rather than driven by their own needs. One student's description of his best attachment was fairly typical,
Medical Student Interviewee 7: Student: there were structured ward rounds, so you were
actively involved […] - some of the consultants up there involve you in the ward rounds so that you really have to make a conscious effort to learn and I just felt that you were being pushed, for me that's better'
Another expressed a similar sentiment,
Medical Student Interviewee 2: Student: I think when you're on the ward you want to have
some sort of standard clinical teaching and not just if the consultant or house officer can be bothered. I think you really have to have something set out.
- 146 -
Additionally students felt that self-directed learning, which they often felt lacked structure did not place the them under the same pressure to learn, and also they suggested did not provide an opportunity for feedback,
Medical Student Interviewee 2: I mean it's not nice to be put under pressure but you learn.
'Do this, you should find this, why are you not.' You seem to be just expected to pick it up and you'll not. These statements calling for structure or order and external pressure to learn have some resonance with the 'having' mode of learning which Fromm (1976) describes,
'Students in the having mode of existence will listen to a lecture, hearing the words and understanding their logical structure and their meaning and, as best they can will write down every word in their loose leaf notebooks - so that, later on, they can memorise their notes and thus pass an examination.' (p: 37). This 'having' mode of learning, it would appear from students’ comments, was encouraged by the 'Study Guides'. These were designed to structure the students’ learning experiences, and along with examinations became an endpoint in learning and arguably militated against students taking personal responsibility for their own educational needs.
Despite this want for clear and logically structured learning, students began to realise and become reconciled to the reality of the variability of their supervisory relationships,
Medical Student Interviewee 3: Student: By the time you get to the fifth year you just, you
know some placements just aren't going to be that great, and you just harden to it (…) by the time you get to your fifth year you know that people are busy and you know people have more important things to do, you're not the centre of the universe on the ward, you're just a medical student. Whichever form the attachment took student supervision was ultimately the responsibility of the consultant grade medical staff however most students identified that the junior house officer often played a significant role in their learning. Some students acknowledged the
- 147 -
importance of the consultant in their integration into the practice area due to their influence on other staff,
Medical Student Interviewee 3: Student: I think the consultants think their juniors are
teaching but their juniors aren't/ I think the consultant at the end of the day is the person who could change teaching on the wards most. Because, it's quite funny when you see if the consultant takes an interest in the students and he's really friendly to you and he's talking away to you the next time the juniors are like really friendly to you as well. (…) But when the consultant's not taking much interest in you then everybody else thinks what’s it matter? However in spite of their value as supervisors often the consultant did not take the primary role in student learning in the clinical arena.
Junior house officers as supervisors Bullimore, (1998) recognises that the role of teaching in clinical practice is not simply the role of single individuals. Although the consultant may be the named supervisor, different members of clinical firms are involved in teaching,
'All the medical staff on your firm have a responsibility for student teaching except perhaps
the house officer, who is considered to be undergoing a year of supervised training before registration as a doctor. In practice house officers often provide much informal teaching and advice and students perceive them as being more approachable than senior staff'. (p: 106) Bullimore suggests that whilst formal teaching may be delivered by senior staff much of the
'hands on' teaching may be delivered by junior doctors. A number of medical students indicated that their relationship with the consultant was sporadic. The junior house officer was frequently the person to whom the student linked, although they had no official supervisory role,
Medical Student Interviewee 2: Interviewer: Who's primarily responsible for you then while
you're on the ward?
- 148 -
Student: I think the consultant that you're under. I don't even know, but I think it is because you're, you get a consultant who supposedly gives you a report at the end of your attachment, but while you're there, you tend to just, it's more the house officers you kind of latch on to. 'cos' it's their sort of stuff you can do. (…) The consultants are responsible for you but you spend most of your time with the house officers.'
Another student proposed that the orientation of house officers made them potentially more appropriate supervisors of practice due to the learning objectives that students were required to achieve,
Medical Student Interviewee 5: Interviewer: Do you find a difference in the teaching approach
between consultants and say SHOs? Student: Yes, 'cos' consultants probably because consultants are, how do you say, they are more interested in epidemiology and things like that and there's quite a big gap. I find I can learn better from a senior rather than a consultant because of the focus, they're more interested in research and things like that. Senior registrars and SHOs, they sit exams themselves so they themselves have to know the management of a variety of things so, we are like, in the same boat.
Other students felt the house officer was the best person to learn from because of the work of the junior house officer allied more closely with the role for which they were being prepared. They acknowledged that because of the busyness of the clinical context there was frequent cancellation of the more formal, structured teaching and therefore the junior house officer filled these gaps with informal direction,
Medical Student Interviewee 4: Interviewer: I suppose what I'm getting at is, obviously it's
nice when you get on with people who are there, but why do you also feel you learned a lot? Student: Well, in [DGH] it's a very busy hospital and a lot of jobs are left to the house officers and at the end of the day it's the house officer that you learn from. You don't really learn from senior staff 'cos' even if tutorials are timetabled they don't always happen, so you basically learn from the house officers.
- 149 -
Others regarded the junior house officer as a compromise in delivering teaching but a necessity because the consultant was too busy. However this may actually fit with an assertion that powerful people are conceived as busy, whilst those with less power are not (Allen 1996).
Medical Student Interviewee 2: Interviewer: Who do you think is the most appropriate person
to support [medical students] then? Student: I think the consultant if they have time. 'Cos' they never really have the time or they don't bother to do that. […]. It would be nice, I mean not much time, just taking five or ten minutes out if they have an interesting patient, but you have to appreciate they have other things to do.'
Medical students however recognised that junior house officers often had little experience in teaching. Whilst teaching others is a defined function within the broad presumptions of the professional role, the expectation that teaching will be demanded of them appeared not to be made explicit and there was little preparation for this role in the undergraduate programme,
Medical student interviewee 5: Student: I guess not everybody who does medicine is a born
teacher (…) no-one's ever emphasised to actually emphasised that one [teaching role], -I mean I've got my house officer job but nobody's said to me, 'Will you be willing to teach students?' Consequently whilst some students reported positive learning experiences others found they were used in the clinical areas to do jobs,
Medical Student Interviewee 12: Student: …when I went to [DGH] I had one week with a
house officer. I had the same consultant for three weeks and I had one week with one house officer and two weeks with another house officer and a week somewhere else and I learned more in about three days in the second week than I learned in the whole, and I learned more in the first two days than in the whole week with the first house officer
and,
- 150 -
Medical Student Interviewee 5: Student: (…) the JHO I was shadowing was not interested.
One minute she gave me a whole stack of really dull work to do: 'Go and do all ECGs or something', and then I wouldn't see her for days on end and that was really frustrating because I was supposed to be shadowing a house officer and my house officer wasn't interested. And I couldn't blame her; not every house officer has a burning desire to teach. Clinical teaching appears in the curriculum documentation to be taken as something of a given and responsibility is handed over to the clinical firm or consultant. This situation has parallels with the findings of Atkinson, (1973) in the Edinburgh medical school over quarter of a decade ago. Most frequently students equated good clinical teaching with individual personalities, people with an interest in teaching who motivated students to learn. Students often felt they needed greater clarity, a framework within which their teaching should take place sometimes suggesting that self-directed learning meant that clinical staff took no responsibility for directing their learning.
Supervision of nursing students The norm for a student nurse in practice is to be attached to a clinical practitioner, a mentor, (although the term supervisor or preceptor is sometimes used interchangeably), 61 . who has responsibility for facilitating and assessing the learning and performance of students whilst on clinical placements. Bevis & Watson, (1989) highlight the importance of the role of mentors, which requires them to be to facilitators and role models rather than transmitters of information and authority figures.
61
Definitions of clinical supervision, mentorship and preceptorship (modified from NBS 1999: 24): Clinical supervisor - an experienced and appropriately prepared health professional who supervises another practitioner engaged in practice and Mentor - appropriately prepared registered nurse, health visitor or midwife who undertakes clinical practice support of students Preceptor - an experienced registered nurse, health visitor or midwife who has undertaken appropriate preparation to support registered but less experienced colleagues in the clinical setting
- 151 -
Although the mentor role may have some parallels with the medical supervisor, as the clinician responsible for promoting the students learning, in many nursing colleges a tripartite arrangement exists for clinical learning. This includes a tutor/ lecturer from the school whose role is to support the development of the clinical staff, create a bridge for the student between classroom and clinical learning. May & Veitch, (1998) report this role to be highly valued by students, however Paterson, (1997) describes the difficulties of being an educational outsider in the clinical areas and having to 'court' and 'negotiate' with staff in order to assure their co-operation in the learning process. The importance of this role and the creation of a partnership in learning between college staff and service staff is emphasised by the UKCC, (1999)(drawing on evidence provided by Watson, (1998)).
'We recommend […] that mentors are better supported in their task and that the preparation, support of and feedback to mentors by lecturers needs to be formalised.' (p: 50). Documentation on the supervision of nursing students was more evident in the nursing curriculum document in comparison to the medical document. However students similarly reported problems of the clinical experience that related to both relationships with the 'preceptor’ and the structure of the placement.
Supervision and the influence of relationships and structure Students in this study reported the difference it made to their integration into the clinical area when supervisors demonstrated that they had planned for the student's placement. In particular a number of nursing students made reference to the benefits of orientation programmes which they suggested made them feel part of the clinical team and familiar with both routines and expectations of them,
Nursing Student Interviewee 9: Student: A couple of times I've had, you know you go to the
ward and you don't even know what's involved in the ward. Mm, a couple of times I've been given packs, you know, beforehand, have been sent out to me beforehand, with a nice welcome letter and who staff are, because if you go in and don't even know who you're asking for unless you find out beforehand. But if you were sent something and it kind of
- 152 -
makes you feel they're interested in you, they value the fact that you are there. (…) So, to know who your preceptor is, to have a welcome pack, to know a bit about the ward itself (…) that's helpful.
This situation contrasted with descriptions from a number of students where the preceptor appeared to have little interest in developing any sort of learning relationship with the student,
Critical Incident Description 1: Nursing Student: This was my first placement, so I was feeling
like a spare part. I had not been oriented to the ward so I didn't know what to do. There was no teamwork on the ward but rather only delegated tasks. I felt like a spare part and was just standing on the ward not knowing what to do. I had been told several times to just go and do things. There was no working with my preceptor, just sent off to do things on my own. I remember one occasion, the staff nurse had found a patient that was covered in faeces. He told me to go and clean her up. He didn’t find out whether I knew what to do and there seemed to be no chance that he was going to help me. He implied that I should just do as he says. The preceptor was just vindictive, other students had said the same. This student also reported that she wouldn’t feel there was any value in telling the 'link-
lecturer' of the problems because the School didin’t do anything about it. Other students reported similar perceptions and whilst this may not have been the case, it is recognised in the literature that there is a potential problem in sustaining sufficient numbers of 'preceptors' (NBS, 1999). This difficulty may imply a perceived low status of preceptorship or lack of commitment to a clinical teaching role in nursing. It may also discourage university staff intervening where problem relationships occur for fear that preceptors will withdraw. One student reported that preceptors were sometimes insufficiently qualified to provide the level of expertise that was required to satisfy the role,
Critical Incident Description 34: Nursing Student: You need someone like the link lecturer,
someone to orientate you. […] There [teaching hospital, medical ward] the level of ability isn't graded in anyway, sometimes an auxiliary could teach you as much. Now I need more technical stuff, but that is picked up in a very ad hoc way, that's if you dare ask. Questions
- 153 -
are often taken as criticisms, perhaps that comes back to the degree or diploma difference, they feel it because a lot of them only have a certificate.
Watson & Harris, (1999) highlight the variability in preparation of preceptors but also acknowledge that mentors’ attitudes are crucial to the effectiveness of students' learning. On placement, students identified a number of occasions where the preceptor had played a significant role in the inclusion of students in the clinical team. The following example demonstrates how this in turn affected the stereotypes of doctors held by the student,
Critical Incident Description 4: Nursing Student: Just as we were about to go into the meeting
my preceptor invited me to be involved, she asked me to give handover on the four patients I had been looking after. That was good because if she'd done it earlier I would have been worried about it. The consultant made me feel important. She nodded, gave me encouragement and just her body language showed she was interested in what I had to say. I really felt I had a role. May be I have odd stereotypes of doctors and think of them as arrogant but this was different.
Numerous students identified positive experiences in which the preceptor had facilitated the students’ inclusion in the clinical team though some students proposed that the allocation of an effective preceptor was 'left to chance' and that often students were 'intimidated' by their preceptor to the detriment of their learning. One student described observing a procedure undertaken by her preceptor,
Critical Incident Description 35: Nursing Student: 'The senior charge nurse was putting on a
compression bandage and she stared putting it on from the knee. I had just had the theory in class so I asked if there were different ways of doing this. I got the feeling that she was thinking, 'bloody student nurse', that I shouldn't ask. She just gave me some fairly flippant answer. Students did encounter problems but those who felt well orientated and supported appeared to feel they fitted in well with the team and as a consequence could admit their knowledge deficiencies and question practices they observed. One student described a model of supervision that she considered particularly effective.
- 154 -
Critical Incident Description 29: Nursing Student: This ward allocated a preceptor and a co-
preceptor, so I always had someone to turn to. They sat me down and really orientated me. On this ward [Teaching hospital, medical ward] they were teaching me as they would have liked to have been. They made time, saw education as important. They were real teachers. I did more on that ward than any. On other wards they just say get on with it. They showed me how to catheterise a lady. They showed me all the equipment, how to set up a trolley, let me ask questions. You were part of it and they seemed to enjoy teaching.
This description appears to encompass characteristics of the supervisory process valued by both medical and nursing students. Support was available from individuals who were recognised by students to display characteristics that made them ‘good teachers’. These characteristics were broadly consistent with the literature on current adult educational practice and included identification of students’ learning needs, providing education at a level appropriate to the students’ stage of development, involvement of the student in decisionmaking and the learning process, approachability and a relaxed style of teaching. Such factors would appear to be facilitative of collaborative learning relationships. However in contrasting the models of nursing and medical clinical supervision education some similarities and differences in process and perceived outcome emerged. A notable similarity was a tendency for qualified staff to compare students’ learning against their own educational experiences i.e. a 'not like that in my day' syndrome that I have described as 'personal benchmarking'. The most notable differences were the educational approaches employed by practitioners for preparing medical and nursing students. These two factors will be briefly considered.
5.3 Contrasting teaching styles for medical and nursing students Students in interview gave numerous examples of positive learning experiences that involved staff who were supportive, approachable and actively involved the student in the learning experience. These characteristics were common for both learning with qualified staff from own and other professions. Though some similarities were evident it appeared that with some exceptions two different perspectives on the role for which students were being prepared influenced the educational approach adopted by practitioners.
- 155 -
'Toughening up' medical students The approach most frequently adopted for medical students appeared to be designed to
‘toughen them up’, or 'learn to stand on their own two feet', encouraging a structured and systematic approach to knowledge and independence of role. The motivator described by all but one of the of medical student interviewees was learning by ‘humiliation’,
Critical Incident Description 7: Female Medical Student: I was working in cardiology with the
registrar and she asked me to listen to the heart because she said the woman had a murmur. I couldn’t really hear it and she asked me a few questions and I didn’t know the answers. The patient was sitting there all the time. She ripped me to shreds in front of the patient, told me I was stupid and incompetent. That’s no way to learn but I guess it’s that humiliation thing again. They should take you outside and explain if you don’t know. if you feel they’re on your side your not frightened of being wrong and that tends to make you come up with the right answers more often. This sort of thing has happened a lot, being told you're inadequate in front of patients.
Another medical student described similar experiences but seemed to accept that ‘learning by
humiliation’ was an acceptable approach whilst suggesting it could be delivered in better or worse ways,
Medical Student Interviewee 13: Student: ...the consultants did ask you questions in the ward
and you did look a bit stupid at times, but that’s going to happen anywhere [...] Like you were humiliated at times but it’s the way you’re humiliated. You can be humiliated and not feel absolutely dreadful about it, it’s the way that it’s done... Although this 'humiliation' experience was widespread amongst medical student interviewees most tended to be philosophical about this educational approach, often seeing it as a useful motivational tool,
Medical Student Interviewee 4: Student: ‘… being pushed to learn can be a bit stressful, but it
makes you get your act together. Somebody who wants to now what you've been doing, learning, how much study you've done.’
- 156 -
Another identified that it encouraged a tendency to hide the limitations to knowledge, and present an air of confidence that was not actually felt that would be a useful part of the detached professional role in the future. This supported the description of medical education provided by Haas & Shaffir, (1982) of a medical culture in which displays of confidence and competence were preferable to acknowledgement of personal limitations 62 ,
Critical incident Description 5: Medical Student: 'It's mainly a humiliation thing again. I think
now it's ingrained into the work ethic - to humiliate you to make you learn. But is doesn't help you feel part of the team. Communication was very difficult with the consultant because of fear. To say 'I haven't done this or that', is very frightening. Sometimes you don't admit it, just bluff.
The approaches to learning expressed by student interviewees appeared to be founded on a pressure to 'know', a knowledge rather that a relationship orientation. This finding might have implications for collaborative development particularly when contrasted with the approach to learning expressed by nursing students.
'Doing nursing' to learn The pressure to 'know', or appear to know, approach in the medical programme contrasted notably with an approach adopted for nursing students in which a 'doing' rather than
'knowing' ethos seemed to prevail,
Critical Incident Description 41: Nursing Student: The philosophy was get stuck in so that you
learn to do […] They didn't make you feel stupid or incompetent and you felt confident to ask if you were unhappy - even if it's stuff that you really should have known.
Nursing students described the importance placed by qualified nurses on going and 'doing' jobs even when the student did not have the necessary knowledge to undertake the task,
62
See Chapter 2, ‘Culture of medical education and practice’ , p: 37
- 157 -
Critical Incident Description 59: Nursing Student: 'The preceptor who was supposed to be
looking after me didn't know the stage I was at, what I was there for. She asked me to put a Conveen on a patient. I said I'd never done that before. She looked at me laughed and told me to just get on and do it
Other students illustrated the differing learning needs, knowledge focus and educational approach adopted by qualified practitioners in teaching different student groups,
Critical Incident Description 57: Nursing Student: The doctor was doing a pleural tap on a
patient. It was just before my finals. He knew this, so he asked me if I wanted to watch. He went over everything step by step. There was a medical student there and he asked us both questions. […] He asked me questions at my level without putting me down. I had told him what I was doing and what I needed to know […] He asked the medical students more intense questions. He was focusing on the practical procedure with me and on the anatomy and physiology with the medical student. When I didn't know the answer, which happened on a number of occasions, he didn't make me feel bad.
Another student nurse observed the difference between medical and nursing roles not in terms of knowledge and practice but rather in terms of technical and patient orientations. The description she provided, whilst illustrating what appeared to be a typical doctor-medical student clinical teaching encounter, indicated how her need to assist the doctor inhibited her support for the patient,
Critical Incident Description 56: Nursing Student: I was assisting the registrar to do a
catheter, a medical student was just standing there watching even though the man was obviously in a lot of pain. If I hadn't been helping I would have been over there holding his hand and talking to him. […] It made me see how different our approach is and what we're there for […] May be he didn't feel it was his place to do that sort of thing [hold the patient's hand], he's just there to learn the procedure. You can see why because afterwards the consultant asked him questions on the procedure, nothing about the patient. I was tidying up listening in thinking, 'Thank God he's not asking me.'
Despite the changes in education, in particular a move of nursing into the University sector and greater practice patient orientation in the medical curriculum it appears that the objective
- 158 -
of ward teaching and learning methods adopted are different. The emphasis for medical students is on pathology, disease processes and technical procedures, whilst nursing students’ knowledge focused on doing practical procedures and knowing ward routines. Whilst humiliation was a regularly used tactic by doctors on medical students these same clinicians often adopted a more humanistic approach in interactions with nursing students. This may highlight a need to explore with staff the underlying ethos and expectation of the students that influence educational approach. It may be that the stereotypical objective, scientific, knowledgeable doctor is perceived to require an air of confident detachment, whilst the more sensitive, caring stereotype of the nurse is exhibited in a more nurturing educational style. This difference would warrant further research, however its recognition may mean that the knowledge economy for the two professions continues to favour very different educational currencies thus sustaining particular modes of clinician investment in it.
'Personal benchmarking' Students were probed for explanations of the particular teaching approaches adopted by different practitioners and the most common response was that staff tended to compare the education of students in relation to their own student experiences, usually in less favourable terms. One medical student explained the use of humiliation as a learned educational technique from qualified practitioner's own experiences,
Medical Student Interviewee 2: Student: I was in London doing my A & E. A registrar and SHO
had a real go at me. I didn’t know something so I asked and they made me feel very small. [...] They were very arrogant so I came back the next day and I said, ‘I didn’t want to be taught by you because I’m not going to learn. You humiliated me and you made me feel small, as if I don’t know anything...’ [...] their reply was, ‘It’s the way we were treated at medical school by our consultants and registrars, So I don’t know if that’s where their arrogance comes from, the way they’re taught.’ Another described a hostile response from a junior doctor with whom she was working despite him only having qualified the previous year,
- 159 -
Critical Incident Description 4: Medical Student: The JHO wanted me to put a Venflon in. I
hadn’t done it before so I told him that I’d like to see him do it or for him to guide me. He just turned and said that he thought it was pathetic that I was halfway through my fourth year and couldn’t put in a line. He was quite aggressive. Such comparisons were also evident amongst nursing staff who particularly identified that nursing students emerging from the Project 2000 programmes had much less practical knowledge than in their day. One student nurse described the response she received at her lack of knowledge about a particular procedure,
Nursing Student Interviewee 1: I’ve never, ever in my three years changed a stoma bag and it
was just the look of disbelief on this staff nurse’s face, ‘What, you’ve never come across this?’, and I, ‘No’ and so she sort of explained what to do, and I felt happy going and doing it myself and plus the lady was very, very helpful. She kept me right as well. But it was just the look of disbelief, she went, ‘I was doing that in my first year’ and everything when she trained.
Observational field notes also supported evidence of this 'benchmarking',
Observational note: [District general hospital, medical ward]: Student nurse asks staff nurse if
a lady can get on a commode. Staff nurse says, 'No, give her a pan', Student nurse replies 'Can you give me a hand then?' and staff nurse says, 'No, give her a female bottle.' Student nurse goes into the sluice, then comes to the door and says, 'This?' The staff nurse says. 'What are you like, what do they teach you in college these days?' and goes and gets a bottle and takes it with the student to the patient.
Even senior student nurses appeared to adopt the habit of evaluating other’s programmes against their own course, and in turn of measuring other practitioner's practice against their own,
Nursing Student Interviewee 1: I was in there with a degree student from XX [another university] who has no moving and handling experience whatsoever, so she couldn’t do
anything, which I find a bit bizarre actually, because we had our moving and handling not long after we started and I think how is there not something in their course that permits them to lift?
- 160 -
The recognition of this 'benchmarking' may in part explain the conservative attitudes and resistance to change evident in both medical and nursing education. It highlights a problem for students in practice who are undertaking programmes of a different form to those experienced by their supervisors. In terms of inclusion of students in order to facilitate collaboration if students are not achieving or demonstrating skills at the level of the
'benchmarks' recognised by the supervisor then the assessment of their competence may be compromised. This may be further compounded when there is a lack of training given to supervisors about the goals of the current curriculum.
5.4 Negotiated participation and self-directed learning Within the course documentation for both medical and nursing programmes were strategies e.g. problem-based learning, shared projects, small group work, which placed an emphasis on the development of students' capacity for self-directed learning. Such strategies the literature suggests, promote the development of competence that is fostered not by teaching to deliver knowledge or teacher-centred approaches but through teaching which engenders specific kinds of cognitive activity (Dolmans & Schmidt, 1996). In practice the development of selfdirected learning skills are oriented not towards traditional pedagogical, teacher-directed, methods but rather towards androgogical methods, the art and science of helping adults learn (Knowles, 1975).
Knowles (1975) identified that the learners must develop a number of capacities in order to benefit from self-directed learning: •
Concept of oneself as being non-dependent
•
Ability to work collaboratively with peers
•
Ability to identify learning needs and translate them into objectives to be achieved
•
Ability to identify and use learning resources
•
Ability to collect evidence
- 161 -
In relation to the 'situatedness' of learning and practice described by Lave and Wenger (1991), self- direction might be proposed to enable the student to negotiate social engagements which facilitate participation, and consequent learning, in the care processes.
In interviews with medical and nursing students there were high levels of recognition that the responsibility for learning in the clinical area resided primarily with the individual student. Students required personal motivation and responsibility and the capacity to negotiate their own learning needs, in order to create many of their own learning opportunities, within the
'busy' clinical practice environment. One student nurse typically stated,
Nursing Student Interviewee 8: Student: … it doesn’t all depend on the qualified staff’s
attitude, it depends a lot on the student’s attitude themselves. If they go in facing a brick wall and don’t want to learn anything then that’s the way it will be. Staff aren’t going to co-operate with people like that, but if you go into a placement wanting to learn and you ask to do things without just sitting back and being told to do everything then it works much better.
Medical students generally mirrored these comments,
Medical Student Interviewee 11: Student: I mean if you are willing to make an effort and go
and speak to patients on their own, go and ask them if you can may be feel their tummy or listen to their chests if they’ve got good sounds then yes you do get a lot out of it. If you kind of think, ‘Oh I can’t be bothered’, which you do, I can’t be bothered, you can have the afternoon off, no-one’s really bothered what you do, then you’ll go away and not put in [time and effort].
A student nurse who appeared to recognise the essence of adult learning, encapsulated how fundamental the ability to pursue her learning was to the role for which she was being prepared,
Nursing Student Interviewee 9: Student: …it’s adult education. No one is going to spoon feed
you anything, and it’s the type of job where you have to be able to think for your self and you have to be able to assess properly and talk to other people. You’ve got to be effective
- 162 -
communicator not just with the patient but with every other member of the team, every other member of the staff you’re working with. And you’ve got to have those skills and I think it has to be put across that it’s the type of job that you have all this responsibility and accountability and it’s quite frightening sometimes. But if you look at it calmly then it all fits into place. And if you can communicate effectively and realise what your job involves then you can make the most of it. But I think you have to learn very quickly that it’s down to you at the end of the day and a lot of people say that. What you get out of a placement is what your prepared to put into it. It’s not up to anybody to spoon-feed you. You know you get given all the ground stuff at School and it’s up to you then to go out and put it into practice.
Although the need to create personal learning opportunities was acknowledged, several students indicated that they did not pursue learning objectives but rather reported for shifts and accepted learning experiences as they arose,
Nursing Student Interviewee 5: Student: I’ve never seen an OT or anything like that.[…] I’m
sure if I’d have asked I could have went down. It never really, I don’t know, tickled my fancy to go down to the OT place.
Other students suggested that rather than personal motivation their learning opportunities were inhibited by the ‘busyness’ of the workplace and lack of support 63 ,
Nursing Student Interviewee 3: Student: On paper it’s [self-motivation], they encourage but
then again down at the college you’re meant to have your link teachers and things like that, where they’d come up and discuss, for example, your objectives that you’ve got for that placement which is self motivated, what you want to learn, what you want to get out of that. But often, if the link teacher doesn’t appear, or hasn’t been able to come to the placement then, and if the placement’s very busy, your just helping out anyway you can and you don’t really achieve your objectives.
The idea of a link-teacher, a bridge between the University and the clinical areas was one difference between nursing and medical students that might be expected to influence the learning relationship in the clinical areas. However the reality as this student suggests was 63
See Chapter 8 'The busyness factor' p: 229
- 163 -
that visits to clinical areas by lecturing staff appeared to be a relative rarity, a finding recognised in the 'Fitness to Practice' document (UKCC, 1999) and suggested to have worsened with the move of nursing education into higher education institutions (HEIs),
'Anecdotal evidence suggests that the role has become more limited since schools and colleges of nursing and midwifery have become part of HEIs, and lecturers have restricted access to students on practice placements in trusts.' (p: 47)
The observational data recorded only one instance where a link-lecturer was present in the field, working with a student,
Observation Note: [Teaching hospital, medical ward]: The telephone rings and is answered by
the ward assistant. It's a call for a student nurse who looks surprised to receive it. When she comes off the phone she says it was one of her lecturers who is coming to see her this morning. She says it will only be her second pre-arranged visit in almost three years.
Though some evidence exists of the value of link-lecturer roles in clarifying student objectives (Marriott, 1991), the paucity of visits for the students in this study was likely to create little impact on learning. This finding was similar to that of a number of other studies, (Dunn et al., 1995, Orton, 1981) which emphasised the importance of the clinical nurse as the primary mediator of student learning objectives.
Some students appeared to recognise that despite the 'busyness' of the clinical domain and on occasions the lack of support this was not necessarily a barrier to their learning,
Nursing Student Interviewee 9: Student: I have days when I’ve gone and worked with the
physio, a day with occupational therapy, I even went on a domiciliary visit with one of the consultants, which was really good. I really have had, but only because I’ve asked Interviewer: So that’s down to you?
- 164 -
Student: You have to do that. If you want to see everything and see everything you just have to push forward because again they’re very busy with their own business and it’s not that they don’t really forget you but you must push yourself forward and say, ‘I want to see this’. Interviewer: From my point of view, one of my responsibilities is education. That would suggest that education was a relatively low priority in the clinical area? Would that be a fair comment? Student: Again, not if you push yourself forward and don’t allow yourself to be forgotten that you’re there. You know I appreciate that they are busy, that the wards are busy, everyone has got their own jobs to do, but somebody trained them, so somebody needs to train me as well. But a lot of it I think comes from the nursing student, you have to be pushing forward all the time or you will be forgotten. Not for any particular reason but just that your put on the sidelines.
This student demonstrated what Freire (1970), in his analysis of oppression might describe as a 'liberated' approach to learning based on personal responsibility 64 . Other students appeared to accept a more 'domesticated' perspective on their education, passively accepting their circumstances, or as some interviewees suggested 'the busyness factor' provided an excuse for less motivated colleagues who did not wish to take responsibility for their own learning,
Nursing Student Interviewee 2: Student: It’s, if you show that you’re enthusiastic and you’re
keen and you’re interested in learning the preceptors won’t hold you back. I understand that it’s may be a wee bitty difficult when you’re rostered, but before that you’ve got ample opportunity, you should be able to go out and go with these people, definitely. I don’t see, I don’t understand anybody whose not had a chance to do that. Interviewer: Because what they were implying was that supernumerary status was a joke. Student: Och, everybody gets so hyped about this, I’m not doing this because we’re supernumerary or I should get to go and see this, but you’ve got to give and take. If you’re working on a busy ward and you’re wanting to go down to theatre and they say, ‘Oh, we’re a wee bit short staffed this morning, would you mind staying on and we’ll try and get you down next week’, people are up in arms, phoning the link teachers, ‘I’m not getting to do this, I’m not getting to do that’, I think you’ve got to give and take. I mean may be that’s wrong but 64
See Chapter 2, ‘Culture of nurse education’, p: 44
- 165 -
that’s the way I feel and I’ve never had a problem, never had a problem and most of my friends I would say haven’t had a problem with that either.
The suggestion within these extracts is that students require motivation and confidence to direct their own learning, but also the negotiation skills by which they can create learning opportunities appropriate to their particular needs in a busy clinical context. The response from clinical practitioners appeared to be an important factor in these developments. A nursing student described having asked a consultant if she could attend an operation, an encounter that also appeared to develop her confidence in communicating with medical staff,
Critical Incident Description 31: Nursing Student: I hadn't been to theatre at all or seen any
operations. I approached a surgeon who was on the ward and asked him if I could go to surgery. I felt very nervous about asking. He gave me a big beaming smile and invited me down that afternoon. When I went down he said it was just a straightforward appendix operation, but he showed me everything and said that I could come back soon. He said it was very uncommon for nurses to ask him directly. It was learning that you can ask for things, take some control over what you want to learn, but you have to have the self-confidence. He obviously was quite surprised, but it shows that doctors are willing to teach us.
A number of students recognised the disparity between what the student required and what the pressures on the clinical areas meant they could deliver. The role of the student nurse as a 'pair of hands' meant that they were considered part of the work force and could not pursue their learning at will, or negotiate the learning they required,
Nursing Student Interviewee 9: Nursing Student: …you tend to get the view sometimes you
don’t have a say as a student. And that’s in negotiating your shifts or the famous thing to say is ‘Negotiate, it’s negotiable’, but then the bottom line is you come away thinking it’s not negotiable…But it depends on how you’re willing to take that. I mean I won’t take that kind of thing and I haven’t had any problems, but I do know people who work shifts they don’t want to work, being used as a pair of hands and feel they’ve nowhere to turn to because they have to do it because they’re a student.
- 166 -
Medical students recognised that their role, as a clinical visitor, gave them considerable freedom to pursue their own learning activity. However for them the challenge appeared to be creating a relationship with the staff in order that they could then participate. A medical student described the importance of his interpersonal skills, and the complexity of trying to 'fit
in' in order to generate learning opportunities, what I have described in the next chapter as 'strategic orienteering' 65 ,
Medical Student Interviewee 2: Interviewer: … what do you do when you go on a new
placement, what do you do to try and fit in? Student: Do as much as I can in the first few days and be as approachable and friendly. Speak to everyone. If anyone’s wanting anything done, house officers or anything, instead of them having to ask you, you sort of keep an eye on what needs done and say I’ll go and do this or I’ll go and do that. Just be friendly to nurses and clean up after you so you look like someone who basically knows what they’re about. If you come across like you’re confident and you know what your doing, basically you have to come across like you’re not going to get in the way, ‘cos’ sometimes I think that’s how you can be seen, that potentially you could get in the way. So if you look like you’re adding to it then that’s a bonus. This student highlights the difficult path learners are expected to walk, remaining out of the way until they identify something they can usefully do, constantly monitoring the area for what is required so they anticipate things with which they might be involved. This sensitivity to the needs of the context would seem to require protracted periods of time on the wards in order to develop this sensitivity, a factor that was not commonly described by students who often left the clinical areas rather than 'hanging about'. A further factor identified by this student was the importance of a ritual display of self-confidence that he did not necessarily feel. This is a recognised feature of medical training but has been argued to emphasise objectification and detachment in medical education (Haas and Shaffir 1982).
65
See Chapter 6 'Participation and marginalisation in the clinical team', p: 188
- 167 -
Another student suggested that the capacity for negotiation called for assertiveness skills a requirement also recognised as important to collaborative relationships 66 ,
Nursing Student Interviewee 9: Student: …added to that [negotiation] is you own
assertiveness […] Without that I think you could be lost or just mumble through, just bumble along for the three years. I think you do that to a certain extent anyway but I think you’ve got to be assertive and take what you’ve learned in School and put it into practice. You know, they talk about this practice-theory gap, you know everyone said it’s widening and the training’s terrible and whatever, but I think it’s up to the student. Everyone’s got a role to play and it’s up to the student to try and close the gap a bit, which you can do.
Although this area warrants further exploration in a subsequent study, what is evident from the data is that students utilise a range of different interpersonal strategies to create learning opportunities for themselves. These include negotiation, assertiveness and diplomacy, all prerequisites for the development of collaborative relationships.
5.5 Summary This chapter has highlighted some of the challenges of developing educational programmes in the clinical domain. Data has demonstrated the inconsistency of the experience received by students and the importance of the supervisory role in including students in the clinical team at a level appropriate to their knowledge and skills.
The medical and nursing programmes explored in this study utilise different methods of supervisory support, the nursing programme incorporating greater levels of management and support including audit and direct lecturer support in the clinical areas. The impact of these systems on the student experience however appears ill-determined from the evidence available.
66
See Chapter 2, ‘Identifying collaborative practices’ p: 28
- 168 -
There are numerous individual differences amongst clinical staff in their approach to teaching but there appears to be an underlying differentiating professional ethos in the approach adopted. In the medical programmes there is a tendency to use 'humiliation' methods. This may in part be explained by the nature of the student product; that is envisaged as objective and independent and 'tough' enough to withstand the isolation of practice. This situation contrasts with more nurturing, less challenging educational methods adopted for nursing students. This situation may be explained by the ‘knowing’ focus of medical education and
‘doing’ focus of nursing education that are consequently perceived to require different educational inputs. It may be that different strategies for promoting collaborative development will also be required, founded on the styles of learning with which different groups of students are familiar.
This chapter also notes the tendency for staff to compare the knowledge and skills of students against recollections of their own at similar stages in their pre-qualification programme. Differences between expectations of individual practitioners and the capabilities of students based on the structure of the programme they are undertaking may influence the degree to which the student is included in the clinical team.
Finally the chapter explores the role of students in negotiating their own needs and role in the
'community of practice' This requires considerable motivation confidence and diplomacy on the part of the student. Such strategies are supported, certainly on paper, by wider curriculum trends, which facilitate more self-directed methods of learning. Whilst some evidence is available to support that androgogical methods of learning better prepare students for practice than traditional methods and facilitate greater capacity for collaboration with colleagues, (Hill et al., 1998), more research is warranted in this area.
- 169 -
CHAPTER 6: PARTICIPATION AND MODES OF ENGAGEMENT IN PRACTICE
6.1 Introduction This chapter explores in more detail the participatory roles and processes of students in clinical practice. It is underpinned by theoretical constructs introduced in Chapter 2, presented by Lave & Wenger, (1991) on 'legitimate peripheral participation' and Fromm, (1993, 1976) on 'having' and 'being' 'modes of existence'. Its aim is to sensitise the reader to the clinical learning experience and provide a map which indicates a number of landmarks that were identified as influential on the roles adopted by medical and nursing student in the clinical arena. Subsequent chapters explore the landmarks in the clinical arena which influence the learning curriculum through their effect on the participatory role of students in practice.
It also considers the relationship between learning, participation and collaborative development and considers broad trends in professional education which impact on this relationship.
The data from this study on the practice role of medical and nursing students indicated that there are three levels of participatory role or modes of engagement in the practice arena. These modes of engagement are summarised as:
•
the 'seeing mode', the observation of practice, often achieved through shadowing members of one’s own or other professions, or from simply observing whilst being present in the clinical arena;
•
the 'doing mode', based on accomplishing certain tasks, skills or procedures, and;
•
the 'being mode' in which students take an engaged and reflective role in the delivery of care by becoming 'real players' in the health care context and assimilating their learning into the actuality of their role performance.
- 170 -
This chapter will first revisit the conceptual ideas on which the interpretation is founded in order to clarify the relationship between participation and the development of the capacity to function collaboratively
6.2 Conceptualising participation and collaborative practices In Chapter 2 the concept of 'legitimate peripheral participation' (Lave and Wenger 1991) was introduced. This provided a means of analysing the role of students in a 'community of practice' or social world. More traditional educational theories centred on the individual indicate that the value of participation for learning is that it provides 'concrete' illustrations and models of the role for which the student is being prepared (Coles 1998). Lave and Wenger's concept of
'legitimate peripheral participation' requires instead a consideration of the relationship between the flow of information in performing different 'learning' roles, the developmental trajectories of learners as they move through different forms of participation in that role and the evolutionary processes of the 'community of practice',
'…, rather than learning by replicating the performances of others or by acquiring knowledge transmitted in instruction, we suggest that learning occurs through centripetal participation in the learning curriculum of the ambient community. Because the place of knowledge is within a community of practice, questions of learning must be addressed within the developmental cycles of that community.’
The value of the concept of 'legitimate peripheral participant' is that it focuses attention on the movement of students towards 'full participation' in the community of practice, goals consistent with those recommended by medical and nursing professional bodies for pre-registration education. The recommendations of the UKCC, (1999) and the GMC, (1993) propose that students should be prepared for the role of a newly qualified staff nurse and pre-registration house officer respectively. It would seem inconceivable how students could be adequately prepared for such roles unless they have performed in such a capacity, albeit with support, prior to completion of their programme. This might be argued to be a self-evident goal but
- 171 -
there is some evidence in both the medical and nursing literature that students have been inadequately prepared for clinical practice (Firth-Cozens, 1987, Melia, 1987). Melia (1987) proposes,
'One of the clear themes to emerge from the students' accounts […] is the students' belief that they learn during their training to be students rather than as one might suppose, how to function as qualified nurses.' (p: 128)
Educational strategies where students adopt more active, participative roles such as problembased learning do appear to better prepare students for practice (Hill et al., 1998, Parsell & Bligh, 1998). Situations where the student participates directly in clinical practice provide the most concrete learning experiences available (Coles 1998, Harden 1998).
Factors affecting participation, which would also appear to be pre-requisites for collaboration in practice include experience, confidence, belief in the value of the professional role and assertiveness (Whale, 1993). Therefore performing a participatory role provides a learning frame within which given the appropriate context, collaborative skills can be developed, performed and care delivered at the same time.
Lave and Wenger's conceptualisation explicates student learning and participation in terms of movement from a peripheral position in the 'community of practice', to a more central role with increasing experience and knowledge. This role may be more participative but it need not necessarily be more collaborative. A second conceptualisation based on the work of Fromm, (1993, 1976) describes an existential movement towards participation based on a communal form of relationship. Fromm, contrasts acquisitive, individualism, the 'having' mode, with concerned communalism, the 'being' mode.
The engagement of medical and nursing students will therefore be considered within these two developmental trajectories, from peripheral to fuller participation in the 'community of practice' and from a 'having', to a 'being' mode of existence.
- 172 -
6.3 'Seeing' and 'doing' modes of engagement in practice Fromm, (1993) explicates learning in relation to his modes of existence. He describes the
'having' mode of learning as one in which students acquire knowledge and hold onto what they have learned but, 'the content does not become part of their own individual system of thought,
enriching and widening it ' (p: 37). The ‘having’ mode describes an essentially acquisitive social character in which tangible products that the individual can ‘possess’ are most personally and socially valued (p:76). This conceptualisation applied to professional development appeared to describe the process of much of the learning that went on in the clinical arena for both medical and nursing students. This was defined by learning at a functional level of 'seeing' or 'doing' in order to gain skills, usually involving watching others practice or carrying out a particular task, but often not engaging the student in a more participative role as an integral and valued part of the clinical community. One student nurse noted,
Critical Incident Description 36: Nursing Student: The ward had regular multidisciplinary
meetings [...] with physios, dieticians and I thought that was really good. Unfortunately I couldn’t go because as a student you’re seen as a spare pair of hands, but I thought the idea was a really good.
This excerpt exemplifies the ‘peripherality’ of the role of the student in practice in that though she participated in selected elements of care delivery there were also elements from which, as a learner, she was excluded. Lave and Wenger argue that this ‘peripherality’ is useful for newcomers as it provides them with an 'observational lookout post' (p: 95), from which they can gradually be absorbed into and absorb the culture in which they practice. This position is both empowering and disempowering. As students move towards fuller participation they become increasingly empowered although the degree of participation is limited, partly as a protective device for the student and also for society at large. As such ‘peripherality’ can be a disempowering position. The ‘legitimate peripheral participation’ concept demonstrates the finely balanced position of the student in the ‘community of practice’. The importance of moving the student towards fuller participation has implications for both the individual and the power
- 173 -
relations within the 'community of practice' and hence social engagements that create the learning structures.
Data from interviews and observations indicated that students perceived their learning needs not so much on social engagements but within more narrowly defined learning trajectories based on functional competencies. Their conceptualisation of personal and professional practice appeared to be perceived as a series of skills or experiences that need to be captured rather than an integration of values, attitudes, skills and knowledge. Evidence of the functional nature of the learning experience and the value placed by students and practitioners on performing particular tasks will therefore be provided. It will be argued that this exemplifies both a high degree of peripherality based on 'seeing' and 'doing' modes in practice and that the fragmentary and often disengaged nature of these experiences creates identifiable limitations in students' learning and limits emphasis on relationships which are fundamental to collaboration 67 .
'Seeing mode': perceived educational value of shadowing clinical practitioners The 'seeing mode' of engagement in practice was primarily defined by students either shadowing practitioners from their own or other professions, or from simply observing activity in the clinical areas, however the emphasis on interaction in such 'engagements' was reported to be minimal. Students interviewed acknowledged some value in accompanying or ‘shadowing’ other professionals but this was generally viewed at the level of useful insight or orientation. Both nursing and medical students seemed to agree that they considered ‘shadowing’ to be educationally restrictive due to lack of clinical participation, as one student described, ‘not
playing a real part’.
Medical students, for example, were actively encouraged to shadow clinicians of their own and of other professions and had extensive time to observe due to their relatively passive role in the
- 174 -
clinical domain. Nevertheless, the frequently stated view was that ‘seeing’ was of limited educational value, even when supplemented by the opportunity to ‘do’, as one student’s comments typified,
Medical Student Interviewee 4: Interviewer: Have you had any contact with staff of other
professions, physios, OTs, social workers? Stud: Yes in your fourth year general practice attachment you spend a day with the district nurse, a day with the health visitor, a day with the physio, a day with the local pharmacist. You do a day with the midwife, you see sort of all the different specialities outside or that sort of thing. Int: Did you feel that was valuable? Stud: It was but there’s no point doing it again in your final year. [...] Int: I mean what were you going to learn? Stud: You are going basically just to see what they do. Like you go sort of with physiotherapy you saw like the ultrasound and the heat they put on and just the different, you see basically when the GP writes a note to go to physio, you see basically what happens, and OT. Int: And is a day long enough? Stud: Plenty yes. Int: You said that with conviction. Stud: Well we’ve done it before, we’ve seen physios before and we saw them really quite a lot in second and third year and well when, like we spent a day in with the practice nurse and a lot of it is just routine bloods and you’ve done that before. It does no harm to do more blood pressures but once you can do it you sort of tend to be able to, you see quite a lot of wounds but you’ve seen, you can see those anywhere.
Medical students appeared to see shadowing visits in terms of gaining a snapshot of the work of practitioners that they could then generalise into a wider picture of the role of whole 67
See Chapter 2 'Nature and Meaning of Collaboration', p: 14
- 175 -
professional groups. In discussions students considered shadowing as an opportunity to see how other professions functioned but it was not acknowledged to involve engaging with other practitioners, gaining insight into their perspectives or reflecting on the impact a particular professional’s role might have on the student’s own. It also had little to do with practising interpersonal or communication skills with fellow professionals. The data suggested that the
‘seeing’ mode was generally a 'fact-finding' exercise viewed largely in terms of its direct functional utility,
Medical Student Interviewee 5: Interviewer: Have you done any shadowing of other
professionals? Stud: Yes but not to a big extent, just briefly. In geriatrics we follow the patient to physiotherapy departments and see what the patient’s actually having and things like that. Int: Do you feel it’s sufficient or should there have been more? Stud: Mm, I think it’s sufficient. At least we know if a patient has like a mobility problem who we should refer to but not great details ‘cos’ it depends if your are interested in orthopaedics because then physiotherapy and occupational therapy, it’s more relevant for your management and things like that. But if you are surgeons or whatever I don’t think physios and OTs will help you a lot.
Most student nurses described infrequent shadowing experiences, however analysis of the encounters they presented indicated an emphasis not only on the technical procedures that they witnessed but also consideration of the relationship with the person whom they shadowed. This was in part because the relationships, particularly with medical staff, appeared to run counter to their expectations. For example, a number of nursing students expressed their surprise at the supportive response from medical staff whom either they approached or the nurse preceptor approached on their behalf,
Critical Incident Description: Nursing Student: I was following a patient and I went to theatre to
see an operation. […] The surgeon was standing on a pedestal so he could see the wound and he invited me up to join him. When I got up there he showed me exactly what was going on.
- 176 -
He was very communicative. I think the thing that was important was the value he placed on me and the recognition that I was there […].He showed a real interest and gave me time. There were no barriers or hierarchy.
Another student nurse described a similarly supportive shadowing experience with a physiotherapist, in which her reflection on the relationship went beyond the technical procedures witnessed,
Critical Incident Description: Nursing Student: One of the senior physiotherapists was seeing
patients on the ward and I was asking if I could help. It was a patient I was doing my care study on, who had a CVA, so I wanted to find out as much as possible. She showed me moving and handling skills. I was observing her and she explained to me each step.
This student provided an interesting footnote which allied to the previous reference to anticipated hierarchy in the medical-nursing relationship,
'Perhaps though I felt comfortable in this situation because she was a physiotherapist and not a doctor so I wasn't intimidated.'
This finding was supported by data from the first stage of an exploratory study of an interprofessional education module for medical, dental and nursing students. Nursing students reported views of the inequality attached to their academic status that was a consequence of the perception of the 'professional' status of medicine and nursing, in which their intended profession was perceived, by nursing students, to be less prestigious than the medical profession (Reeves & Pryce, 1998).
Medical and nursing students shadowed staff but the general pattern from medical students was of limited interest due to lack of relevance to their perceived learning needs. Nursing students focused far more on the relationship and notably when shadowing doctors appeared generally grateful for the attention they received. This observation was fed back to students for comment as data collection progressed. Nursing students' explanations of their peers' responses
- 177 -
to shadowing were founded on two expectations, (a) that doctors would be either too busy to teach them, or (b) that they were 'too important'. Both these factors highlight status inequalities, between the nursing student and doctor, which Allen (1996) in her analysis of doctor-nurse relations also recognises,
'Status inequalities are […] constituted through our use of time. We make less demands on the time of the powerful, the powerless are thought to have more time on their hands.' (p: 423)
This inequality might be explained by traditional professional hierarchy or gender differentiation, both of which are closely interwoven into the medical-nursing relationship. The data did not indicate which might be the most influential factor but what was significant was that traditional perceptions of status differentials prevailed.
Medical students were generally very robust in their explanation of the limited interest of their peers, in the work of others. They frequently used the term 'arrogance' to describe other medical students' behaviour. One student described,
Medical Student Interviewee 10: Student: You cannot believe his arrogance, the way he [a fellow medical student] puts everyone down, 'Oh, I can do this […] and he just won't listen to
anyone'
Another highlighted the high expectations some medical students have of their clinical experience,
Medical Student Interviewee 2: Student: I know some people think they’re the soul of the
universe. When you go on to a ward you’re there to be 'teached' [taught] and you’re there to be, everyone should be receiving you gratefully (laughs), you know what I mean. Like everyone should be going out of their way to make sure you’re having a good time…
Observations of students in practice also supported a distinction in day to day activity of medical and nursing student roles. Both were heavily weighted towards ‘doing’ modes of
- 178 -
practice or defined tasks but medical students had greater discretion in being present or absent from the clinical arena, whilst nursing students viewed their ‘doing’ role as actual, if lowly, contributors in care delivery.
'Doing' medical and nursing work Medical and nursing students' clinical roles adopted different degrees of 'doing', essentially undertaking task based functions. The 'doing' of medical and nursing work indicated a differentiation in the roles of medical and nursing students. Medical students undertook defined tasks, whilst the role adopted by nurses was more engaged with patients and they were more likely to be seen as part of the nursing team than medical students as part of the medical team. A description of role that appear to summarise the different 'doing' modes and mirrored the roles qualified practitioners were observed to adopt, was that of 'functional visitors' for medical students and 'resident hostesses' for nursing students. The evidence to support these labels will be discussed in this section 68 .
'Functional visitor' or 'resident hostess' Typical ward activity for medical students was 'hanging around' awaiting the next learning opportunity, which when it came along comprised delegated tasks, demonstration of a procedure or observation of an activity. As they had no clear role on the ward they would also come and go largely as they pleased, often because time spent in the clinical areas competed with requirements to complete assignments. Medical students’ survival appeared to emphasise completion of assignments which student interviewees suggested were monitored more closely than time spent in clinical areas, which frequently had little structure and was consequently viewed by senior students as a less productive allocation of their effort,
68 Similar roles adopted by medical staff will be discussed in Chapter 7 ’The resident hostess follows doctor’s orders’ p: 217
- 179 -
Medical Student Interviewee 6: Student: I felt like I waited around an awful lot last year and
don’t do it so much this year, maybe that’s because you learn. You just approach it differently, you think, ‘Well, if there’s nothing happening I’ll go. I’ve got coursework to be getting on with, I don’t need to be sitting here.
Students appeared to be learning to be detached from the clinical area, attending for specific purposes, but feeling no allegiance or involvement with the wider development of the ward. This development is consistent with the 'visitor' role of medical staff observed and recorded in clinical field notes.
Another medical student identified a motivational element to the students' choice of activity, that time in the clinical areas might be preferred as an easier option rather than a valuable learning experience,
Medical Student Interviewee 7: Student: …if there’s nothing happening some people would like
you to stay on the wards, so you’re sitting around, where really you could be going away and for example working on other work. You know, like looking up things in the library or whatever, this wasn’t the case for me. When I found that we were quiet I would just disappear and do other work elsewhere and then come back, see if there was anything going on. And that’s how I worked it because otherwise you would be just sitting around doing nothing a lot of the time, which is great if that’s what you want to do.
Providing medical students turned up for certain key events e.g. ward rounds or tutorials, the organisation of their learning appeared to largely reside with them. The phenomenon of coming and going by medical students was supported by the observations of nursing student interviewees, who frequently expressed sympathy for the non-involvement of these students. They most usually described the medical student role on the wards as being 'to do bloods'. Thus in turn the student nurses begin to conceive a functional, visiting role for medical staff.
The exception from observations of medical students however was A & E where students were attached to a doctor, whom they shadowed as they saw different patients. The shadowing experience however was not one of simple observation described by students in other areas but
- 180 -
rather involved prolonged contact with a single practitioner. Students described how they would gradually start ‘doing’ more and eventually seeing patients on their own and reporting back, thus there was a degree of autonomy, responsibility and participation in service delivery. It is important to recognise that students were quite senior when attached to the A & E department, however this still contrasted with their ward-based practice at a similar stage in their programme which comprised more intermittent interventions. This pattern of shadowing also exemplifies that this form of learning need not involve the purely functional or acquisitive role described earlier but rather can involve the student, encouraging their participation in practice, and emphasises responsibility and relationships with clinical staff.
The role of the 'resident hostess' Nursing students identified that they were encouraged by university teaching staff to ‘go and
see’ what other professionals did in practice. However the emphasis in their clinical role appeared to adhere to a traditional model based on 'doing' nursing (Benner, 1984), involving
'getting the work done’, (Melia 1987) One nursing student described,
Nursing Student 4: Student: … you've got to think about nursing staff and patient care, nursing
staff are carrying out tasks' tasks and more tasks, and not building a good relationship with the patient, they've got not time because they're carrying on doing tasks.'
The following observation illustrates the typical pressure on students to go and 'do',
Observation Note: [Teaching hospital, surgical ward]: Student nurse is hovering around the
nurses' station. Charge nurse says, 'Are you not going to watch that central line?' Student nurse says, 'They said they'd give us a shout when they're ready'. The patient is currently behind the screens but she is being positioned and the procedure explained to her. Charge nurse says, 'Oh, well can you just go and help Mary with those beds ready for the admissions?'
Rather than encouraging the student to observe or participate in the procedure the emphasis resides in a culture of ‘doing‘ nursing work. This focus on 'doing' is consistent with a wider
- 181 -
agenda in health care. The UKCC, (1999: 34) 'Fitness to Practice' document, for example, acknowledges the 'lack of practical skills literacy, an inability therefore to do nursing. Similarly the government agenda for health care driven by evidence-based practice (Davies, 2000b) 69 implies that there is an objective ideal to care delivery i.e. a generalisable best way of 'doing' nursing.
Nursing students interviewed in this study generally concurred with the view that the emphasis in their training should be on 'doing' suggesting that deficiencies were largely related to insufficient opportunity to practice particular skills. The idea that ‘doing’ nursing rather than learning by observing also appeared to have been largely internalised by the senior nursing students interviewed in this study,
Nursing Student Interviewee 1: Student: There are a few students that come in and they’ll say
well, we’re only observing, we can’t do anything and they’ll try and like try that for so long and the staff do go on about them. 'Can they not just do something?' and you can see their point.
Nursing students were actively involved in the care delivery process and did not have such freedom to come and go from the ward in spite of their supernumerary status for much of their training. Also several nursing students felt a strong commitment to delivery of care and therefore tended to engage actively with the ward work rather than pursuing their own educational needs.
'Doing nursing', looking busy and learning the rules of engagement Evidence from this study indicated considerable discomfort amongst nursing students with
‘doing nothing’, a discomfort with which, in my role as researcher, I felt some sympathy 70 . Field
69 In Scotland this has resulted in a number of different bodies designed to improve clinical effectiveness on the basis of 'best evidence'; Scottish Needs Assessment Programme (SNAP), Clinical Resources Advisory Group (CRAG), Scottish Intercollegiate Guidelines Network (SIGN), Scottish Health Purchasing Information Centre (SHPIC) and Scottish Clinical Audit research Centre (SCARC). 70 See Chapter 3 ‘Role of the researcher', p: 73
- 182 -
notes on student nurses illustrate this point particularly with juniors, who appeared decidedly uncomfortable when not directly occupied,
Observation Note: [Teaching hospital, surgical ward]: A year one student nurse walks up to the
nurses’ station, then walks half-way up the ward, then returns again. She sits down on a chair and immediately looks uncomfortable - she bends down and fastens her shoelaces in turn, then unfastens them and fastens them up again. She stands up walks over to the wall and looks to be intently reading the notices. She then bends down and again fastens her shoelaces.
Another student was witnessed to make three laps of the ward in immediate succession without evident purpose but appearing to be more comfortable being on the move rather than waiting by the nurses' station for instructions. These students appeared uncertain as to what they should do and were not evidently attached to anyone from whom they could seek direction. They consequently appeared alienated from the activities of the clinical team and from social engagement.
Melia (1987) describes two important components of the student nurse’s occupational socialisation as 'learning the rules' and 'getting the work done'. Junior nursing students apparently recognised rules that prevented them from sitting down or taking themselves off the ward, but appeared to be uncertain as to what their role should be. At this stage facilitating the
‘seeing’ and 'doing' mode may be appropriate for the student who has little understanding of their role, so that they begin to develop the foundations for the ‘being’ mode. Learning the rules of engagement are necessary before a more participative and self-directed role can be developed and become integrated into a personal/professional frame,
Critical Incident Description 1: Nursing Student: This was my first ward so I was feeling like a
spare part. I had not been oriented to the ward so I didn't know what to do. There was no teamwork on the ward but rather only delegated tasks. I felt like a spare part and was just standing on the ward not knowing what to do. But I didn't know where to go or who I could speak to. My preceptor just sent me off to do things on my own.
- 183 -
More senior nursing students, who had become familiar with the ‘doing’ mode of engagement appeared to value it, providing it was consistent with their level of experience so that performed practices and self-perception of ability remained congruent,
Nursing Student Interviewee 1: Student: …a lot of the time I have noticed that we are […]
exploited. We’re not getting the chance to do certain things because the wards are sometimes short. […], sort of being used to fill gaps here and there where there’s maybe not an auxiliary on duty. I’ve noticed that in the last six months, that you are being fitted in, you know on the off duty, when there’s not been an auxiliary on and that does happen. I don’t mind coming in and getting on with it but then you sometimes think well I’ve sort of done this, like the past three years, you know, I want to be doing something, doing more I think.
This student did not appear to resist this informal inclusion in the staffing numbers, therefore in turn might be said to be colluding with the behaviour of staff and 'fitting in'. May & Veitch, (1998) describe such actions as strategies of trading their labour for learning opportunities but this may simply be easier for the student. However, one nursing student did emphasise the importance of 'give and take' in clinical learning, finding a balance between the need to provide care for patients and her own learning needs.
This idea of being used as a 'pair of hands' was a recurrent theme amongst nursing student interviewees, who often felt that the ‘doing‘ of nursing meant that they were delivering care but not fulfilling a complete nursing role,
Critical Incident Description 26: Nursing Student: The nursing staff are split into two teams on
this ward, so I was working with a staff nurse. I was behind the curtains with a patient and when I'd sorted him out I came out and she [staff nurse] wasn't there. So I carried on and ended up preparing all the patients. I had to find another student to help me in the end.
The language here highlights the danger of the 'doing' ethos. The patients are referred to as commodities or objects that have to be 'prepared'. One witnessed episode highlighted this objectification of a patient in practice.
- 184 -
Observation Note: [Teaching hospital, medical ward]: A student nurse is feeding breakfast to a
fairly moribund patient who is sitting in an armchair. The student looks bored and flicks through the patient's care plan and occasionally stares very intently at the patient who makes no eye contact. There is no communication between them, only occasional touching of the patient's mouth to make her open it for another spoonful. After several minutes when the lady has refused to open her mouth again the student sighs and gives up.
One may be critical of the nursing student's treatment of this patient as an object but this might be argued to parallel with a description amongst students that they too were treated by some staff as a commodity,
Nursing Student Interviewee 3: It's not being part of it that I really hate. There are times when
you're working on the ward and older staff will refer to you as 'the student'. Not by first name, but just get 'the student' to do it.
These findings were supported by observational field notes, which recorded potential inhibitors to collaborative development. Nursing students had high levels of involvement with direct patient care and low level of involvement with the running of the ward and as a consequence limited opportunity to interact with medical staff. This was largely because nursing student activity of 'doing' nursing work centred on bays delivering direct patient care whilst medical staff spent most of their time at the doctors’ desk or as ‘functional visitors’ seeing patients for brief intervention-based interactions. Nursing students' working space created a professional distance and limited contacts that might have helped to overcome some of their fears of the medical profession.
Responses to the 'functional visitor' role and impact on learning Medical students’ appeared to cope with their lack of activity in a number of fairly typical ways, regardless of the clinical area to which they were ‘attached’. Observed strategies included congregating in small groups to chat if other students were present, sitting in the staff room or doctors' room if available, awaiting direction, or leaving the ward area. Ultimately all these
- 185 -
actions appeared to result in the same outcome, as one medical student described, to make the student ‘invisible to clinical staff.’
Medical students’ learning opportunities based on occasional functional interventions, the ‘doing’ mode of learning was also consistent with the objectives identified explicitly within the medical curriculum. This adopted ‘procedure check lists’ as both a form of assessment and a tool to direct the learning of students in the clinical area 71 ,
Medical Student Interviewee 5: Student: …we usually have a procedure check list that we need
to sign up and before I start the block I will just look through the procedure check list, I just circle those that I can, I will have a chance to do during that placement. Therefore delivery and things like that we definitely need to do it in the O & G, you can’t do it in the medical, can’t do it in surgery so, yes, do you get what I mean?
Consequently medical students often evaluated the quality of their learning experiences in terms of task availability,
Observation Note: [Teaching hospital, surgical ward]: A female medical student arrives on the
ward -she stands at the doctors' desk behind a doctor who is reading a set of notes. The doctor leaves and the student sits down. A second female student arrives and they both sit and chat. One student says ' Nothing happening here?' The other student replies, ‘Not even any catheterisations today.' First student, 'Its' been like this all week'.
Although the procedure check-lists provided explicit direction for the student on learning objectives and were observed with some envy by one nursing student interviewee, they also highlighted a situation in which clinical areas often failed to provide the opportunities that the
'doing' oriented students felt they required. One medical student reported, that the result of limited task availability was the creation of a competitive culture, a struggle for practice with fellow students,
71
The effect of different forms of assessment on participation is discussed in Chapter 4, ‘Monitoring and assessment of
clinical practice, p: 127.
- 186 -
Medical Student Interviewee 6: Student: ...when there’s so many people there’s less work for
you to do, there’s less experience for you to get and when you’re having to struggle over who’s going to do the next bloods […] you lose out in that way I think, you don’t get as much chance to practice.
Two students who I came across sitting in a ward staff room, as they described ‘killing an hour
between tutorials’, identified competition between medical students for blood taking, putting in Venflons and clerking and with nurses for urinalysis, urethral and throat swabs. They suggested that it was usually through approaching nursing staff that they got these 'jobs done' and the nurses would then 'sign them off'. Thus the ‘doing’ did create a need for interprofessional contact in order to acquire skills and it was possible for nurses to act as gatekeepers to learning opportunities.
Despite the difficulties of gaining clinical experience and the focus that medical students had on tasks, largely to the exclusion of all else in the clinical domain, there is support in the medical education literature for the task-oriented approach to clinical medical education. Harden et al., (1996) propose that an approach to learning based on task achievement provides a useful trigger for wider learning. The reality from interviews and observations would suggest that the pursuit and provision of evidence of successful completion of the task for these students became an end in itself,
Observation Note: [Teaching hospital, surgical ward]: Two medical students approach a staff
nurse on the ward. She says can you hang on ‘til I’ve put this away - she returns and one medical student says, ‘Can you sign this, it’s a note to say that we’ve taken a history’, The staff nurse asks, ‘Am I supposed to read it?’ [procedure book]. The medical student replies, ‘No, it’s just to say we’ve been here.’ The staff nurse signs the form.
Students valued the explicit nature of skills acquisition and the ‘seeing ‘ and ‘doing’ modes of learning as a route to achieving learning objectives and developing clinical confidence. They also reported not feeling useful or involved with practice delivery. Nursing students were actively involved in 'doing' nursing work but the result of this was that they considered
- 187 -
themselves as a 'pair of hands', delivering care but limited participants or exponents of the wider role of qualified nurses and often with minimal contact with medical staff. In recognition of their fears, and expectations of doctors as self-confident, intelligent and potentially threatening this limited contact is of concern as experience was not available to dispel these perceptions.
The next section will present data of more integrated or ‘holistic’ approaches to professional role development presented by some students that might more appropriately be encompassed within the ‘being’ mode of learning in practice.
6.4 'Being' mode of engagement in practice So far what has been described in the ‘seeing’ and 'doing’ modes of learning in practice is predominantly functional and fragmentary selection of learning experiences, within the
‘community of practice’, by medical and nursing students. This approach conflicts with the mode of ‘being’, which Fromm, (1976) argues requires integration of knowledge involving activity. Not simply busyness, but also inner activity or reflection on practice. This inner ‘activity’ may not have any ‘product’ in the sense of tangibly, measurable outcomes or 'work' and is therefore problematic to witness directly from the data given in the following section. What is inferred in this section is evidence of the ‘being’ mode of learning based on observations and interview data, that will be argued to provide a more holistic link with clinical reality and thus create a more integrated context for preparation for collaborative practices.
Group effectiveness has been recognised to require a reflective approach in order to understand and respond to objectives, strategies, processes and the organisational and wider environments (West, 1999). The notion of reflexivity is central to the ‘being mode’ of learning in which students are no longer passive receptacles of what they hear and see but actively engage with the learning process. Engagement in learning appeared to be influenced at the individual, interactional and actional level by a number of different factors. These factors primarily centred
- 188 -
on a more holistic, involved, or participative role in clinical practice. Harden, (1998a) described this as ‘transprofessional education’ (See Appendix 11) in which students are prepared for practice through participation in 'real-life' settings. The outcome of such a participative role described by students was the creation of contacts 72 , and; feeling both valued (externally generated) and valuable (internally generated) in the clinical domain 73 . Consequently the 'being
mode' of practice founded on participation and engagement in practice is argued to provide greater collaborative potential than other forms of engagement.
This section will therefore explore the engagement of the student in the learning process, the relationship with the mode of 'being' and the relevance of the concept to preparation for collaborative practices.
Participation and marginalisation in the clinical team In the data in this study instances and experiences which were often most highly valued by students involved direct participation and feeling of inclusion in the work context. This was the most commonly cited theme of the critical incident interviews in which students were asked to describe positive collaborative learning or working experiences. Students described actually participating in care in more egalitarian, relationships with clinical staff through which they gained first hand experience of collaboration in action, learning and performance at the same time. The organisation of medical students' attachments which were of generally short duration resulted in limited time to establish relationships 74 , however they described experiences in which their participation was encouraged,
Medical Student Interviewee 5: Student: …in hospitals […] during a ward round, depends on
the teams some of them are very good and some are not. For the good teams they […] ask you to participate in decision-making and what we would do for this patient and what if, and things like that.
72 73 74
See Chapter 8, ‘Contact between participants’ p: 251 See Chapter 6, ‘Feeling valued and valuable as a person’, p: 194 See Chapter 4
- 189 -
The notion of inclusion was central to enabling students' adoption of a 'being mode' of engagement through their perceived personal value, as a result of becoming part of the team with a useful contribution to make. Data indicated that this response was facilitated by a supportive relationship with one individual or a well-planned and progressive educational experience appropriate to the particular students’ needs. A nursing student described her encounter with a consultant surgeon,
Critical Incident Description 39: He treated me as if I was one of the team, as if I was one of
the staff nurses. He appeared genuinely interested in what I thought.
Another nursing student in a care of the elderly setting described a progressive process of engagement in the delivery of care,
Critical Incident Description 41: …everyone worked together and you had your own patients to
look after. […] For the first day I followed my preceptor around. On the second day I followed one patient for the whole day to all the areas. By the end of the week you were really well orientated, you knew your way around and knew all the staff […] The philosophy was get stuck in so that you learned to do. But it was well planned so you felt they wanted you there.
Conversely students described instances where there were strong feelings of exclusion, however such instances were interchangeably cited with reference to both intraprofessional and interprofessional relationships. For example, one student nurse was critical of her nursing colleagues,
Critical Incident Description 43: We were there just to do odd jobs, there was no teaching and
we weren’t included in anything. In then end it just became easier to keep our heads down, so we sat around in the day room.
Issues of collaboration are not therefore simply about interprofessional working, but of relevance to all interactional encounters in and with the ‘community of practice’.
- 190 -
'Invisibility' of medical students Medical students' descriptions of feeling largely 'invisible' meant that rarely were they able to give examples of close participation with the clinical team, with the exception of general practice where senior students often saw ‘their own patients and participated in team
meetings’. Intraprofessionally medical students involvement with senior medical staff was frequently observed and described as ‘attachment’ to a large entourage of clinical staff on ward rounds, or in formally delivered tutorials. Students identified more positive experiences with junior medical colleagues, with whom they felt more comfortable 75 .
Critical Incident Description 6: Medical Student: The level of doctor I was working with was
important because as they were more junior you can be more helpful and they need you more. Also JHOs are more helpful because they're more at your level.
Interprofessionally on the wards a number of students highlighted that rather than inclusion in practice there was an animosity that prevailed between medical students and nursing staff,
Medical Student Interviewee 2: Student: Before I came here, my aunt, she’s a nurse. she says,
When you’re on placement, the nurses they all feel sorry for you and they feed you and stuff. No they don’t not at all - they can make life really unpleasant for you.
Another student described the problems of inclusion whilst performing a junior role,
Critical Incident Description 3: Medical Student: I was working on the ward and I was asked by
the JHO to go and get some discharge forms. I went to get them and the sister just started shouting at me. Who was I and why didn’t I ask where things were. It was a case of shooting the messenger. After that I realised what she was like and made sure I avoided her. She just didn’t seem to like junior doctors. She was a different person with more senior staff. It was lack of respect, she just didn’t seem to have any respect for junior doctors and seemed keen to give them a hard time. That sort of attitude isn’t going to get people working together.
75
See Chapter 5, ‘Junior house officers as supervisors’, p: 147
- 191 -
There was no evidence from the observational data of overt unpleasantness towards medical students by nursing staff but I used this scenario in a seminar on collaboration with a group of third year medical students. The strength of feeling was striking with a high level of concordance with such an experience being expressed. The observational data may have been influenced in part by my presence, however my observation did support the contention that students were excluded by virtue of their 'invisibility' to nursing staff, an experience that some students might have considered equally discomforting. Another medical student described the marginalised role, in which students find themselves in clinical practice,
Critical Incident Description 2: Medical Student: Often as a student you just don’t know whether
you should get involved or not. Your just expected to hang around and if somebody wants something you don’t know whether you should respond or let somebody else.
The description provided by medical students suggests a situation of being on the outside or at the periphery of the clinical team, consequently limiting the interactions to which they are exposed and the degree to which they participate.
- 192 -
Medical student responses to their marginalised team role Responses to this marginalised position of medical students appeared to result in four levels of engagement within the clinical context. I describe these under the following headings, which represent a series of progressive stages towards the 'being mode' of engagement 76 :
•
Avoidance - in which students minimise contact with clinical areas and staff within those areas primarily by absenting themselves; this might be argued to increase the detachment from the clinical team;
•
Strategic-orienteering - in which students try to understand 'the rules' by standing back, observing but being overtly friendly to everyone with whom they had contact.
•
Peripheral engagement - in which students model the 'blinkering' behaviour 77 of their qualified colleagues in which certain 'players' in the clinical arena become 'invisible'. This required students to have an understanding of 'the rules' and was therefore exclusively adopted by senior students who had an understanding of who were the central players in the team. The ‘peripherality’ of their role was maintained by them being 'blinkered' by others as a consequence of their student role;
•
Full engagement - no longer a marginalised position in which staff accepted them as a full participant 78 in the clinical team and represents the actualisation of the 'being mode' of engagement in practice.
These responses appeared to be influenced by a number of factors, which included response from staff, duration on the ward, stage of training and personal. Thus at the extremes medical
76
This is not to imply that a student will necessarily move through these stages, they may actually adopt one or more strategies for managing their relationships, however this sequence provides a framework for evaluating stage and progression 77 'Blinkering’ behaviour was an observed response to avoiding making contact with others and is discussed in Chapter 8, See‘Clinical blinkering: a response to busyness’, p: 238 78 In an absolute sense there is no such thing as 'full participation' as this implies some definable participative centre to the 'community of practice'. However 'full participation' represents a stage where the learner feels that they have transcended their student status, to quote a number of nursing students, a time when everything 'just clicked' and they became equal contributors with qualified staff in the care delivery process.
- 193 -
students appeared to adopt an approach within which they either engaged with or avoided close participation with clinical colleagues.
Nursing students' exclusion by medical staff Nursing students inhabited a less marginalised position due to their having a more defined role on the ward, however most interviewees described exclusion by medical staff, thus inhibiting collaborative working or the capacity to 'be' engaged team players. Some nursing students adopted the avoidance strategy described above and a number of interviewees also described their 'invisibility' to senior medical staff,
Nursing Student Interviewee 1: Student: ...in certain places that you go consultants won’t even
look at you, won’t even acknowledge that you’re there.
This was a problem particularly for senior nursing students who felt it left them unprepared for working with medical staff in their soon to be qualified role,
Critical Incident Description 65: Nursing Student: A doctor wanted to go round and he asked
me for a staff nurse. He obviously didn’t want me to go round because I’m only a student. I’ve only just arrived on this ward so I wouldn’t have been much help, but this happens all the time and now I’m in my third year, I’ve been excluded from a lot of things and you start to feel stupid asking because you feel you should know by now. But if you haven’t had the opportunity, been made part of things and been involved, then how can you?
Exclusion of students from performing a fully participative role was considered to inhibit students’ opportunity to practice to the level for which they were being prepared. What was also reported frequently from both medical and nursing student interviews was the feeling of value that inclusion generated, a facilitator of the 'being mode' of engagement that that appeared to enhanced the collaborative performance and learning potential.
- 194 -
Feeling valued and valuable as a person Throughout the data student interviewees raised issues relating to their relationships and experiences with others in which they felt valued by others and valuable for the contribution they made to care. At its most effective this appeared to involve the disappearance of the student-qualified staff division in favour of mutuality, working with a common purpose, a response that has been argued to best facilitate the 'being mode' of engagement. Whilst data to support this contention exists throughout the analysis I considered that specific examples should be provided to support the value that students ascribed to their involvement in care delivery or 'full participation'' 79 in the 'community of practice' (Lave and Wenger 1991). One nurse explained,
Nursing Interview 5: Student: This has been the best ward I've been on. I think its because I'm
further on in my training and about to sit my finals. You feel totally part of the team and you're given so much responsibility, which is good. You feel like a proper member. A number of nursing students described a time when everything 'just clicked' in which they felt involved, and their learning was no longer a series of learning episodes but rather directly relevant to the role for which they were being prepared'
Nursing Student Interviewee 9: Student: You know, I hadn't joined it [learning] all together and
then all of a sudden it just clicks and it's brilliant because you know exactly what you're doing.
Contrasting 'participation' in the medical and nursing student role The notion of integration or 'full participation' was not an idea presented by medical students, indeed a number of students suggesting that they did not really know what was expected of them when they qualified. The closest they came to total role performance was in the PRHO shadowing experience on the wards that they would subsequently work. Discussions with medical students often indicated that they didn't reach a state of completion or feel prepared,
79
Refer to footnote 95 for clarification of idea of ‘full participation’
- 195 -
however when this was probed further they usually related this back to insufficient practice of technical skills.
Changes in nursing education have removed nursing students from the staffing establishment, with the exception of the last six months of their training, however it was in that final 'rostered' period that their 'full participant' status was achieved. This state appeared important for their self-perception of themselves as 'being' nurses and becoming one with the 'community of
practice',
Nursing Student Interview 5: Student: .. because I'm rostered now, that's probably why I feel
more of the team […], you know because you're classed as one of them and not just an extra. For one student this integration into the ward culture related to her knowledge of routines that, whilst arguably giving her a degree of power, also made her feel useful. At the same time as feeling part of the team she still recognised some distinction, in relation to the hierarchical structure due to her student status,
Critical Incident Description 6: Student: The JHO was new to the ward. She had not been
oriented so could not find her way about and therefore needed to ask staff for direction and guidance. The JHO approached me to ask advice on how to complete some paperwork. It was being asked something that was so good. The practicalities of ward work hadn't been covered in her training so she was having to ask. I think she came to me because the trained staff treat new medical staff badly. I was being seen as part of the team but different, somebody she could approach.
No such period of ‘rostered’ service exists for medical students, although the pre-registration year post qualification may provide some equivalence. However at this stage the student has become a doctor and the literature suggest often receives little support in fulfilling the demands of their new role (GMC, 1993). The JHO in the example above perhaps recognised the transitional stage of the pre-registration year and therefore continued to feel some allegiance with the nursing students. One medical student's comments highlight some of the frustration of
- 196 -
this transitional stage, when they consider that they should have become a useful member of the team others inhibit their playing out of what they consider to be their role or 'function',
Medical Student Interviewee 2: Student: …they don’t make their junior staff as welcome and
perhaps don’t give them as much responsibility . Er, like I just spoke to one of the JHOs who’s just finishing and they said ‘If you’re on Ward XX it should be the JHOs who should be clerking the patients in, not the SHOs and then telling the JHOs. So they’re not having responsibilities, they’re acting more like secretaries. The SHOs coming in telling the JHOs, ‘This is the diagnosis, this is the management, this is the test you need to do’, and so that’s how all the bad feeling arises. Interviewer: So the JHOs really just a functional job, do this, do that, do the other thing? Student: Yes, yeh. Interviewer: Without having to think about it? Student: Yes, exactly. And so when they start their senior house officer, that’s when they really do start practising and then they start from the beginning anyway because that’s when they start their training, if you see what I mean.
'Busyness' and feeling valued Situations in which both medical and nursing students appeared to feel most valuable were often when little time was available to support and integrate students but when they were given responsibilities that challenged them due to demands of workload. One medical student described a situation,
Critical Incident Description 6: Medical Student: There was a real lack of medical staff to cover
the unit so I was helping out, doing admissions and bloods and things. I really felt like part of the team working like this with the JHOs. They gave me confidence because they were relying on me. We could all work together to get the job done and that was very satisfying
A nursing student expressed similar feelings of involvement,
- 197 -
Critical Incident Description 26: Nursing Student: We were working one night and it was really
busy and it was just me and two students on my part of the ward. I was the most senior and they were asking me things, but there was no hierarchy. It was good fun and relaxed. It's just so good to have some responsibility but also feel part of a group that's working well together.
This student recognised the value of having responsibility whilst feeling she was contributing some thing to the care of patients. During my supervisory experience one of the supervisors (HM) expressed her experience of research students in two groups, as 'radiators' and 'drains'; students who shared and gave something back to the relationship and others who simply took from it. The 'having' mode perhaps expresses best the 'drain' and the 'being' mode, 'radiators'. Perhaps what students are expressing here is the reward that they gain from being able to give something back to a context from which they are constantly taking for the purpose of their learning. Thus whilst students must take from the clinical context in order to learn through observation and practice, perhaps the greatest learning reward is where they can also 'radiate' or give back something in the learning process. This was expressed by a number of students in relation to one-to-one encounters they had with clinicians in a learning relationship in which they felt valued and their views and experience were also valuable. This notion of giving back to others and sharing would seem to be fundamental to the process of collaborative practices and encapsulates Fromm's concept of ''being' 80 .
This section highlights that excluding students from practice has a compounding influence in that they may begin as one student described, to ‘keep their heads down’ or actively avoid clinical staff. Such a response would appear to be counter to collaborative development. Students are consequently unable to or discouraged from role rehearsal for the professions for which they are being prepared. This was not the experience described by all interviewees but what was particularly striking from the observational data was the lack of interaction between medical and nursing students and practitioners of other professions. Thus if opportunities for contacts are not available to students due to avoidance of, or non-inclusion in, the practice 80
As discussed in Chapters 2 and 5
- 198 -
setting, then preparation for becoming part of the clinical team or practising collaboration in action, is likely to be inhibited.
6.5 Summary The aim of this chapter has been to sensitise the reader to the different modes of engagement in practice and to indicate some of the factors that may be influential on learning and collaborative possibilities. Broad trends in professional education are indicative of more integrated forms of learning and moves away from disciplinary purity which is argued to limit understanding of the complexities of practice. Such trends also represent a move to link more closely both concrete and abstract ideas in the pursuit of learning relevant to practice. However learning based in practice and based on participation ultimately provides the context in which the relationship between concrete and actual practice can actually be realised. This Chapter emphasises the importance of considering how students engaged in or participated in practice.
In the clinical domain students engaged in practice in three different ways, 'seeing', 'doing' and
'being'. Different patterns were evident in data from medical and nursing students, indicating the former was largely founded on seeing' and intermittent 'doing', whilst the latter emphasised heavily the value placed on 'doing' nursing and nursing students played a more evident role in care delivery. Thus the 'fullness' of their participant role created different perspectives and was likely to generate different interpretations of role and a range of responses by students.
The 'being' mode in which the student actively participated in the clinical team appeared to provide the most favoured mode of engagement. Students were provided with the opportunity to become involved in the care of patients and their inclusion made them feel valued and valuable. However, the participative role was influenced by a range of factors. It is these factors that will provide the substance of subsequent analytical chapters.
- 199 -
CHAPTER 7: THE CLINICAL TEAM: PARTICIPATION, HIERARCHY AND MEMBERSHIP 7.1 Introduction The most frequently cited method of enacting collaborative care in the clinical arena is founded on the concept of 'the team' (Miller et al., 1999, Opie, 1997; West, 1999). This Chapter illuminates the context in which students’ participation is enacted or enabled, in which they have the opportunity to learn and perform collaborative practices, to become of part of 'the
team'. As the descriptions will demonstrate, this is not simply the individual student developing, practising or participating in skills performance. It is also about role interpretation and meaning based on social, historical and cultural legacies of the medical and nursing professional relationship, which has emphasised hierarchical, intellectual and gender divisions. The proposition underlying this Chapter is that if this legacy is understood by students, practitioners, educators and even patients then its influence may be acknowledged, providing a basis for renegotiations relevant to the needs of a prevailing health care climate based on closer working relationships.
The Chapter therefore includes a brief review of the historical doctor-nurse relationship to illuminate the legacy that weighs heavily on practitioners' development of collaborative working practices through its influence on the participatory process of role enactment. The Chapter draws on ward rounds as a rich exemplar of role differentiation in practice, considers the changing nature of doctor-nurse relationships and briefly examines position of the patient in the collaborative process.
7.2 Overview of the doctor-nurse relationship The relationship and subsequent potential for collaboration between individual practitioners working in the team context cannot be understood without appreciation of the historical, cultural and social differences that exist between the medical and nursing professions. This is a
- 200 -
complex context into which students are being socialised and illumination of some of these factors might aid the interpretation of the team function and the participatory roles adopted by practitioners and in turn students.
Davies et al., (2000) in a commentary on doctor-nurse collaboration identifies that,
'Individually, nurses and doctors may strive to overcome the lingering images of their
professions, but there is a weight of tradition, including a tradition of gender thinking, to contend with. Nursing is no more conducive to collaborative working than is medicine. Both need to change if a collaborative model is to work.' (p: 1022)
Davies et al’s assertion is supported by a wealth of literature on the relationship existent between doctors and nurses, (Porter, 1995, Mackay, 1993, Allen, 1997, Wicks, 1998). Much of the literature emphasises the differences of power, gender, status and financial reward between these two closely allied professions that militate against effective doctor-nurse collaboration (Finlay, 2000a, Dingwall & McIntosh, 1978). Indeed, Mackay, (1993), following a study of doctors and nurses working together in hospitals, recognises the considerable differences and in describing the professional relationship proposes that,
'…their worlds are so dissimilar that it is surprising that so much common ground has been
established in day to day working relationships.' (p: 40)
Analysis of this relationship has focused on a range of different factors and has changed over time as will be outlined.
The 'doctor-nurse game' Perhaps the mostly widely cited analysis of the relationship between doctors and nurses is the work by Stein, (1967). Stein described the relationship as an oft cited, complex 'doctor-nurse
game' which retained the dominance of the doctor whilst enabling the nurse to covertly participate in decision-making, the cardinal rule being to avoid open disagreement. In a
- 201 -
reflection on their earlier study in a subsequent paper almost a quarter of a decade later, Stein et al., (1990) identified certain significant changes in the doctor-nurse relationship that had occurred in the intervening period,
•
Nurses want more autonomy and to be seen as equal with other members of the multidisciplinary team;
•
Nurses have a vehicle for change, the different nature of nurse education and socialisation emphasising collegiality rather than hierarchy;
•
Nurses feel freer to challenge and were able to make more decisions without consulting with medical staff
•
Doctors feel betrayed, angry and puzzled as they have not perceived the relationships as hierarchical in the first instance (though Stein et al propose that those in power often never realise the oppression their position imposes).
Stein et al (1990) asserted that doctors were unhappy with these changes considering that they were indicative of nurses who no longer wished to nurse, preferring nurses who cheerfully did as they were told. The suggestion appeared to be that a fundamental attribute of nursing, from the medical perspective, was doing what you were told. A characteristic that would appear counter to the development of collaborative practice.
Negotiating doctor-nurse boundaries Changing the relationship between doctors and nurses consequently requires a radical reform of the historical positions. Allen, (1997) analysed the doctor-nurse relationship, exploring the changing boundaries that the conditions described by Stein create, as nurses move into areas of medical work that were traditionally the sole domain of doctors. This situation, she argued was likely to create an increased need for inter-occupational negotiation due to associated tensions as staff and patients redefined their different roles. However, her clinical observations although limited in scope revealed little evidence of the tensions one might expect from change.
- 202 -
Allen, (1997) proposed that social mechanisms are in place which largely retain the traditional order of health care delivery whilst recognising that nurses participate in medical decisionmaking to a degree that belies their position in the prevailing, formal organisational hierarchy.
However as the health care arena becomes more complex and roles are redefined the definition between medical and nursing territory becomes more blurred. In such a situation, Maines & Charlton, (1985) argue, is created both the context and need for 'negotiation' between the professions,
'…when rules and policies are not inclusive, when there are disagreements, when there is
uncertainty, and when changes are introduced.'
Svensson, (1996) describes the consequent relationship between doctors and nurses as a
'negotiated order'. Strauss et al., (1963) first introduced the term 'negotiated order' to describe the dynamic flux of social order within psychiatric institutions. Subsequently this term has been used to describe the constitution of social order and negotiated interactions that take place in a number of different contexts e.g. prisons, (Thomas, 1984) and clinical teaching in nursing (Paterson, 1997).
Svensson proposed that the term 'negotiated order' provided a more appropriate means of understanding the interaction between doctors and nurse on wards than the traditional doctornurse game (Stein et al 1967). Stein et al’s views have been challenged in a number of papers. Hughes, (1988), for example, identified that temporary or situational factors occur in the practice setting which elevate the power of nurses, whilst Porter, (1995) suggested that doctors are not always keen to dominate and nurses frequently openly attempt to influence decisions. Some of these ideas are recognised in Stein et al's re-visitation of the ‘doctor-nurse game’. Rather than doctors and nurses playing some defined roles in a 'game' their relationship is in a constant state of flux over 'territory' and the 'separateness' of their roles (Paterson, 1997). Within this conceptualisation therefore the capacity of individuals to 'negotiate' with others will
- 203 -
be fundamental to the development of a collaborative relationship (Kyle, 1995). However a number of factors are identified in the literature that will influence the relationship and the consequent negotiating positions.
Hierarchy, gender and the professional relationship Wicks, (1998) argued that the dominant factor in the doctor-nurse relationship remained hierarchical differentiation. She asserted that there is a need to question the acceptance of the current divisions of labour in health care, which she claimed to be based on 'a nineteenth
century conception of master/servant gender appropriateness'. Whilst she acknowledged that this may be masked beneath a social context in which respect and politeness smooth inequitable relationships, she suggested that these divisions segregate health care with the medical problem dominating all other aspects of the patients life. The outcome of this situation she described as,
'... the relationship based on a division of knowledge, power, and authority, which constantly
threatens to overflow and to bifurcate the essential experience of being sick and wounded or dying'.
In analysing conflicts between doctors and nurses many identify the influence of gender in which nursing has historically been female, and medicine male, dominated. Although changing gender socialisation is beginning to erode the influence (Johnson, 1992), Carter, (1994) predicts that increase in the number of male nurses is unlikely to change nursing being defined as woman's work, unless men abandon their dominant positions and women stop upholding the position. Davies, (2000a) suggests that gender, the male gender, is so intimately bound up with the ideal of professionalism that only by reconsidering professional identity can a more equitable relationship prevail,
'They [nurses] serve as adjunct to the medical profession in its operation of the gendered
professional ideal. In an overall process of healing, they integrate caring with curing. In doing
- 204 -
so they help to reproduce the traditional professional identity for the doctor because that identity can be sustained only if his or her encounter with the patient is a fleeting encounter.' (p: 349)
Davies' proposition is that the alienation and objectivity of the doctor can only be sustained by the professional detachment that the nurse allows him to retain. This resonates with the role of the doctor as 'functional visitor' and nurse as 'resident hostess' 81 , a role differentiation founded on historical gender differences and hierarchical inequalities that has evident implications for realising collaborative relationships.
Power and the doctor-nurse relationship Henneman, (1995) proposes a post-structuralist analysis of the medical-nursing relationship to illuminate the barriers to collaboration created by the educational and socialisation processes, with power as a dominant feature. Drawing primarily on the work of Foucault, (1975), Hennemann argues that it is forces outside of particular disciplines that affect their development and subsequent relationships. In particular she recognises the wider social changes that have influenced thinking about power and knowledge in medicine and nursing.
Foucault argues that power and knowledge are two concepts that are inextricably bound. Henneman proposes that the control of scientific knowledge by medicine has created problems for collaboration. However the power created by this knowledge is not, within Foucault's conception, resident in particular individuals i.e. individuals do not 'have' power, but rather 'power' is a strategy that may be exercised rather than possessed. Thus if power is not fixed but rather can be influenced by individuals the opportunity for shared power based on individual relationships exists. Changes however require healthy self-esteem, mutual respect and professional confidence as empowering characteristics in the promotion of collaboration as individuals realise their own potential to redress the 'exercise' of power imbalances (Kyle, 1995).
- 205 -
Wider social changes, in particular changing power relations between medicine and nursing influenced particularly by the professionalisation of nursing and achievements of feminist occupational sociology (Porter 1995), have resulted in a gradual transition in the power relations. Porter, (1995) acknowledges that this has in part been influenced by the 'usurpation
of previous medical monopolies, and exclusion', utilising such practical strategies as the nursing process to create diagnostic and prescriptive systems independent of medicine.
Porter describes four idealised interaction types which whilst defining changes in medical and nursing power relationships identify it to be an oscillating process influenced by the interactive approach adopted. It is therefore influenced by contextual and individual characteristics. These interactive 'types', Porter describes as:
•
Unmitigated subordination - the evident superordination of doctors and subordination on the part of nurses;
•
Informal covert decision making - the playing of the doctor nurse game described by Stein (see above) to maintain the traditional order;
•
Informal overt decision making - recognising the considerable decision-making influence of nurses in informal interactions (Hughes, 1988), and
•
Formal overt decision making - in which nurses have legal status for nursing diagnosis and prescription involving an identifiable body of 'nursing knowledge' through which they can exercise power.
Porter recognised, in his ethnographic study, that each 'type' of interaction was evidenced and that change in medical-nursing relationships was occurring over time,
'there was evidence that power relations between nurses and doctors had altered in favour of
rational dialogue, at a cost to discourse based upon the unquestioned power of doctors. However, whilst nurses felt more able to make their voices heard, their position was limited by the power that remained in the hands of their medical colleagues.' (p: 183) 81
See Chapters 5 and Chapter 8
- 206 -
However the wording of his ideas suggests an arguably more traditional perspective on power as something that medicine inherently 'has' rather than the Foucauldian view of one which it has learned to 'exercise'. This position of medicine 'having' power appears to be supported by Mackay et al., (1995) who propose,
'The facts of life must not, however, be ignored. The dominant occupational group in the
provision of health care continues to be the medical profession. It is doctors who retain final and legal responsibility for patients. Doctors enjoy undoubted supremacy in the management and direction of the health care team. Without doctor's goodwill to listen, the contributions of other professionals can be marginalized.' (p: 8)
This statement contrasts with the vision of the future proposed by Peckham, (1998) who recognises a problem inherent within the current medical structures, that might undermine the supremacy of doctors’ position in the health care social order,
'The UK method of organising hospital-based medical staff into consultant firms encourages
isolation both of medical decision making and of support when something goes wrong.'
Peckham proposes that the power balance in health care that has historically favoured medicine, power that has more currently been socially sanctioned and derided, will be redefined through 'clinical governance'. He suggest that senior doctors’ performance as advisors, teachers and mentors will be assessed by junior medical colleagues and by non-medical input, with assessment based not only technical competence but on 'the quality of their relationships with
patients and other staff.' Current professional policy on the revalidation of doctors by their own professional body appears to support this contention (GMC, 2000). Thus, to return to Foucault's contention, nurses may come to realise that doctors have exercised power but it is not something that they inherently have, and therefore can be shared.
Despite wider social and professional changes the literature indicates that the relationship between medicine and nursing is founded on a long historical legacy influenced by such issues as education, status, gender and power and the investment of society in its individual health via
- 207 -
medicine. It is into this cultural maelstrom that teams must emerge, students must become participants and collaborative practices develop. The perspective students provided on the clinical team and the relationships witnessed constitute the next section.
7.3 Nature of the Clinical Team Extensive literature was evident in the literature of the link between collaboration and teamwork, therefore student interviewees were all asked directly in interview if they considered that patients would perceive health care staff working as teams. The response to this question was broadly affirmative by both medical and nursing students. All the interviewees linked teamwork, founded on good communication processes, as essential to quality of care delivery. Positive descriptions of teamwork were most frequently reported by interviewees in general practice or community experiences, in part due to the overt group contact, which was less evident in the hospital context
Medical Student Interviewee 2: Interviewer: …where have you seen teams, groups of people
working particularly well together? Student: (…), general practice especially, because you have your GP and you have your district nurses (…) I mean they communicate with things like physios and stuff as well, social work department as well, depending on the problems of the patient (…) What I've seen so far it's, general practice is more organised, it has team meetings. I've actually been to meetings where all the different parts of the team have been there. I mean I'm sure it happens in hospital but I never saw it and we've never been asked to go along to any of the meetings. If we see any professionals in the hospitals we see them on their own and maybe go with physios for a day, the OTs for a day. I've never seen them all kind of meeting up and saying 'This is what we do for the patients', or 'This is what I'm doing, how could we be changing to make it better for patients'. Whereas I see that all the time in general practice.
Another area that was singled out for recognition of its teamwork by interviewees was psychiatry. Support for the observation was again based on the regularity and the style of multiprofessional meetings, which were described by a number of students as 'relaxed', or
- 208 -
'informal'. Descriptions by students of the mental health arena also appeared to be exceptional in the inclusion of patients and family in team meetings.
One medical student described the oncology unit as team-oriented in its approach, a factor that she assigned to regular contact due to the prolonged close proximity created by the organisation of the oncology service. This student also commented on the importance of the reception and secretarial staff in making her feel included in the clinical team. Observational field notes identified that they had an evident role in enhancing the atmosphere of inclusivity, by acting on occasions as an interface between the ward staff, ward visitors and students and often being on first name terms with senior nursing and medical staff 82 .
I had personal experience of this feeling of inclusivity whilst collecting data. I recorded a number of episodes of 'small talk' with the ward clerical assistants on different units and their offers of tea I noted made me feel more accepted in the unit. This role of tea-making and 'small
talk' was also observed with visitors to the ward who were waiting to see the nursing or medical staff. On one occasion, this was at a time of considerable distress, when a grandfather was waiting to see his granddaughter who was having a seizure following a drug overdose and all the medical and nursing staff were in attendance. Consideration of making refreshments may seem a rather innocuous activity however it appeared to symbolise an empathic and supportive relationship, a means of making a person feel cared for. It also appeared to equalise otherwise hierarchical relationships and a number of students cited the consultant who made coffee at the end of the ward round and how it made them feel included and made him more approachable. Tea-making may therefore provide a valuable team-building function.
‘The team’ and the non-professional Typical descriptors of teams by students included core groups of professionals. In a study into the meaning of multiprofessional working, Cable et al., (1999) identified the importance of non-
82
See Chapter 8 ‘Experiential biographies’, p: 258, for an indication of the value of contact and getting to know people.
- 209 -
professional staff in the smooth process of care delivery. However there was no evidence, (with the exception of some general practice areas with which I had contact in my capacity as a lecturer), that team meetings included anyone other than clinical professionals.
The importance of the construction of the team resides in the identification in Cable et al’s study and analysis of a social work department by Young (1981) of the informal power that resides with certain non-clinical members of the team. Thus if continuity is to be achieved a wider perspective on the 'team', or the organisation and relationships of staff groups is required. A porter for example, refused to wait for a patient whom he had come to collect for a chest x-ray because the patient was in the toilet. The result was that the patient had a prolonged wait to go to the x-ray department and medical staff were delayed in reviewing the patient's care. Such an example provides evidence of the importance of considering the development and constitution of teams in delivering continuity of care 83 .
Another illustration involved the domestic staff who had considerable contact with patients chatting to them as they cleaned around the ward in a more relaxed and informal relationship than their professional colleagues. What was apparent however was their apparent ‘invisibility’, similar to that experienced by students, unless ‘professional’ staff had a particular task to request of them. That is, their role in the ward functioning was apparently largely invisible to the clinical staff in a collegial sense. Thus whilst interprofessional teamwork appeared to be at least acknowledged the importance of the role of the non-professional was poorly represented. If, as Cott, (2000) proposes, accompanying greater diversification of health care there will be a tendency to utilise cheaper more subordinate staff, then it would appear that the nature of the team needs to be redefined within a more inclusive structure.
The description provided to illustrate this point aims to highlight some of the complexities and vagaries of what constitutes a clinical ward team. The different players move in and out of the picture as central to patient care at different times of the day and with different patient care 83
See Chapter 2 'The practice context'’, p: 25
- 210 -
needs. In the general medical and surgical wards where observational data was collected there was little evidence of formal team-building processes due to some of the factors discussed in previous sections. There was evidence of a core of people who might be conceived as the 'team' however non-professional staff were largely excluded, as were students. However small activities such a 'tea-making' appeared to have disproportionate effect on the atmosphere of inclusivity and approachability that it created. It symbolised a degree of acceptance.
This section has indicated some of the factors that influence teams and issues of team membership. Observations suggest that in reality an evident hierarchy exists in which medical dominance still prevails. This has a potential inhibitory effect on both collaborative development and the preparation of students, as they observe the behaviour of senior staff who have by definition survived and succeeded within the system. This relationship between seniority, hierarchy and role performance will be explored in the next section.
Seniority and hierarchy in the clinical team Seniority appeared from observational data to play a significant part in the roles played out by team members, both in terms of the relationships with staff but also in their frequently observed distance from patient care. One student nurse acknowledged,
Nursing Student Interviewee 9: Student: Some consultants are excellent, great manner with the
patients, sit down at the bed with them, you know don’t tower above them and ask the patient what they think. But that’s not the norm I wouldn’t say.
Some opportunistic data that I collected as a father-to-be in a midwifery unit highlighted a difference in the physical proximity in interactions with the patient by junior and senior medical and midwifery staff, to which my earlier observations and interviews had sensitised me. Over a period of nine hours numerous different staff entered the room and a consistent pattern of behaviour began to emerge. The student nurse and SHO came and sat on the bed to talk, the staff midwife stood at the bedside and the senior midwife, consultant and registrar stood at the
- 211 -
foot of the bed behind a bed table each time they entered the room. This positional differentiation associated with seniority was also noted in observations of ward rounds with senior medical staff almost always taking the lead.
These behaviours were repeated in a number of the clinical areas observed and although as the student above highlighted some senior staff displayed an open manner, this sort of approach was much more evident in junior staff. The reasons for this distinction remained unclear despite some probing in subsequent conversations with staff in other areas (I considered it inappropriate to probe in the area in which it was initially noted due to my role as relative rather than researcher). Two explanations proffered were that increasing professional distancing was a consequence, and possibly and expectation of seniority and that differences were the product of a changing orientation towards the training of health care professionals in communication skills.
Observation of the nursing staff indicated that more technically demanding or treatment oriented functions e.g. drug rounds, were most likely to be in the domain of more senior staff. Contrary to some of the nursing literature senior ward nurses did not appear to distance themselves from direct hands on care with patients. What was evident however was that senior staff could choose to remove themselves from this care delivery at their discretion. Charge nurses were, on several occasions, observed to start a shift helping to get patients out of bed and 'do washes', but would on occasions then leave these duties to take up something else. Evidently they were subject to multiple demands but staff with whom they were working were frequently unaware of this change which would gradually become apparent. The junior staff would then have to re-prioritise their work to accommodate the absence of the senior member of the nursing team. Consequently some students reported their preference for working with nursing auxiliaries rather than senior nurses as they felt they received better support.
One charge nurse also described the changing relationship between nursing and senior medical staff,
- 212 -
Observation Note: [Teaching hospital, medical ward], 'It’s changing the way we are with
doctors. I use first name terms for a lot of them now. Not in front of the patients of course'. I ask her if this is age related i.e. senior staff expecting their titles to be used, however she says, ''No, one of them is in his fifties, it's just what you feel comfortable with. They call you by your first name so I do the same.
She also added an important proviso that supported the notion of hierarchy that evidently still prevailed in the clinical domain,
'They're very colour conscious though' she points to her epaulettes, 'they only really talk to charge nurses and senior staff nurses'.
The 'whiteboard', an apparent symbol of role divisions between different professions and grades of staff as only nurses were allowed to write on it, also appeared on one ward to support the prevailing hierarchy inherent within the health care system. The consultants were written as title and surname, the nursing staff were written as title, first name and surname and the junior house officers were listed by first name only. Medical and nursing students' names were not written on the 'whiteboard' at all. Names and titles appeared to signify a rank within the organisation, thus first name terms may symbolise a changing relationship between senior medical and nursing staff but this informality had not apparently infiltrated the junior ranks. Thus the models to which students are exposed appeared to emphasise a prevailing hierarchy inherent within the clinical domain.
This hierarchical differentiation was also evident in one of the few activities that brought groups of clinicians together in the ward areas, namely ward rounds. The nature of the ward round will be explored as an exemplar of 'team' dynamics and in particular the roles and relationships of medical and nursing staff that were observed or were described by students.
- 213 -
Ward round roles Busby & Gilchrist, (1992: 340) describe the ward round as, 'potentially the most valuable time
for sharing information, problem solving and planning treatment, both for the professional and the patient.' Ward rounds were observed in this study to take a number of forms. There were large multiprofessional rounds of up to thirteen different members of staff and students. There were also administrative rounds, usually comprising a middle grade doctor and junior house officer, who would check test results and change treatments as required. This occurred at the patient’s bedside, or more accurately on many occasions at the foot of the bed. Ward rounds also sometimes involved simply going through records without seeing the patient, or standing at the ward 'whiteboard' and talking through each patient’s case. These sometimes formed the preparatory stage of bedside ward rounds.
The teaching rounds that occurred usually involved relatively large numbers of people. The medical student role ranged between that of 'camp follower' in which they trailed behind the qualified staff entourage, to one of 'scrutinised demonstrator' where certain tasks e.g. an examination of the chest, or information was requested of them. This emphasises the fact that the role of students, whilst generalisable to a degree, is not a single definable concept but changes with different circumstances. As a consequence students must be sensitive to prevailing conditions and circumstances and perform accordingly. Such a finding perhaps provides evidence of the need for 'emotional intelligence' as well as traditional cognitive intellect described in Chapter 2 84 .
Nursing students often reported having seen rounds happening, but very few had actually attended one. Student interviewees asked to describe their experience of ward rounds often focused on the purpose of the round suggesting that although they were potentially were useful for encouraging communication between the professions nurses were not always 'invited'. The use of the term 'invited' by several of the nursing student interviewees perhaps suggests that ownership of the ward round is seen as residing with the medical staff. Rather than a team
- 214 -
function therefore the ward round is primarily a medical construct. The associated lack of inclusion evidently caused some problems in communication and co-ordination of care as one student nurse described in the surgical ward in which she was working,
Nursing Student Interviewee 3: Student: ...it happens quite a lot here. The doctors come onto
the ward and don’t say they’re there and kind of start the ward round and you like see them half way through, kind of thing’.
A ward sister was observed to make the point to a consultant that nursing staff should be present in doctor-patient encounters, although she did this in a tone suggesting a degree of humour, which appeared to diffuse potential tension in the confrontation,
Observation Note :[Teaching hospital, surgical ward]: 'Consultant comes out of a bay with
registrar and junior house officer. Charge nurse says, 'Did you take a nurse with you to see that lady - how will we know what you've said?' Consultant replies, You can always speak to me'. Charge nurse says 'Do we have a diagnosis then?', Consultant, No, she's coming back to see Prof next week - haven't you looked in the notes?' C/N 'When did you write in them? Consultant, ‘About 11.30am' C/N 'Do you think I've got nothing better to do than run around reading notes. There is then a general banter about patients and who is going to look after them, all very light-hearted. The consultant says, 'Is that clear?’ C/N replies 'Crystal', Consultant 'There's a surprise'.
Atkinson, (1981: 3) discusses the concept of medical 'gaze' first proposed by Foucault, (1973). Within this conceptualisation it was conceived that 'the superstructure of theory fell away to
reveal a pure, uncontaminated perception of the patient and his illness.' The consequence of this situation is that the medical 'gaze' may block out, or sees no place for, the 'gazes'. of others i.e. professionals or the patient. To arguably over-emphasise the point there is the idea that the doctor possesses an uncontaminated and objective perception of the truth of the patient's problem and therefore there is no need of other professionals.
84
See Chapter 2, ‘Identifying collaborative practices’, p: 28.
- 215 -
A difference in the organisation was evident in ward rounds between medical and surgical wards. In the former these were often extensive, relatively frequent e.g. daily and at defined times. This compared with the surgical unit in which rounds were of a more ad hoc nature, often led by a middle grade doctor rather than the consultant.
Doctors as leaders Observations indicated that the medical staff exclusively led the ward rounds however the degree of participation of nursing staff was variable. At one extreme this involved shared decision making,
Nursing Student Interviewee 2: Student: ...on the ward rounds (...) they’re having their
conversations, doctor’s asking how the patient’s been, the nurses saying, and then they’ll probably say what’s to happen and maybe have a wee conversation about what they should do. ‘What do you think nurse, do you think we should get him out of bed today or do you think it’s a bit soon? How do you think they’re doing? You know, like that ...I suppose that is everybody working in a...I see everybody as working in a team.
Other students were less positive about the nature of the ward round and highlighted their observations, which were supported by my own field notes, in which the frontal position in the entourage indicated the apparent hierarchical organisation. The most frequently observed format of the ward round was consistent with the stereotype of the consultant leading with the middle grade medical staff, the nurse following, the junior house officer pushing the notes trolley and medical students following up the rear. No student nurses were observed on ward rounds, though two of the nine nursing student interviewees reported having been present on at least one. Recognising that these students were all in the latter stages of their preregistration programme this would seem a low proportion participating in this potentially collaborative activity.
One student nurse described her perception of the role relationships in the ward round,
- 216 -
Nursing Student Interviewee 3: Student: ...sometimes they [medical staff] can be a bit off, like
you may as well not be there. Sometimes doctors are talking amongst themselves and you’re sort of tagging along at the back saying, ‘What was that, sorry I didn’t catch that’, you know they’re not as much talking to you as to their own colleagues.
However what was almost always evident was the lack of involvement of the patient in the process. One student nurse expressed her concerns,
Nursing Student Interviewee 9: Student: I don’t exactly agree with the way ward rounds are
done, you know the actual process of the ward round. I don’t like this standing at the end of the bed and discussing the patient thing (…) this big entourage of people swamping this patient and all talking about them which does make patients quite nervous. And you’ll find a lot of them will ask the nurse afterwards, ‘What did they just say to me’, because they don’t know what’s just been said to them. Mm, but the role really I think is for everyone to put in their piece of information about that patient and hopefully to make a joint decision about the patient and on the whole that’s what’s happened.
Another student nurse drew upon the distinction between the medical and nursing role as a rationale for more shared involvement in the ward round,
Nursing Student Interviewee 3:Student: Doctors [are] very much interested in the patient’s
condition and how the condition’s progressing whereas the nurse is possibly more involved, the nurse is there all the time, not just dealing with that particular condition that the person’s in hospital with, but dealing with that whole person. You know, in their personal hygiene, the eating and drinking, everything as opposed to that one condition. The doctor might be interested in (...) just the diagnosis really rather than, Is she sleeping alright?’, ‘Is she eating properly?’, you know
Observational and interview data on ward rounds usefully crystallises some of the issues regarding interprofessional working. As this section aims to illustrate it highlights in particular the different roles and orientations of medical and nursing staff in the clinical area and the hierarchy that appears to continue as a significant component of the relationship.
- 217 -
Changes in the context of health care, in particular the changing role of nurses and the greater inclusion of the patient in their own care have occurred. These two factors were raised by student interviewees in relation to the purpose and development of more collaborative behaviours. Some of the evidence collected to further illuminate these issues will therefore be considered in the next sections.
Changing doctor-nurse relationships and current social order Two dimensions central to the development of collaborative practice that recur in the literature and were outlined in the overview at the start of this chapter are equality between professions and role clarity of both one's own profession and that of others. In interview data both medical and nursing students defined the medical role largely in terms of diagnosing, prescribing and directing the care process. The nursing role definition was less clear. Both groups however reported that that their clinical experience had demonstrated that nurses did more than they had anticipated prior to entering the clinical arena.
The ‘resident hostess’ follows doctor’s orders In numerous interviews nursing students acknowledged that an important part of the role they were being prepared for was to follow doctors orders, evidence of the ‘resident hostess’ servicing the doctors needs in the practice area. On occasions there was some reticence in proclaiming this fact,
Nursing Student Interviewee 1: Interviewer: What is it that you’re responsible for and the
consultant or the medical team are responsible for? Student: Medical team being responsible for coming to the right prognosis and diagnosis, prescribing the correct medications and the nurse’s responsibility is carrying out the doctor’s orders if you like, but it’s also the nurse’s responsibility if she notices anything in that time to go and report it to them, but they’ve also got to be able to identify what the actual problem is, so
- 218 -
you’ve got to have a wide understanding as well, to be able to go back and report, you’ve got to know what to look for. And what’s relevant as well. Interviewer: You smiled when you said ‘carrying out doctors’ orders’, why? Student: I didn’t want to say that, but you know, like prescribing, administering the prescribed medications or doing their peak flows or whatever like that. Interviewer: Why didn’t you want to say it? Stud: Because I just said that doctors weren’t on this higher level than what we were and what I’ve just said contradicted myself saying that we’re carrying out their orders.
However students also described, most usually in specialist units, the important role nursing staff had in directing junior medical staff and the closer affiliation of roles,
Nursing Student Interviewee 7: Student: The thing I’ve noticed more, especially working in the
more specialised area of coronary care, the house officers ask the nurses their advice a lot of the time. You know, that a nurse might read an ECG and what have you. A nurse will notice something, may be the doctor has a wee glance and says, ‘Right, that’s fine’, but then they’ll [nurses]…, ‘No wait a minute, take a wee look here, would you may be look here’. So they’re
carrying out a lot of things. They do defibbing [defibrillation] here, probably more in the specialised areas, probably with your extended practice role and the cannulation and whatever, venepuncture that kind of thing.
Two medical students described the distance between medical and nursing staff due to the problem of arrogance amongst their own profession, a term not used by any of the nursing students. Some nursing students reported a lack of respect, most prominently from the data this related to doctors expecting nurses to tidy up after them,
Nursing Student Interviewee 5: Student: ... there can’t be much respect there if you just expect
somebody to pick, clean up after you. I mean there’s not much respect there at all.
- 219 -
Mackay (1993: 129) supports this contention expressing the ‘Resentment and irritation at being
expected to tidy up after doctors.’ Students described action that nurses were taking to address this issue, an overt demonstration suggesting that a more assertive culture could be developing in nursing, consistent with a quality proposed to be required for collaboration 85 .
Nursing Student Interviewee 1: Student: … nurses used to tidy up after the doctors. You know
when they were like giving injections and now that’s sort of changing because there are notices up everywhere that you go, ‘We are not tidying up after you’, like clearing away empty syringe packets and things like that. So I think the message is slowly getting across that we’re important as well.
Technical competence and nursing status Another means of influencing the relationship between nursing and medical staff was for nurses to take over the roles traditionally carried out by doctors e.g. blood-taking and intravenous drug administration, a move that some nursing students considered would enhance respect for them by demonstrating their equivalent technical competence. This move described as the nurses’
‘extended role’ was also acknowledged to ease the burden on medical colleagues,
Nursing Student Interviewee 8: Student: I think because […] the nurses in certain areas are
starting to take over more of the responsibility that they (doctors) once had, (…) it must be a relief to a lot of the junior house officers that they are getting some of the workload taken off of their hands. So they maybe realise that we’re not just there to tidy up after them, we’re capable of doing things that they can do.
This move, which both medical and nursing staff appeared to acknowledge as positive, highlighted an interesting paradox. Nurses frequently referred to the ‘busyness’ of the ward and yet they were witnessed to be taking on further tasks. This may be explained as an example of nurses trying to rationalise the off-loading of junior doctor’s work on to them. Alternatively, it 85 Assertiveness is identified as a defining characteristic of collaboration, Chapter 2, ‘Identifying collaborative practices’, p: 28
- 220 -
may support the contention that professing ‘busyness’ confers advantage and allows the selective acceptance of further tasks, of a technical rather than interpersonal, strategically planned or educative nature.
Discussion of this move with clinical nursing staff suggested that respect from medical colleagues for demonstrable technical competence was one reason for accepting an ‘extended
role’, despite some evidence that nurse take on roles that medical colleagues do not want (Mackay, 1993).
Changing roles, continuity of care and learning opportunities Nursing students’ interviews and informal discussion with clinical nursing staff suggested that a prime motivator for the adoption of traditionally medical roles was that it increased the continuity of patient care and consequently nurses' satisfaction with their role,
Nursing Student Interview 9: Interviewer: … taking on the extended role, taking on some of the
tasks. (…), do you think that’s a beneficial move from the patients’ point of view? Student: From the patient’s point of view perhaps. It depends how many people were involved beforehand. If you had lots of different people coming and doing lots of different tasks for that patient then if the amount of people can be reduced then it’s good for the patient because they get to know somebody, they’ve seen that person before, they’re not continually having to be introduced to somebody else. There was also some evidence of nurse-doctor boundary changes leading to duplication of roles, or lack of clarity as to who was responsible for carrying out a particular task. Thus the potential for fragmentation or mismanagement of patient care remained,
Nursing Student Interviewee 3: Interviewer: Some of the changes in nursing are about
changing roles. Are there any areas where you see it’s not very clear where sort of the nurse ends and the doctor starts? Areas where there is maybe overlap in terms of role or function?
- 221 -
Student: There is sometimes. (...). A lot of IV drugs and things like that (...) Should the nurse be doing these IV drugs or should the doctor just be putting in the Venflon and leaving it at that or should they [the nurse] be doing it? There’s a lot of that goes on and the nurses are like, ‘We’ve got no time to be doing this, this is their job and the doctors are saying, ‘Well I’ve put the Venflon in, so that’s now your job.
From an educational perspective, medical students were less assured by the changing nursing roles, particularly because students identified considerable competition for opportunities to practice skills in the clinical work place. One medical student who had a part-time job as a phlebotomist expressed her concern over the risk of becoming de-skilled,
Medical Student Interviewee 1: Student: I think that that’s, that’s good (laughs), but then (…)
does that mean the JHO won’t get practice as well?. At the moment you know, as a phlebotomist you go and take the bloods and the patients say, Oh, please come back, don’t let the doctor do it’. I feel that’s a shame because the JHOs they can’t do it because they haven’t had enough practice, they haven’t had enough training, (…), OK that’s great the nursing staff coming and taking bloods. I mean that would be brilliant, and doing the IVs, but shouldn’t the doctor know how to do all those as well? And from my experience I find most of them can’t and they hurt the patient more than they should.
Nurses showed signs of moving further into the technical domain traditionally held by doctors but there was little evidence of medical staff becoming more involved with the ‘dirty work’ (Hughes, 1984) that is the traditional domain of nurses. The effect of this situation is that not only are medical-nursing boundaries shifting, but this in turn will have an effect on the nursesupport worker and nurse-patient/relative boundaries in order to accommodate the increasing nursing workload (Allen 1996). Rather than an equalisation of medical-nursing roles evidence existed of what might be described as 'the doctor-nurse game' (Stein, 1967) in action around the area of 'dirty work' ,
Observation Note: [Teaching hospital, surgical ward]: Surgical registrar comes to the nurses'
station and reports that a patient has vomited. The SSN says, 'You can get a mop and bucket. He laughs at this and says, 'Yeh, after the ward round. The registrar turns and walks down the
- 222 -
ward and the SSN calls after him, 'Which bay are you in George' he says 'Three, thanks very much' and she goes off to get the mop and bucket'.
Both parties appeared to acknowledge their respective roles in this situation, and the lowly status of the activity involved but they played out a small charade to avoid confrontation of the fact that the nurse role, in addition to delivering patient care, involved servicing the doctor’s needs.
Similar covert inter-plays were witnessed in all the clinical areas, which emphasised a mutual recognition that the nurse was there to look after the doctor. A common occurrence involved a doctor asking the nurse if she could tell him where to find something and the nurse would go and get it. Making an indirect request for help was interpreted in certain instances as a request for the nurse to act. This is arguably consistent with the fundamental role of the ward nurse as
'resident hostess' looking after the needs of the 'visiting' doctor described in relation to student roles in the previous Chapter 86 .
One final and rather striking observation further highlighted that although roles may have changed in a number of areas staff still recognise their roles and responsibilities,
Observation Note: [Teaching hospital, medical ward]: A patient in the bay nearest to me stands
from her chair and falls flat on her face. There is a collective gasp from the observers. Medical students and phlebotomists are all standing watching but it is only the nurses who move forward to help her (...) The patient is left on her back on the floor for several minutes until the JHO who has been sitting behind me intervenes, standing up and saying, seemingly to herself but loud enough that all can hear, ‘What on earth are they doing?’ The nurses then lift the lady into her chair and the doctor begins to check over her, moving her limbs and asking if she has any pain anywhere. A student nurse remains with the patient during the examination but all the other nursing staff leave.
Whilst the doctor, ‘functional visitor', intervenes to carry out the examination, the nurses i.e.
'resident hostesses', put the ward, including patients back in order.
- 223 -
This section illustrates some of the models to which students are exposed and the nature of relationships. Rather than a simple performance between individuals these are underpinned by historical and cultural differences and the chapter well exemplifies the multiple interpretations and symbolism of encounters that occur. Within such a context students begin to develop their identity and sense of belonging, therefore understanding the complex prevailing factors is important in understanding the learning and working context within which clinical teams operate.
So far the chapter has focused on inter-staff relations, however a fundamental purpose of understanding and developing collaborative practices is to benefit patient care. This chapter will therefore conclude with a brief review of the relationship between the team and the patient.
Discontinuity of Care and Patient Exclusion Although students considered that staff did generally work in teams a number of students identified that the patient was rarely involved in discussions or the planning of their own care. They also were able to differentiate between 'good' and 'bad' teams usually defined on the basis of communication, but were unclear as to how this might benefit patients beyond the development of 'a better atmosphere'. Therefore despite the development of a culture of student inclusivity or interprofessional collaboration and team orientation the patient may continue to be excluded in the care process because of the form the team takes,
Nursing Student Interviewee 5: Student: We do have, multidisciplinary teams (…), but I
sometimes find that the patients aren’t getting involved as much as they should, it’s just more on like the doctors, nurses, sometimes the dieticians and occupational therapists, it all gets written down on paper and sometimes they don’t always sit down all together and discuss, (…) I think everybody comes in separate, one person like an occupational therapist will come in and see you, then somebody else comes in and see you and I don’t think it’s getting related sometimes.
86
See Chapter 6: ''Doing' medical and nursing work', p: 178
- 224 -
Interviewer: So you just see sort of fragmented care? Student: ...and the patient’s got rights and everything but as regards the multidisciplinary team the conversation is never usually directed at the patient,
In this study one of the few occasions where staff were witnessed to come together in the ward area, as has been discussed in this Chapter, was the ward round. Ward rounds often involved large groups of staff approaching a patient laying flat or sitting up on the bed. Patients were often asked a number of questions but only on two occasions did the consultant leading the round make active attempts to involve them. On both these occasions the consultants involved sat on the bed and engaged with the patient to the exclusion of the rest of the team, rather than the more typical model of having a team discussion with the patient present. Medical and nursing students who had attended ward rounds concurred that although they had witnessed staff making joint decisions these were considered to usually exclude the patient.
Waterworth & Luker, (1990) provide some evidence that patients may not always wish to be included in decisions on their own care however loss of patient centrality in the care process appeared to be as a result of poor co-ordination and lack of continuity. In a hospital environment in which there is increasing specialisation of roles, rapid throughput and low staff to patient ratios can be detrimental to patient care. The following edited extracts from my observational field notes, during a five hour period of observation, situated in the main corridor of a medical ward in a district general hospital, illustrate the problem of both role specialisation and lack of co-ordination,
Observation note: [District general hospital, medical ward]: 7.30am Man in room behind me is
visited by a student nurse - she goes in and stands chatting to patient for several minutes (she is the fourth member of staff in a fifteen minute period; 3 nurse, 1 doctor)…student nurse leaves and then the monitor alarm goes of so she returns to the side room…enrolled nurse goes in to collect breakfast tray … student nurse goes back into cubicle behind me and says, ' I'll come and give you a hand to wash later…alarm has been going off for five minutes in room behind me, student nurse and health care assistant go into room but student nurse soon leaves although alarm continues to sound…SSN goes into cubicle and switches off the alarm and says,
- 225 -
'I'll come back to fix it in a wee minute'…SSN and student nurse go into cubicle, SSN says, 'XX (student) will be back to give you a wash in a wee while…domestic comes on to ward, goes into the cubicle behind me and starts to mop the floor, chatting to the patient as she mops around…student nurse goes into cubicle apparently to start patient’s wash but comes out a second or two later as a buzzer is going…E/N is walking past cubicle and sees patient is trying to climb out of bed - she goes in and sits him down and calls student nurse who comes back and E/N leaves..9.15am ECG Technician arrives wanting to do an ECG on man in cubicle, but he is still being washed student nurse finishes and ECG technician goes in. Student nurse says, 'I'll just wait outside and stands against the wall writing in the patient’s folder…9.40 Phlebotomist goes into side room to take blood from patient as she leaves the lady from the WRVS goes in asking if he wants anything from the trolley..10.15 doctor goes in to see patient, shortly after student nurse goes in as well, she then comes out again and asks for help to lift a patient from a staff nurse who has just arrived on the ward.
This extended and edited extract I believe well illustrates the loss of patient centrality in the care process and indicates the benefits that greater collaboration could bring. Delineation of different roles meant that this patient who was confused was confronted by numerous different staff for examination, blood-taking, washing, ECGs in a apparently uncoordinated manner. Particularly noteworthy was that when the doctor was with the patient the student nurse left the cubicle to get help with lifting the patient up. It appeared that such an activity either did not constitute part of the medical role, or the student was unwilling to ask the doctor for help in this activity. Also perpetually as one staff member arrived another one left, so there was little opportunity to develop continuity of care or advocate on the patient's behalf.
Such examples highlight the benefits that collaborative practices, which deliver more coordinated care could offer. The literature indicates that it is not simply a question of developing teams and teamworking and encouraging the student to participate but requires the right sort of teams to be developed.
Miller et al (1999) in case study analyses of a range of different clinical teams present three types of multiprofessional teamworking, 'integrated, fragmented and core and periphery’ (See
- 226 -
Appendix 18). These methods of working they suggest do not seem to be related to context i.e. hospital or community, nor to be influenced by team size.
Miller et al (1999) explicitly state that it was not the objective of their research to suggest that the 'integrated' form of working was 'the effective way to work multiprofessionally' (p: 102). However they suggest that no other form demonstrated the same level of collaboration and teams practising the other two forms of working appeared to more commonly express both difficulties of working together and fragmentation of the multiprofessional group. If students are therefore to develop collaborative practices it is not simply a question of participation in the clinical team but also requires the appropriate models or concrete examples within the 'community of practice', in which learning and performing collaboratively can occur concurrently.
7.4 Summary This chapter has provided an illustration of group relations within clinical practice, with particular emphasis on the relationship between medical and nursing staff. This was designed to sensitise the reader to the context in which the meaning of relations with other staff develops. The Chapter outlined the social, historical and cultural legacy within which medical and nursing relationships might develop in order to understand the multiple perspectives that create the clinical context or 'community of practice'.
The literature supports the dynamic nature of the clinical context with roles and relationships being described as the product of negotiations, influenced by traditions and defined by status, power, gender and educational imbalances. Acknowledging the legacy and its continuing impact between medicine and nursing in terms of hierarchy and perceived power, the student interviewees also indicated factors that enhanced the relationships and included regular social contact, good communication, a relaxed and informal working environment and a clearly defined patient population. Symbolic action, most notably the act of 'tea-making' were
- 227 -
significant influences upon the environment and when undertaken by senior medical staff were interpreted as reducing hierarchy and facilitating inclusion.
The team provided the most notable organisational construct, however this was largely professionocentric, with subordinate staff e.g. domestics and porters not being seen as part of the team. Students similarly were often excluded from the team or at least parts of it. Thus certain actions or relationships were restricted to qualified staff and even then sometimes only across defined hierarchical strata.
The ward round was used as an exemplar of prevailing hierarchy, with students often being at the bottom of this structure. This was also used to demonstrate the multiple roles demanded of students and to introduce the utility of 'emotional intelligence' described in Chapter 2. The ward round was presented as a multidisciplinary concept but was also indicated to be a primarily medical construct which other professions serviced, thus emphasising a degree of professional distance.
Changes were also discussed in relation to the medical-nursing relationship as nurses take on more traditionally medical tasks. This indicates the ever-changing nature of the boundaries between the two professions within which students must construct a sense of professional identity and the 'community of practice' must constantly reformulate itself. Evidence was presented that the reformulation is a largely one-way movement, with nurses taking on medical roles with little reciprocation, therefore reinforcing the value placed on medical tasks at the expense of nursing care.
Finally this Chapter considered the relationship of the patient to the collaborative team. Ultimately changes in practice and the recognition of issues of hierarchy, cultural differences and power relations are considered worthy of illumination only in so far as they benefit patient care. Collaborative practices must therefore be considered in relation to the facilitation of participative and engaged patient roles in their own care process. This study indicated problems
- 228 -
of continuity of care in current modes of practice and the exclusion of the patient from the existent team process.
The next chapter will focus more closely on the organisational structures and working patterns of the two professional and student groups and discuss the impact of different trajectories on the role performed.
- 229 -
CHAPTER 8: MAKING CONTACT: BUSYNESS, 'PROFESSIONAL SPACES' AND PERSONAL KNOWLEDGE
8.1 Introduction Collaboration is fundamentally reliant on relationships and as such is dependent of the nature and quality of contacts between different players. This Chapter considers the issue of contact from a number of different perspectives. Firstly it considers the 'busyness' of the clinical environment and the impact that this has on interpersonal engagements between students and qualified staff. It examines the notion of 'invisibility' described by some students and scrutinises the observed behaviour of clinical staff, a process termed 'clinical blinkering', in relation to students and offers explanations of this behaviour. Secondly it considers contact between members of the 'community of practice' in relation to the 'professional spaces', meaning the working patterns of doctors and nurses which limit contact and are a recognised source of conflict (Walby and Greenwell, 1994). Thirdly it presents the 'contact hypothesis' proposed by Hewstone and Brown (1986) and subsequently considers the contacts experienced by students. Finally it introduces the concept of 'experiential biographies' (Allen 1996), a concept based on levels of social knowledge of other individuals, which facilitates the transcendence of professional role boundaries on the basis of mutual trust and respect, which are a most usually the product of prolonged contact.
8.2 The ‘busyness’ factor Changes in the demand for and organisation of health care have resulted in the need for significant transformations in patterns of hospital care (Department of Health, 2000), that have implications for the preparation of medical and nursing students for practice. Miller et al (1999) acknowledged a more rapid throughput of patients, whilst Dent, (in press) describes limitations on learning opportunities for students due to fewer in-patients, shorter stays, more acute problems and higher student numbers. A regularly acknowledged feature of the clinical learning
- 230 -
environment, described by students in this study as having an impact on their relationships with staff, participation in care and strategies for learning and practice, was the 'busyness' of the clinical learning environment.
Melia, (1979) described the 'busyness' of the hospital environment in terms of the 'turbulent' nature of the workload which is characterised by a number of features, not simply patient throughput. She proposed that because of the patient centrality of the workload, the care process is fundamentally non-rationalisable as it occurs against a backdrop in the pace of work where an emergency is always possible. Staff also have to manage unpredictable patient needs and often conflicting interprofessional timetables (Zerubavel, 1979) e.g. medical ward rounds versus nursing work. Additionally Allen, (1997) identified that hospital workforces comprise diverse occupational groups with their own cultures, careers and patterns of practice resulting in problems of co-ordination. Allen proposed that this situation is exacerbated in the UK by resource limitations.
This study suggests that the situation is also exacerbated in certain areas, most significantly teaching hospital general wards, by student throughput 87 . Students identified that 'busyness' or organisational turbulence had a detrimental effect on their education and participation in care and was a contributory factor in them becoming 'invisible' due to what I have described as the activity of 'clinical blinkering'.
'Busyness' of the clinical arena Despite eighteen years of working in and around the hospital environment one of the most striking features of the clinical area, during periods of observation, was the density of 'human
traffic'. I used an unstructured, descriptive method of activity recording in the clinical areas (See Appendix 9), in order to generate a detailed account of practice. However on a number of occasions it was necessary to resort to simple noting of numbers and 'types' of staff present
87
See Chapter 4, ‘Student numbers and ‘production line’ learning’, p: 110
- 231 -
because of the diversity of personnel and activities being played out concurrently. Though this might be argued to be a flaw in the methodological design, i.e. lack of structure creating recording overload, the following early examples from the observational records highlight the density of personnel, of what is described in this study as the 'busyness factor',
Observation Note: [Teaching hospital, surgical ward 10.00am]: Difficulty in recording the
numerous activities, therefore count of staff currently in view; 3 staff nurses, 3 student nurses, 1 senior house officer, 2 junior house officers, 5 medical students, 1 domestic, 1 ward clerk, 1 nursing auxiliary, 1 porter, 3 phlebotomists, 1 speech therapists (n=22). Information from white board indicates 34 patients on ward at present),
and,
Observation Note: [Teaching hospital, medical ward 12.00pm] Staff count at this time around
nurses’ station; 1 nursing auxiliary, 3 medical students, 1 senior staff nurse, 2 senior house officers, 2 junior house officers, 1 medical technical officer, 3 staff nurses, 1 nurse tutor, 1 pharmacist, 1 pre-registration pharmacist, 1 physiotherapy assistant (n=17)
Similar patterns to those described prevailed in all the ward areas in which formal recordings took place, both in teaching and district general hospitals, although it was evident from observational data that the density of 'human traffic' was higher in the former. Peaks in activity involving large staff numbers occurred exclusively within office hours. The data collection area that was an exception to this finding was the accident and emergency department. Although peaks and troughs occurred in this area these did not tend to create the crowd scenes described above in which large entourages of staff descended at one time, with multiple, often quite diverse purposes.
This observation supports Headrick et al's., (1998) contention that clinical teams are not created in some structured or well planned way but rather are people who are thrown together and are expected to function in a co-ordinated fashion. It also strongly supports Melia's, (1979) contention of hospitals as turbulent environments. The complexity of the interactions within the
- 232 -
clinical domain, and the numerous encounters potentially required, make achievement of coordinated collaborative working in the context of a wider ward level network problematic. A student nurse gave what she described as a fairly typical example of a failure in the coordination of care,
Nursing Student Interviewee 2: Student: Classic example would be dietician coming up onto the
ward. Well, first of all the nurse will have sent down a referral saying the patient is not getting adequate dietary intake and they’re needing like a high calorie diet. So they’ll come up and assess the patient and then they’ll decide that they have to have supplements. So, that’s fine they come up on the trolley and nobody follows them up, nobody knows if the patient has actually drank them. You know, after the meal times, or actually taken account of if they are actually eating all their meals. Sometimes the supplements are left in the fridge and they go out of date and they’ve never been handed out. (...) Interviewer: Why does that happen? I mean is it some sort of organisational structure that’s in place that makes that come about?
Student: I don’t know. I think though working in coronary care, there’s a smaller unit and probably because the patients are quite ill there’s like an importance for it I don’t know if you understand? It’s important up in the wards as well but when you’re looking after about twenty patients it’s a lot harder to make sure they’re all getting exactly what they need.
A medical student also described a problem of duplication of work to the detriment of patients. She cited one example from when she was working as a phlebotomist in which she had just taken blood from a patient as requested and was leaving the ward when she observed a junior house officer about to repeat the test unaware of her intervention 88 . Her purely fortuitous intervention prevented a painful test being repeated. Thus in a busy clinical context where patterns of care are complex involving the input of a range of professionals interviewees reported breakdowns in co-ordination and monitoring of care occuring on an apparently regular basis. There was no observational data evidence of severely detrimental repetitions of work but much duplication of work was apparent, in particular relating to common information being
88
This offers support to the value of collaboration discussed in Chapter 2
- 233 -
requested of patients by different staff. Evidence also existed of the prioritisation given to medical work over patient care in busy environments.
Prioritising medical work and patient care in busy situations A nursing student reported a striking example of the priority given to medical work in a critical incident interview. She described dealing with a confused patient who was trying to climb out of bed and was being restrained by herself and a staff nurse,
Critical Incident Description 43: Student: This confused man was trying to get out of bed and
we were trying to stop him. The consultant came on to the ward with a group of other doctors to start his round and the staff nurse just said, ‘I’ll have to go’ and left me with this man’.
The incident suggests that the priority of patient safety was relegated below medical routine and illustrates the prevailing power of the doctor. From an educational perspective what was perhaps even more striking about this incident was the student's response to it,
Critical Incident Description 43: Student: ‘What else could she [the staff nurse] do, I was too
junior to do the round so she had to go’.
The student appeared to have recognised the priority given to medical routine over direct patient care, and it was only when I reflected the description back to her that she began to question the situation stating,
Critical Incident Description: Student: ‘I suppose she didn’t have to go, she could have made
them wait or asked them to help even. Yes, I suppose if it was a physiotherapist we would have made them wait’ 89
This student recognised a hierarchy in which there was some equivalence of status with staff such as physiotherapists, but a marked hierarchical distinction between nursing and medicine 90 . 89
This example highlights the value of reflection in learning and the facilitation of students' reflection on their own
- 234 -
Interviews with students and conversations with staff in the clinical areas both highlighted their perceptions of ‘busyness’ as an inhibitor of quality of patient care, a view supported by both medical and nursing student interviewees,
Nursing Student Interviewee 1: Student: …nurses are sort of rushed off their feet already,
wards are short staffed wherever you go and its just… Interviewer: What do you think suffers then? Presumably something's got to give if they're rushed off their feet? Student: The patients are going to suffer because there's not enough time, you know for communication with the patients, the best patient care because they're not going to have as much time. I mean, a lot of the time you don't have a lot of time, especially the trained nurses, they don't have a lot of time to spend with the patients. The only time they spend with them is if they're washing them or doing their care plans or giving out drugs and really that doesn't make up a lot of time in the working day. But it's, they're so rushed off their feet 'cos' they've got a lot, with the wards being short staffed they have more patients to look after, so they've got to set aside time for everyone. And if you've got someone who's really ill on the ward or a few heavy patients then it does start to tell and you can see the nurses getting stressed out.
Similarly a medical student expressed the view of ‘busyness’ being to the detriment of patient care. Priority was given to pleasing the consultant over providing for the patient’s needs, another strategy required in the clinical staff 'survival tool kit'. Yet the difference between a consultant’s priority and a patient’s priority was often unclear in tangible terms. What the interviewees seemed to actually be referring to was a conflict that ‘busyness’ created between balancing interpersonal and functional approaches to care,
Medical Student Interviewee 1: Student: The doctors, the junior doctors, some times I wonder
if they have too many jobs to do so actually they are not giving the quality of care for patients. … but you have to understand that the doctors have other things to worry about, what the consultant says. personal experiences. 90 Hierarchical divisions within the clinical team are also discussed in Chapter 7, ‘Seniority and hierarchy in the clinical team’, p: 210
- 235 -
The data appear to support the contention that the ‘busyness’ of the clinical area promotes the functional over the interpersonal, staff focused on completion of task with resultant routinisation rather than individualisation of care.
‘Busyness’ as an inhibitor of team-building 'Busyness' may in part explain the lack of formal team-building strategies e.g. team-meetings, that were observed in the clinical areas. Discussions with students in general wards in the teaching hospital supported the observational data that clinical staff meetings were unlikely to occur. Only one student reported witnessing a meeting and that was because of a specific incident in the clinical situation, thus it was of a highly focused nature addressing a specific problem rather than as a team-building exercise.
The emphasis on function contrasted with the 'meetings' at the end of ward rounds described by medical students attached to a small district general hospital where the consultant sat and had coffee with staff. These 'breaks' or informal meetings had no clear function but students described how they appeared to cement relationships between staff. Nothing similar was reported in the general wards in the teaching hospital but this occurrence had some parallel with reports from students working in the mental health arena in which staff frequently came together for 'social breaks'. Students described such meetings as relaxed and informal and on a number of occasions it was even reported that the patient was present, however one student explained the contrast on the basis of 'the pace is different in psychiatry'.
Critical incident descriptions from nursing students contrasted general and mental health domains. The suggestion was that the latter was 'more laid back', and was described to be much more focused on inclusivity, and creating strong relationships rather completing specific, particularly task-oriented functions. These discussions brought back memories of my own psychiatric ward experiences as a student nurse being told to go off and read the newspaper
- 236 -
and relax on the ward. I was informed that patients did not want you to be 'doing things' but just for you to be there if they needed to talk to you. I also remember how I struggled with such a different philosophy of care to the one that had been espoused in all my general nursing training, which constantly emphasised 'doing' nursing. One nursing student compared his experiences of mental health and general hospital placements,
Critical Incident Description 7: Student: ‘On this ward [mental health] there were regular
patient review meetings with the multidisciplinary team. In this meeting there was a discussion of a patient ready for discharge with the social worker, medical and nursing staff and the patient’s family. I had my own patients allocated. I was seen as a fairly senior member of staff despite being a student, so I could decide on treatment although other staff were available if I wanted to discuss anything. At the meeting the consultant asked my views on the patient. I just felt valued. This is very different to how it is on the general wards where you don’t feel involved. Staff don’t know what you’re there to do. There’s just no time.
It was unclear from the data whether the perceived seniority of the student in this description was an indictment of the stigma of mental illness, i.e. an idea that high level of skill or experience is not required in mental health care, or excellence in collaborative practice. Several students described feeling considerably more valued in mental health arenas then in general ward areas, where they were perceived as junior by both nursing and medical staff.
Advantage conferred by ‘busyness’ The 'busyness factor' was reported by staff and students and is undoubtedly well evidenced but its regular statement may also confer certain advantage on clinical staff. To draw on Freire’s (1970) classical perspective on ‘oppression’, ‘busyness’ may allow staff to take a 'victim' stance in a situation out of control. In such a context Freire would argue that staff can rationalise a situation that they cannot manage therefore legitimising their inability to create time to build team relationships, interprofessionally integrated approaches to care or educate students. Students frequently reported and appeared to accept the ‘busyness factor’ as an inhibitor to educational input,
- 237 -
Medical Student Interviewee 2: Student: ... it's difficult because they're busy. They don't have
time to be spending with you going through your examination. It really depends on the hospital, the staff and how committed you want to be at the time.
Similarly a consultant whom I approached for permission to accompany and observe his ward rounds on which medical students were present, was evidently uncomfortable at my request. He emphasised at some length that,
Observation Note: [District general hospital, surgical ward] Ward rounds are a ‘business facility’-
not for teaching, teaching goes on elsewhere. We don’t have the time, there’s too much going on’. Other consultants on the same ward were frequently observed teaching students on their ward rounds suggestive of different prioritisation of their clinical and teaching responsibilities.
There can be little question that all the clinical areas observed were busy places but the observations also indicated that there was degree of predictability to activity. Peaks tended to relate to certain events such as ward rounds, getting patients up, meal-times and 'on-take
days'. Even the accident and emergency department, that by its very nature is unpredictable, had periods that staff could identify as usually ‘being quiet’. Annandale et al., (1999) describe the function of ‘harnessing unpredictability’ or ‘taming the untameable’ in order that planned care can be delivered and resources be maximally utilised. However as has been argued it appears that staff can gain certain advantages by emphasising the unpredictability in that focus can remain on short-term goals rather than the strategic and co-ordinated delivery of care and/ or education.
- 238 -
‘Clinical blinkering’: a response to busyness Considerable flexibility amongst staff was required to cope with the care of a rapidly changing patient population. This demanded constant re-prioritisation of work in order to satisfy the particular demands of the situation. Nursing and medical staff were observed to be frequently intercepted and diverted from a current task by patients, relatives or other staff. Thus there was evidence to show that patterns of working in the areas observed and in which students had worked did not always deliver the best care for patients. In addition to limitations in the inclusion of patients in the clinical practice environment the same areas viewed as clinical learning environments were also identified to be deficient in their capacity to include students. An observed strategy adopted in response to ‘busyness’ that effectively excluded groups of people from clinical participation or engagement, what I describe as ‘clinical blinkering’.
'Clinical blinkering' and student 'invisibility' Students were asked in interviews to describe their clinical learning experiences. Several medical and nursing students, though more commonly medical students, described their
'invisibility' to staff. A strategy described as 'clinical blinkering' in this study was observed to support the interview data through which staff avoided engagement with students.
The development of ‘clinical blinkers’ appeared to be a part of a 'survival tool kit' for qualified practitioners. This process involved staff studiously avoiding any eye contact or acknowledging the presence of another. One medical student with whom I had discussed the issue of conflict between medical students and nursing staff stated,
Medical Student Interviewee 4: Student: There’s no reason for any conflict with them [nurses]
because they don’t even know you’re there. As long as you keep your nose clean and they don’t want anything then you don’t speak to them and they treat you as if you’re not there. There’s no question of arguments because you don’t have anything to do with them and they’d rather you weren’t there.
- 239 -
This was not restricted to students but was used for avoidance of engagement with patients and other, usually non-professional i.e. porters and domestics, staff members. On several occasions nursing and medical staff were witnessed to have developed this capacity in delivering patient care,
Observation note: [Teaching hospital, surgical ward] Patient is calling out for a bed-pan, a
nurse walks past the bay waiting for two other nurses to go for her coffee break, but doesn’t acknowledge the call. She walks back again but the patient is still calling out, but she still does not respond. Another patient catches her arm and says. ‘Mrs XX is calling you’. The nurse says, ‘Oh I‘ll go and get someone’. It appeared in this instance that the nurse was temporarily ‘off-duty’ due to it being her coffeebreak time and was therefore able to ‘blinker’ herself from the patient until another patient intervened more directly.
I also recorded, on a number of occasions,, in my field notes, what I considered to be personal exposure to ‘clinical blinkers’. For example on an early observational visit to a ward a staff nurse approached me. She had been interviewed in an earlier part of this study whilst still a student and asked about progress. Numerous exchanges occurred between us on this occasion over this visit. On the next visit the ward was much busier but the same staff nurse was on duty,
Observation Note: [Teaching hospital, medical ward] Staff nurse who I’ve interviewed
previously and was so friendly last time keeps walking past my chair to get into the room behind. She is evidently busy but appears to be choosing not to see me even though we had a long chat when I was here last week.
This action may be an unsurprising response, a defence mechanism to minimise interaction with others when busy but such action has a potentially disempowering effect as I noted from personal experience as observer. A reflective note that I did not recollect writing at the time but came across on reviewing the data highlighted my response to having become 'invisible' to staff,
- 240 -
Observation Note: [Teaching hospital, medical ward] Specialist registrar answers the phone. He
goes and asks the staff nurse about a lady going to the Integrated Teaching Centre. The staff nurse says, ‘I know about her just tell them she’s not gone yet’. I know she has gone but don’t speak up. I feel somehow distanced and awkward in speaking out, perhaps because I have been largely unacknowledged for most of the morning. I feel somehow removed from the situation. This gives me a feeling of a lack of involvement, powerlessness. Is this how medical students feel as they are largely ignored?’
If large ‘team’ size or the 'busyness' of the clinical environment encourage the exclusion of all but core professional members of the team, then one might argue that this could undermine the engagement of more peripheral individuals. Such out-groups of non-professional staff or students therefore are excluded from collaborating or engaging in the care of patients and from the subsequent learning process. In relation to the model proposed by Lave & Wenger, (1991) the 'peripherality' of learner role would be increased by their 'invisibility'.
Explaining ‘clinical blinkering’ A rationale for ‘clinical blinkering’, may be to limit interactions and consequent frequent reprioritisation of work, in order to retain a focus on patient care. 'Clinical blinkering' was observed being used on a number of occasions to avoid patient care, priority being given to such to other activities such as nurses' coffee breaks and ward rounds.
This section therefore reflects on a number of issues. The clinical areas are busy places, a factor that appears to detract from the education of students. Staff develop certain strategies for surviving in the busy environment including 'clinical blinkering' and prioritisation usually based on tasks rather than relationships. 'Busyness' allows the justification of the maintenance of the status quo rather than constant change and therefore is less threatening for staff, an acceptance of 'domestification' as described by Freire, (1970) in order to maintain the status quo. The detrimental effects of this 'busyness' is that students and others are excluded from participation in care delivery and engaging with staff. This limits their opportunity to develop collaborative relationships and to participate and learn from interactions with those from other
- 241 -
professions. Limitations of contact were also a product of another factor, the working patterns of doctors and nurses, the 'professional spaces' occupied.
8.3 'Professional spaces' in clinical practice Differences in the time and space work patterns of medical and nursing work appeared to create a barrier to developing relationships and to communication both inter- and intraprofessionally. In an analysis of the division of labour in general hospital, Allen, (1996) proposes that the boundaries between different professional groups can be understood in terms of a 'temporal-spatial framework'. These are the working patterns in terms of duty periods or rotations and geographical spaces occupied, or in the case of students in practice might best be described by the clinical allocation periods and the roles adopted. The value of the analysis of such patterns is indicated by Zerubavel, (1979) who, in a study into the effect of 'patterns of
time' in hospitals, identified how temporal organisation of labour can become the basis for staff allegiances that cut across conventional sources of social differentiation. Walby et al., (1994) also identified that different working trajectories of doctors and nurses were a significant source of conflict between the two groups.
Working patterns, conflict and collaborative relationships In her analysis of a district general hospital Allen, (1997) contrasted the length in post of doctors and nurses in terms of 'transience' and 'permanence'. Nursing staff were largely recruited from the local community, trained locally and their turnover in specific posts was low. In contrast junior doctors rotated between clinical areas as often as every three months, senior house officers every six months and registrars every year 91 . Unlike their nursing counterparts few of these doctors had been recruited locally. This pattern reinforces, at an organisational level, the description given in the previous chapter of medical staff as 'functional visitors' and 91 The Calman reforms to registrar posts now mean that registrars remain in a particular geographical locality for the duration of their higher training but still move around different hospitals during the training period (Calman, 1993).
- 242 -
nurses as 'resident hostesses'. In such a structure nursing staff have a long term connection with, and arguably commitment to, a clinical and geographical area whereas the junior medical staff, to use a phrase coined by Melia, (1987) to describe the transient role of student nurses, were just 'passing through'. As a consequence relationships between medical and nursing staff constantly had to be rebuilt with each change of medical staff.
Allen argued that different working patterns created discontinuities in experience and status. She found that nurses wielded considerable power over junior medical staff who were disempowered by lack of local knowledge of in-house protocols and aspects of ward organisation. Allen also proposed that the power created by 'permanence' augmented the influence nurses had over medical practice and education.
At a unit level Allen identified differences in duty periods and patterns. Nurses worked a threeshift system, each of eight hours duration to cover the 24 hour period, medical staff worked
'office hours' i.e. 9pm -5am, with additional on-call hours. This pattern was similar to those witnessed in this study, although some units had moved to two 12 hour shift pattern, as I was informed by one ward sister, 'to increase continuity of care.'
Walby et al, (1994) undertook a study of medical and nursing staff working in a range of hospital settings. They identified that although some of the causes of breakdown in relations were frequently workload and staffing levels others were differences in working patterns, routine and priorities (Table 8) :-
- 243 -
Table 8: Sources of conflict between nursing and medical staff in general hospitals (Walby et al, 1994)
•
Low staffing cover
•
Stress and tiredness
•
Theatre lists running over time
•
Bed availability e.g. admission, discharge and outliers
•
Communication failure e.g. bleeps
•
Variability in routines e.g. ward rounds, handovers
•
Consultant absenteeism/ disinterest
•
Different medical/ nursing budgets
Mackay, (1993) 92 reported that shift patterns are the source of much resentment between medical and nursing staff, particularly in relation to the medical on-call period, with junior doctors often reporting that 'they are being called at night for trivial and unimportant matters.'
(p: 53). Mackay also reported that the defined shift-patterns for nurses compared with the more 'flexible' hours i.e. staying on beyond the office hours period, worked by medical staff led some doctors to suggest that 'while they care about and feel a responsibility to their work,
nurses do not.' (p: 54) Territorially Mackay identified differences in the 'spaces' occupied by doctors and nurses. Medical territory was broadly 'the hospital' and the nurses territory was generally confined to a ward or particular clinical area. Doctors had considerably greater freedom to roam and were consequently not under the same level of scrutiny as their nursing colleagues. Walby et al., (1994) proposed that 'the bleep' is a physical representation of the significant territorial differences between the two groups, an electronic means of communication required because of lack of physical proximity.
Mackay, (1993) also proposed that the more widely spread responsibilities of medical staff throughout the hospital meant that doctors often had to balance priorities between different
92
This work reports on the same study as that described by (Walby et al., 1994)
- 244 -
wards. Nursing staff had a relatively insular perspective focusing only on the local group of patients for whom they had responsibility with little consideration for wider departmental or hospital priorities. Thus failure by medical staff to respond promptly to calls from one group of nursing staff because of competing priorities elsewhere was a much reported source of conflict between medical and nursing staff.
The descriptions of patterns of practices outlined above broadly mirrored my own data, with conflicts over bleeps, differing shift patterns and geographical patterns of responsibility being observed and described by student interviewees. This provided two distinct models of practice for medica and nursing students in clinical areas and reduced the potential for contact with those from other professions. This was exacerbated because at a still more focused level even within single clinical areas, medical and nursing personnel gravitated around different physical locations.
Doctors’ and nurses’ ‘spaces’ Each clinical area had defined medical and nursing administrative centres. The 'nurses’ station' appeared to be the pivotal hub of the ward to which visitors were directed for information and towards which nursing staff gravitated in quiet periods of activity in the clinical area. All areas had a 'doctors' area' where forms were filled and notes written or read by medical staff and where they would often sit to take coffee whilst continuing with their administrative processes. This spatial separation created a more isolated work pattern for doctors than nursing colleagues who tended to be working with other nurses for most of the time and to leave the clinical area in groups for breaks. Thus a communal or group culture was more notable with nurses gathering together for breaks and in quiet periods to chat and also more formally for regular exchanges of information, 'handovers'.
The exception to this pattern was the A & E department where all staff, doctors and nurses, had a communal area where breaks were generally taken in mixed professional groups. The
- 245 -
atmosphere in this unit appeared less hierarchical than the ward areas in both teaching and district general hospital. Doctors and nurses were on first name terms across the grades and the social intercourse between different staff members was suggestive of a high level of interpersonal knowledge.
The physical characteristics of different areas showed some consistent patterns, which influenced engagement patterns with patients and other 'human traffic' through the clinical areas. The form of the 'nurses’ station' was fairly consistent between hospitals and wards, i.e. a desk accessible to visitors, staff and patients with communication links (telephones, often a computer and extensive information material). The locations defined as 'medical areas' ranged from a desk (teaching hospital wards), to a separate room (district general hospital wards), to a partially enclosed glass booth (A & E department). The common factor about the medical areas appeared to be that they protected the doctor from direct contact with the 'human traffic' on the ward. In A & E distance was created between doctor and ward activity by a physical glass barrier, in the district general hospital wards this was by the remote geographical location of the doctors' office and in the teaching hospital wards this was by the desk being sited facing the wall so the doctor was sitting with his back to anyone who entered the ward. This contrasted with the nurses' station which served as a reception desk/information centre facing out towards visitors and in view of the 'whiteboard', a board containing names and other data of all patients on the ward which served as the key area for information exchange between staff members. Once again this demonstrated the 'hostess' role of the nurse with the 'visitor' role of the doctor. The nurse was responsible for welcoming, informing and being accessible whereas the doctor kept a degree of distance and intervened only intermittently.
The 'whiteboard', provided an interesting symbol of differentiated ownership of space between clinicians. This board clearly fell into the domain of the nursing staff who controlled the addition and removal of information. Questioning staff about this observation it was suggested that anyone could write on it, however despite extensive field recording no-one but nursing staff were seen amending the information (during the observation periods there were also no
- 246 -
witnessed instances of student nurses writing on this board). Tacit ownership of this information facility in reality appeared to reside almost exclusively with the qualified nursing staff. This description provided an example of an 'unwritten rule' that students entering the ward areas suggested they had to learn.
The physical layouts offer an illustration of a separation between doctor and nurse functions. Medical staff deliver a service through defined interventions whilst nursing staff manage the ward routine, co-ordinate activity, create the general ambience of the area and act as an interface between patients and other staff. Identifying the value of such differences as well as similarities is important in order that staff perceive the specific value of their individual role albeit in close association with the roles of others.
Differing medical and nursing patterns of practice Separation of roles is further supported by the differing patterns of practice evident in this study. The observational data and my past experience of practice both suggested a marked separation of the working spaces and shift patterns of doctors and nurses. An observation episode, demonstrated the division created by the shift pattern of nursing compared with the on-call nature of medicine,
Observation Notes: [District general hospital, surgical ward, 7am] Doctor [JHO] sitting at desk
in theatre greens filling out forms. The nurses are currently going around the ward, the nurse in charge is doing the IVs and the ward assistant is sorting out some documentation. The nursing staff all appear fresh and go off eagerly to see the patients, this contrasts with the JHO who appears tired, stretches occasionally in his seat and yawns frequently.
Nurses arrived and left at relatively defined times, most usually after an eight or twelve hour shift dependent on the clinical area whereas junior doctors appeared to have a high degree of flexibility in their working practice despite the introduction of defined shift periods for junior doctors in some areas,
- 247 -
Observation Note: [Teaching hospital, surgical ward, 9.45am] Two JHOs are sitting at the
doctor's desk chatting. One says to the other, 'Do you mind if I go home?' Do you mind if I don't stay for this afternoon's ward round - seems pointless hanging round for six or seven hours - then I'll let you go tomorrow. Other JHO agrees to this.
Another source of conflict was also created by the newly introduced shift patterns for junior doctors. As part of the initiative to reduce junior doctors' hours some clinical areas had introduced an eight-hour shift pattern. In theory this might have reduced the 'professional
space' as most nurses also worked eight-hour shifts. However in practice the start and finish times were different for junior doctors and nurses. Doctors were frequently seen remaining after their allotted time because of a request by more senior colleagues who continued with the traditional 'until the work is finished' mode of working practice. Thus organisational theory and organisational reality appeared to be moderated by traditional expectations of senior colleagues.
The power of local knowledge The primary source of conflict identified from this new shift pattern resided outside normal working hours when junior doctors had to cover large numbers of wards beyond those on which their own consultant had patients. Consequently doctors did not know the patients and were reported, by a number of students, to be unwilling to come and attend to patients of whom they had no prior knowledge,
Nursing Student Interviewee 1: Student: …I have noticed that on a couple of occasions, when
it's been a doctor from another ward who you've had to bleep to get things done, often several times (…), it's just like it's too much bother to them to come all the way along here, to do things and some of them can be quite snappy, and when they come they don't know anything about the patient.'
The point made by the nursing student above regarding the knowledge level of doctors about patients was raised by a number of others particularly emphasising this in relation to the out of
- 248 -
hours medical cover. This issue of communication highlighted a notable difference in activity between the two professional groups. Nurses expended a considerable amount of time handing over information to nursing colleagues, described as 'report' or 'handover', and taking up to an hour between shifts. There was no reported mechanism for this occurring between changing medical shifts. Consequently nursing staff spent considerable time informing doctors of the circumstances and requirements of particular patients.
Collaboration and communication Evidence was collected in this study, from student interviewees, that spatial differences created a source of conflict relating to the prevailing communication processes,
Nursing Student Interviewee 5: Student: The nurses all communicate well with the doctors, it’s
the doctors who are a bit slow on the uptake sometimes – getting things done and that. You have to bleep them and bleep them which is a bit annoying when you’re needing something done, but I know they’re busy as well. Interviewer: Why do you think that is? I mean why, you said ‘slow on the uptake’? Student: I don’t know, there just they all seem so young these days 93 and it’s just I don’t know, they may be don’t take their job as seriously as they should, you know. Interviewer: Have you had any experiences that would support that? Can you think of any occasions where that’s… Student: Just regularly, you bleep somebody and it’s ten or fifteen minutes. You’ll bleep them again and it’s still another ten or fifteen minutes before they come to the actual ward or even phone.
93 This was an interesting comment from the nursing student who during the course of the interview told me she was twenty three, therefore probably no older than the ' young doctors she referred to. Therefore rather than a reflection on their age, this seemed to be a put down strategy, possibly picked up from more senior nursing colleagues. i.e. part of the developing discourse or narrative that indicates seniority or status. In my clinical experience in A & E this was associated with anecdotal stories that were told as true experiences of a particular nurse but I heard them in 'identikit' form in a number of different departments.
- 249 -
Students identified that 'professional spaces' between the two professions required good information exchange in order to maintain continuity of care. Indeed the most commonly cited feature of teamwork discussed by both medical and nursing student interviewees related to communication, in particular relating to 'the bleep'. Frustration for nurses was based on awaiting a response from the doctor whereas the doctor’s frustration related to being unable to get on with the work due to constantly having to respond to the bleep. On one occasion I observed a junior house officer who was trying to give the intravenous drugs on a ward have to break off to respond to five phone calls in as many minutes. One nurse emphasised the problem,
Nursing Student Interview 9: Student: …some nurses, they'll bleep the doctor for one thing
instead of finding a lot of things that need to be done at one time, you know the doctor will come along and do that one thing and then sort of five minutes later something else needs to be done so it's on the phone to the doctor again.'
Communication between nurses and doctors was also a source frustration to medical staff in another domain. The introduction of primary nursing involved one nurse having twenty-four hour responsibility for assessing, planning and evaluating the care of small groups of patients. Consequently doctors frequently approached nursing staff to be told that 'she's not my patient' and they would then have to search around for the primary nurse which in my observations, on occasions, involved considerable expenditure of time for the doctor.
The issue of communication between staff was explored in student interviews. Both medical and nursing students reported having numerous classroom sessions on communicating with patients but none on communicating with colleagues, even with those of their own profession. Experience in this area was largely 'on the job', learning by watching others.
Patterns of working evidently created barriers to the development of relationships and to communication. The bleep appeared to be both a status symbol, a weapon for nurses and a source of frustration to medical staff. As the importance of the bleep began to emerge from the
- 250 -
data I asked students if they had any teaching on use of the bleep. Most had been shown how to 'bleep' someone and medical students had been shown the mechanics but there was little evidence regarding education in the use of the bleep in terms of workload management. There was also no method through the bleep system of differentiating an urgent from a routine call.
If clinical staff are to function as teams the different parameters of practice and the roles adopted are worthy of scrutiny. Review of patterns of nursing observed might be described in terms of 'being' a nurse on a particular ward for the duration of the shift with a structure most predominantly defined by coffee-breaks, certain patient interventions e.g. drug-rounds, and medical routines e.g. ward rounds. In terms of participation in the widespread activity of a particular clinical area, the nursing staff were the central hub. The pattern of junior doctors' work, the doctors who spent the greatest amount of time in contact with the nursing staff, was focused on 'doing' certain tasks, remaining on the ward until these were complete and then leaving. Their involvement with the machinations of particular wards was more transient. The pattern of senior doctors' work also involved 'doing' defined tasks but was more sporadic, entering the ward for short periods with a defined purpose and leaving again. This again differed from A & E where senior medical staff worked alongside juniors, dressed in similar
'uniforms' and were available in the clinical areas for prolonged periods.
Analysis of the patterns of engagement evident from the data are interesting because they closely mirror the roles adopted by students in their clinical experience. The design of the experiences provides a close working model of the particular form of practice for which they are being prepared. It is important to recognise that these patterns have been identified as a notable source of conflict in previous studies and therefore questioning their rationale and perpetuation appears to be a justifiable pursuit. (Walby et al., 1994, Mackay, 1993).
This analysis of professional spaces demonstrates that there are numerous challenges for the development of collaborative practices in the clinical domain. It also indicates a number of potential areas of development in student preparation. Most fundamentally these professional
- 251 -
spaces reside in a physical or constructed distance between different members of staff. In some instances this may be for sensible logistical reasons but it limits the degree of contact between staff of different professions. The issue of contact will therefore be reviewed in light of the data collected and its contribution to the development of collaborative practices amongst students explored.
8.4 Contact between participants The concept of 'professional spaces' begs the question as to whether a reduction of
'professional spaces' and hence creating more regular and prolonged contact between different professional groups would reduce conflict and so enhance communication and collaboration. This section will explore the value of 'contact' and describe student experiences of contact with other professional groups.
Hewstone & Brown, (1986) in a review of intergroup relationships identified that contact between members of different groups can have both positive and negative effects on relationships. Numerous interprofessional education initiatives described in the literature have been designed to create the opportunity for non-clinical interaction between students of different professions e.g Annandale et al., (2000), Mires et al., (1999), Pomeroy & Philp, (1994) with variable results. A small body of research has also considered the creation of contact between students in the clinical work place however this is often in manipulated or closely controlled settings e.g. Wahlstrom & Sanden, (1998), Freeth & Reeves, (1999).
Hewstone & Brown, (1986) identified that numerous factors are required to create positive encounters between different groups. These include institutional support, equal status of participants, positive expectations, a co-operative atmosphere, successful joint work, concern for and understanding of differences as well as similarities, experience of working together as equals and perception that members of the other group are 'typical' and not just exceptions to the stereotype. Little attention has been given in the literature to contacts between medical and
- 252 -
nursing students or between students and qualified practitioners of other professions as they occur in practice.
Supportive and combative medical and nursing student contacts Data from this study suggests that minimal contact between nursing and medical students within this Faculty was the norm. When it did occur students sometimes described it to provide very positive and supportive learning experiences, however on other occasions interactions were at what might be described as a combative level.
Despite extended periods of observation in the clinical areas contacts between medical and nursing students were witnessed on only two occasions. These interactions were both instances where a medical student asked a student nurse the location of something, this due to nursing students' greater familiarity with ward practices. Nursing students described in interviews that they had on occasions, had informal contacts with medical students on the wards. These might be categorised as students making ‘small talk’, conversations in passing and were given little import by the students themselves. However one might argue these were normalising interactions i.e. social over professional interaction. Reports of interactions which were more purposefully directed i.e. professional over social interaction, occurred occasionally in the interview data and these descriptions were often of a collaborative nature,
Critical Incident Description: Nursing Student: I was working in gynae outpatients and there
was a medical student there as well. They were doing a minor surgery list and we were both keen to see as much as possible so while we were there we worked it out between us, who should do what. We just organised it well between us and we were willing to take turns. He [the medical student] had started after me so he was asking me things. I thought, I know
something that he doesn't and that was really good. Not competitive but you think medical students are so brainy they know everything.
Descriptions suggested that, on occasions, a bond existed between students because of their mutual student status, which in one instance, unified them against a qualified practitioner,
- 253 -
Medical Student Interviewee 1: Student: In the first year we go out to the GP and I actually did
my attachment there with a nurse. And I did it, a student nurse and I did see the difference […]. I mean we did complain about it because the student nurse was made to feel very bad. The doctor didn’t really treat her as nicely and he, kind of ignored what she had to say. And I think she made a complaint to one of the doctors and I went up to back her up as well.
Differences between medical and nursing student knowledge Interactions between students also appeared to make them aware that similarities and differences existed between their learning objectives. It also emphasised the value of different foci on the delivery of care and how sharing of knowledge could be beneficial,
Nursing Student Interviewee 8: Student: I don’t mean to put medical students down or
anything but I don’t think they get as much practice, say with basic nursing care, as they should so they come to a student nurse rather than make themselves embarrassed and look silly in front of a qualified nurse. They tend to come to the student nurses and say, 'Look, I mean how do you work this BP machine?' and I'd be looking at them thinking, 'Hold on a second, you should already know this.' But that's just one example. I mean you're more than willing to help you know and it can go vice versa, because say I wasn't quite sure. Say a woman had a urinary tract infection and it'd now be like, I'd have some signs and symptoms but I wouldn't be quite sure and rather than make a fool of myself I'd turn to the medical student and say, you know, 'Does this warrant for this person to be commenced on antibiotics.'
Nursing students were viewed to have practical monitoring skills whereas medical students' area of expertise was of pathophysiology and treatment. Recognition of these different roles provided a forum for mutual exchange of knowledge. The contact in this instance also provided some insight for the nursing student that medical students, who as a group were often identified by student nurses as highly intelligent, did not have all the answers or a monopoly on knowledge. An atmosphere of co-operation was more normal in the data but on a small number of occasions, nursing students identified instances of conflict with medical students. One nursing
- 254 -
student, for example, rather vehemently described that medical students adopted a pattern of behaviour like senior medical staff and bypassed nursing students,
Critical Incident Description 30: Nursing Student: often medical staff brush passed you as if
you’re not there. It’s good to feel useful and for them [doctors] to see that you can do something. Particularly with medical students, they never ask you, they always go straight to the charge nurse. When you’re walking around with the tea trolley they really snub you and you have to say ‘scuse me, scuse me’ just to get round. I live with a medical student and they [his friends] don’t talk to me because I’m a nurse 94 .
Another nursing student identified that her greater practical knowledge created a position of power that could be exploited in the relationship with medical students and in turn her recognised powerful position created by greater clinical confidence proved advantageous. She described an almost combative encounter with a medical student,
Critical Incident Description 22: Nursing Student: A medical student was walking down the
ward. He called out, 'nurse', and I responded. He said, 'Not you, a proper nurse. He paused and then said, 'I suppose you'll do' He needed help with a drip. This really annoyed me - you feel as if they see you as useless or stupid or something. I got my own back though several days later. Someone said they needed a doctor and these two medical students were standing near by. I said, 'Well they're no good to you.' and walked off. I know it's childish but it made me feel a lot better.
Educational lessons for collaborative development The skills of collaboration between staff may be an important goal of student preparation but simply creating contacts may evidently not be sufficient and may even be counterproductive. Issues of respect, communication, self-esteem, negotiation and power-relationships and capacity for conflict-resolution all appeared to influence contact encounters in practice. These may therefore provide some areas for non-clinical educational development. However, it is hard to envisage how such skills might ultimately be developed without practice in the clinical 94
Whilst this may be something of a caricature of the actual relationship this student has with her medical colleague house mate and his friends it is notable that this student assigns her relationship problem to her role as a nurse.
- 255 -
setting. Thus there is a need for students to practice and reflect on encounters and nonencounters with others, that is, consider why contacts with other professionals are successful or not.
One area for reflection for example may be the apparent 'unwritten rule' that nursing students described, that they should not approach medical staff in the clinical area but rather information should be filtered through more senior nursing staff,
Critical Incident Description 24: Nursing Student: The problem is, that it isn't seen as the
student's role to contact the doctor. Only qualified staff can do this. There's an unwritten rule that a student doesn't speak to the doctor - in fact most of the time were invisible. It's difficult to know the boundaries, what should be reported to a nurse and what to a doctor. It's something that should be given more attention in the School.
This rule was considered by some students to be a self imposed inhibitor due to an apparent lack of confidence on their part,
Nursing Student Interviewee 4: Interviewer: Have you had any opportunity to develop a close
working relationship with medical staff? Student: Not really no. Interviewer: Is that because, why is that? Student: Mm, because your, being a student, […] the say [say so] never lies on you so it would always be taken a step higher to consult the doctor. You’d obviously consult them if you felt a problem and the places were busy, but often if you had a problem you’d report that problem to a member of nursing staff who’d then report it to a doctor rather than you go straight to a doctor. Interviewer: Why is that? Student: Just because you’re working with the nurses all the time and you probably feel more comfortable approaching nursing staff. You might be made to feel a bit stupid if something that
- 256 -
may not appear to be important, nursing staff would probably find it quite important, especially if it’s a change.
Other students assigned this lack of confidence to make contacts as due to either experiences or expectations of responses from others, which highlighted the influence and longer term consequences of the interactions to which students are exposed,
Critical Incident Description 64: Nursing Student: I was looking after a patient whose blood
pressure had dropped low. I asked him to see him. He was very obliging, saw him straight away and told me when I should call him, if his blood pressure hadn't come up. Because he was so obliging and told me exactly what the plan was I felt more confident. I would be much more likely to approach them [junior house officers], which is good, because sometimes you leave things just because you're nervous of speaking to them. Also I've seen them make silly mistakes so you realise they're human too and so you can work together. It would be good if we got to know medics sooner, but medical students tend to come, do their own thing and then leave so you don't have much contact.
Such examples highlight the importance of developing the student's confidence as in this instance. In a number of other descriptions the students appeared to be inhibiting their own interactions due to fear of looking foolish. Thus the development of learning environments that are secure and supportive are required to counter this barrier. On direct questioning in interviews student nurses suggested that there was no status difference between doctors and nurses but their behaviour suggested otherwise. Students rarely spoke to medical staff, instances of speaking to senior medical staff being almost non-existent in the field notes. Where an interchange occurred this was generally only in response to students being asked a direct question. What was evident in the description was also that students felt favoured when senior medical staff spoke to them, perhaps because, as the student indicates in this incident, of the rarity of it as an event,
Critical Incident Description 19: Nursing Student: The consultant singled me out and spent
about ten minutes explaining what he was going to do. I almost died of shock. He was a very nice man, but doctors don't normally talk to you do they.
- 257 -
Medical students' contacts with nursing staff were equally acknowledged to be infrequent, nursing staff typically being described as ‘unapproachable’. Rather than contacts with nursing staff being the norm for students these were exceptional events. A number of medical students recognised the divide that existed between medical and nursing professions in which qualified nurses in particular usually did not see that they had a role in teaching medical students. One student identified an instance where the division was not evident and indicated the value of such an encounter,
Critical Incident Description 1: Medical Student: 'I approached one of the staff nurses and
explained to her that I needed to learn to do injections. She was very willing to teach me. She took me round the ward and let me watch a few. Then she let me do it but she guided me. It was more like a doctor-doctor than a doctor-nurse relationship. There was no them and us […] I have been taught that if ever I'm in doubt to ask one of the nurses. But it's not always that easy. Some of them aren't very approachable.
Thus professional divisions evidently inhibit contact between students and qualified staff but certain individuals appeared to transcend this.
Medical students’ ‘rite of passage’ One final area of note in relation to contacts with clinical staff related to fifth year of the medical programme in which medical students undertook a PRHO shadowing experience in preparation for the role that they would undertake on completion. This provided the best evidence in the observational and interview data of involved contact between medical students and nursing staff,
Observation Note: [District general hospital, medical ward]: Two staff nurses stand and have a
joke with a medical student. She tells them that she will be working as a JHO on this ward next year and one of the nurses replies, 'We'll have to think of something we can do to you'. They all three laugh.
- 258 -
What the nurses appeared to be describing went beyond simple contact or exchange but was mutual recognition of a sort of 'rite of passage', the admittance to the clinical domain by having a trick played. No observations were made of these 'rites of passage' in practice but my own clinical experience had exposed numerous events where jokes were played on new staff as initiations, as they were tested for their capacity to 'take a joke'.
Another medical student described the value of the PRHO placement in moving beyond simple contacts to one of involvement in the clinical team,
Medical Student Interviewee 7: Student: '… in particular the PRHO placements, I think that's
been the first time that I've felt involved as much as we could be, not only the docs but also the nurses as well. I think it would be fair to say. […] may be it's because we're getting to the end of the course and maybe people have a bit more faith in you or maybe it's the fact that they know it's going to be your next job, your next post and so may be that makes a difference.
A number of factors arising from the data appear to influence the contacts between students and others. These include perceived rules, self-confidence, role performance, knowledge, seniority and potential duration of the contact with others. One other factor that was also identified in the data as important was the idea of being known to staff. The literature suggests that such personal knowledge of others creates a basis for relationships in which professional allegiances are transcended in favour of personal trust. This idea will briefly be considered to emphasise the importance to collaborative development of being known to others.
8.5 'Experiential biographies' Allen (1996: 327) coins the term 'experiential biographies' to describe the division of labour
'based on trust and personal knowledge of staff skills, rather than formal occupational qualifications'. The value of contact was highlighted in the previous section but what Allen also argues as important in defining the allocation of work are the social relationships which exist. Perhaps the most evident factor in influencing these relationships was longevity of service in a particular area. Many junior nursing staff referred to senior medical staff by formal titles
- 259 -
although I witnessed numerous examples of nursing auxiliaries and health care assistants being on first name terms with consultants. Similarly senior medical staff would often approach, for advice, a health care assistant who they knew rather than a staff nurse who they did not.
Conversations that occurred in these situations often highlighted personal as well as professional knowledge of the other with the consequence that hierarchical distinctions were not defined only in terms of organisational seniority but in terms of personal relationships and the informal power that this might confer.
Both medical and nursing students frequently reported that clinical staff needed time to get to know them in order to devolve more responsibility, hence their call for longer placements/ attachments 95 . When staff became familiar with students it was reported that they were more likely to allocate responsibility on the basis of a student's perceived competence rather than their stage of training. As was reported elsewhere, 96 particularly for medical students, it was rare for staff to get to know students well. A medical student reported how radically her teaching hospital experiences contrasted with those in a small district general hospital,
Medical Student Interviewee 4: Student: …the porter for example would stop you in the corridor
and say I hear you’re from Ireland…everybody knew who you were so you'd end up doing things there's no way you'd do them in a bigger hospital just because they knew you.
The suggestion is that underlying the requirement for a more flexible and inclusive division of labour is the need for staff to actually get to know students. Medical and nursing student interviewees both reported the improved opportunities for learning they encountered when working with junior staff whom they had got to know prior to their qualification.
95
This highlights the value of exploring the duration of clinical experiences as discussed in Chapter 4, ‘Duration and
pattern of the clinical learning experience’, p: 120 96 See Chapter 4, ‘Location of medical student attachments’, p: 109
- 260 -
In considering the position therefore of the medical and nursing students' role and knowledge of their 'biographies' the organisation of coffee breaks provides for interesting comparison. Organising and going for breaks amongst nursing staff were central to the clinical routine and this occurred almost exclusively in groups. What was observed in most of the clinical areas were periods where staff who were ready to go for their coffee or meal breaks were waiting around for staff to complete their jobs so that they could all go together. This contrasted with junior medical staff who tended to have their drinks at their work-station, go off individually to take a break elsewhere or congregate in student only groups. Some senior nursing staff did report that middle grade, and in district general hospitals senior grade doctors, did take coffee with them but this was not witnessed in any observation episode and in further investigation appeared to be a relatively infrequent event. The opportunity for what Playdon, (1999), describes as
'professional conversation' and the building up of information to formulate an 'experiential biography' appeared to be inhibited by lack of social contact in the clinical domain. The consequence of this, within Allen's, (1996) thesis, is that there is a subsequent reliance on less individualised mode of division of labour based on stage of training or grade rather than witnessed competence or personal knowledge.
Perhaps the area that best defined the utility of the 'experiential biography' was the A & E department in which medical and nursing staff had considerable time for social discourse and frequently went for coffee breaks together. Conversations between staff in this area frequently indicated knowledge of both personal life and professional background. However it is worth highlighting a cautionary comment made by one student nurse working in this area that relates back to the issue of 'exclusion' from the clinical team discussed in Chapter 6.
Observation Note: [Teaching hospital, A & E]: Everyone seems to know everyone else very well
and they all get on but it's really hard coming in from outside when you don't know anyone and really feel out of it'.
- 261 -
Much professional and policy literature supports the development of teams for enhancement of care delivery but the development of strong personal and professional bonds between staff may result in the exclusion of others including students and patients.
8.6 Summary This Chapter has identified a number of factors important for consideration in the preparation of medical and nursing students for collaborative practice. Firstly it outlined influence of the
'busyness' of the clinical environment, the impact this had on the resources available to students for learning and the inhibition of opportunities to develop relationships with clinical staff. It provided explanation of this behaviour in two ways; firstly as a survival mechanism in a chaotic and unpredictable environment; and, secondly in terms of advantage conferred to clinical staff by emphasising 'busyness', which allowed behavioural selectivity in terms of activities undertaken or relationships engaged in. The Chapter also discussed the issue of the different working trajectories occupied by respective professional groups and the potential for conflict that such 'professional spaces' generate. Data suggested that students are drawn into such conflicts and become critical at an early stage often due to lack of understanding of the organisational structures, roles and conflicting priorities that different groups have to manage. The concept of 'professional spaces' also indicates the very different models of practice within which medicine and nursing operate. In the former there is a high degree of autonomy and spatial freedom, but this might also be described as an isolated or individualistic model of operation. This model of practice contrasts with that prevailing in nursing which is geographically more restricted, managed and communal.
Different models operate but a fundamental effect of different spatial practices are limitations that this places on interprofessional contact. Students report limited experiences of contact with other professions, both practitioners and student, and as a consequence they have little experience of interacting with others and their 'biographies' are little known. Consequently rather than an individual relationship with clinical staff students are often treated as a
- 262 -
homogenous mass. This situation is exacerbated by the pressures of the clinical workplace and has significant implications for the education and learning of students in the clinical context.
- 263 -
CHAPTER 9: CONCLUSIONS, LIMITATIONS AND IMPLICATIONS
9.1 Introduction Collaboration is being promoted in both policy and practice as a way of achieving seamless health care for the complex problems with which patients present. Increased specialisation, often founded on the technological development of medicine, but also on the recognition of the link between health and social factors such as housing, education and employment, have resulted in a more fragmented service. Collaboration is seen as a strategy to address these problems.
The principle aim of this study was to describe the clinical experience of medical and nursing students in order to develop an understanding of how their programme may or may not prepare them for collaboration with others. Exploration of two groups of students from different professions, who may expect to work closely after qualification, allowed comparisons of structures, processes and outcomes to be made and illuminated potential areas of conflict and opportunity. Collection of data by a number of different methods and from a range of different sources enabled a comparative picture to be constructed of the planned experience, the perceived reality of student experiences and the context in which learning occurred.
The study was a single case study based on a medical and nursing programme in one Faculty, and as such does not claim to provide a representative or totally comprehensive picture of the clinical learning experiences of medical and nursing students. However this study does provide a basis for comparison against other programmes and illuminates issues that may influence collaborative development and may be transferred to other contexts.
- 264 -
9.2 Main Findings The main findings of this study have been discussed throughout the analytical chapters, however these are summarised and briefly reviewed in this section.
Collaboration as a dynamic construct
•
Collaboration is ultimately founded on interpersonal relationships and as such is a dynamic construct, which is constantly regenerated and therefore only has meaning in specific contexts.
•
Collaboration is a ‘situated activity’ and therefore can only be realised directly through participation in practice.
Efforts have been expended in the measurement of collaboration in practice and the utility for such endeavours can be seen as ways of facilitating more generalisable application or implementation in practice. However such approaches tend to attempt to measure collaboration indirectly based on proposed associated characteristics and appear to be founded on the assumption that collaboration is objectively definable, a somehow reifiable concept. This differs from the conceptualisation proposed in this thesis that collaboration is a dynamic and constantly regenerated, or reconstructed concept, which only has meaning when operationalised in specific circumstances and as such is only recognisable in retrospect and directly realised through participation.
This thesis recognises the value of collaboration to delivering effective and appropriate care. Collaboration practices however are ultimately founded on the development of relationships between individuals. Education and organisation of services therefore need to be developed to promote and support these relationships.
- 265 -
Learning to collaborate
•
Collaboration is not an enacted empirical attribute and consequently there is no simple blueprint curriculum for learning collaboration by ‘doing’ it.
•
Learning to collaborate is not just a cognitive attribute, but has a social, moral and emotional content and context i.e. ‘situatedness’.
•
The complexity of collaborative development demands that learning and practice comprise both participative and reflective components.
•
Participation and subsequent learning is not based on a replicative or absorptive process deriving from intentional instruction, rather learning is an integral and consequently generative aspect of practice.
Whilst conditional factors play an important part in developing contexts conducive to collaboration, and the development of appropriate attitudes and competencies may be promoted through both uniprofessional and interprofessional education strategies, this thesis argues that ultimately collaboration relies on the interaction between two or more individuals. The realisation of collaboration therefore requires students to participate in such interactions. Learning is the inevitable part of working with others in social settings and the learner also has the role of co-participant in a collaborative process. Learning to collaborate is not simply a information-processing or the transfer of right attitudes or culture. Rather collaboration is more subtle, complicated, negotiated and influenced by the interpretation of co-participants. In short collaborative care delivery is a 'situated activity', a process that can only directly be realised through its practice and as a consequence generalised or abstracted definitions of collaboration or knowing the rules of collaboration do not assure its performance.
The challenge therefore for educators and for organisations promoting collaboration is to recognise that common experience may result in multiple meanings amongst the different players. Consequently collaboration cannot be pigeonholed as a single definable entity that can be taught and thus implemented. Collaboration is not a straightforward product of political,
- 266 -
organisational or group directives, rather it is an entity shaped by individual interactions, reflections and the interpretations of participants. Recognising this complexity is fundamental to educational development, the achievement of collaborative practices involving participation and reflection on social engagements.
The analytical utility of participation and engagement in practice
•
Participation provides a useful analytical device for exploring medical and nursing clinical learning as a preparation for collaborative practices
•
Participation involves development of meaning, identity and sense of belonging in a
‘community of practice’, therefore an intimate relationship exists between social engagements, the participative process and the potential for collaborative development. •
Recognition of the importance of participation raises questions about the social organisation of medical and nursing education in relation to the professions and clinical domains for which students are being prepared.
•
Different modes of engagement (‘seeing’, ‘doing’, ‘being’) create different degrees of opportunity for participation and actualisation of collaboration in practice
Participation and consequent learning in practice settings based on social engagements, provides the opportunity for students to learn about collaboration while actually performing it i.e. delivering a collaborative service. Such 'learning by doing' involves the development of meaning, an identity and a sense of belonging within a 'community of practice'. It also alludes to the intimate relationship existent between social engagements, participation and the potential for collaborative development.
The focus on learning as an integral form of social practice raises questions about the social organisation of medical and nursing education in relation to the professions and clinical domains for which students are being prepared. Different modes of engagement create differing degrees of opportunity for creating links between participation and the actualisation of collaboration in
- 267 -
practice. The 'seeing mode' allows students an opportunity to adopt a peripheral role in practice and observe roles, rules and relationships. The 'doing mode' enables students to practice fragmented elements of their role. However, it is only ultimately the 'being mode' that can create the holistic opportunity to both learn and deliver, or actualise, collaborative practices simultaneously in 'real life' contexts.
Participation, engagements in medical and nursing student roles
•
Medical students engage primarily in ‘seeing’ and ‘doing’ modes, based on functional and transitory models of learning and working, the primacy of which place students at the periphery of the ‘community of practice’.
•
Nursing students engage primarily in ‘doing’ and ‘being’ modes, based on delivering ‘hands
on’ care with other nurses, the primacy of nursing work involves students in nursing teams but engagement in the ‘community of practice’ is limited by personal, professional and environmental conditions. •
Nursing students’ role as ‘a pair of hands’ and medical students’ ‘invisibility’ are both potentially limiting features of a curriculum in which students pursue their own learning needs and require to make contact with others.
Medical students have been identified in this and other studies to learn or engage in practice primarily in 'seeing' and 'doing modes' of practice. These provide useful peripheral vantage points in order to learn about the role and possibly to develop an understanding of the rules of practice but there is limited emphasis in such engagements on relationships with others. Medical students role performance is therefore largely at the periphery of the 'community of
practice'. A more central participative role, particularly with colleagues from other professions is deferred until the pre-registration house officer period. The opportunity for collaborative relationships with colleagues of both their own and other professions is restricted by the primacy of 'seeing' and 'doing' modes of engagement, which result in the adoption of highly functional and transitory forms of learning and working.
- 268 -
In contrast nursing students adopt more 'doing' and 'being modes' of engagement. They actually perform as nurses although in a limited form. Limitations to their role are largely influenced by the learning curriculum i.e. personal, interpersonal and environmental constraints, rather than the 'teaching curriculum'. The 'teaching curriculum' appears to assume high levels of involvement with practitioners, and longer duration and focused location of placements appear to facilitate this process. However, the 'learning curriculum' defines the nursing student role in terms of 'unwritten rules' and the capacity of the student to transcend these in an acceptable manner is an important personal characteristic.
Teaching curriculum: maximising collaborative preparation
•
The emergent picture of the taught and planned clinical medical curriculum indicates a lack of emphasis on intra/ interprofessional relationships in practice. Features to support his include:• Organisation and form of clinical ‘attachments’ which are isolating • Clinical education strategies based on ‘teaching by humiliation’ • Emphasis on knowledge culture and power of assessment by examination
•
The emergent picture of the taught and planned nursing curriculum indicates greater emphasis on relationships and clinical support in practice. Features to support this include:• Organisation and form of clinical ‘placements’ which are extended and localised • Clinical education strategies based on support and monitoring • Emphasis on ‘doing’ culture in which students deliver care directly as members of the ‘community of practice’
•
A model of learning and working based on collaboration may not be the most appropriate preparation for ‘fitness for (current) practice’
•
Little emphasis is placed on equipping students to negotiate their own learning needs
Medical students were identified as being ‘attached’ to medical teams, or firms, whilst nursing students were ‘placed’ with nursing teams. This was identified in the terminology adopted in
- 269 -
respective curriculum documents and manifested itself in practice in the role students performed. Whilst nursing students were directly engaged in 'doing nursing' or 'being nurses' or delivering care directly medical students were often shadowing staff or peripherally present in the clinical area with only an intermittent and functional involvement in clinical care delivery. The effect of this was that interactions with clinical staff were often limited and focused on completion of tasks. There was little emphasis on the development of relationships with clinical staff, an important finding in light of the definitions identified in the literature, which suggest that collaboration is founded on relationships with colleagues.
The emphasis on the relationship with clinical staff was influenced by a number of features of the 'teaching curriculum', primarily the organisation of clinical experiences and the supervisory relationships. Nursing placements were often of six weeks or longer and involved working similar shift patterns to clinical nursing colleagues. As a consequence students worked closely with other nurses and participated in the delivery of care. They also undertook most of their clinical learning in a single hospital, so became familiar with hospital routines and with staff in a number of clinical areas. As a result there was a more communal and inclusive orientation to their role and a lesser demand for autonomous decision-making than medical colleagues.
The organisation of medical students' clinical experiences was somewhat different. They moved between attachments frequently, often over considerable geographical distances, to different clinical areas in a number of hospitals. Consequently they were far more isolated than their nursing student colleagues and often had little time to develop relationships with clinical colleagues. There was also little requirement to do so because of their largely non-participative role. The 'seeing' and 'doing' modes of engagement demanded little in the way of developing relationships with others and consequently provided a poor context within which collaborative practices could be performed and learned.
The feeling of inclusion by students often related to the nature of supervisory relationships experienced by students. An interesting finding in this respect was the differing forms of
- 270 -
teaching styles adopted for the two groups of students. Teaching of nursing students by medical staff often was quite nurturing and informative compared to the approach to medical students which was often confrontational and demanded a high level of knowledge and display of professional confidence. To polarise teaching strategies identified in this study, whilst medical students clinical teaching appeared to frequently adopt a behaviourist approach nursing students were exposed to more humanistic teaching and learning methods.
This highlights important issues relating to the role for which students are being prepared. Nursing students have some familiarity with a more communal role and demonstrate group behaviour in many activities. Doctors however are frequently required to act in a manner that demands the capacity to work in isolation. Consequently medical staff are confronted with a tension that at one level demands collaborative practices whilst at another level requires the ability to work in isolation.
In the current climate an argument could be made that an undergraduate medical programme founded on the development of collaborative practices may not prepare students for the demands that will be placed upon them when they emerge into the ‘real world’. This will be particularly the case if students have never adopted the 'being mode' of learning and working in the course of their undergraduate programme and this requires questions to be asked of the relationship between education and service delivery. If medical students are to continue to work in relatively isolated and alienated roles after qualification then to raise expectations of inclusive and collaborative roles may be detrimental to their personal well-being. There can be little value in developing collaborative practitioners with common role outlooks based on similar clinical learning models who are then unable to cope with the rigours and demands of their own professional role.
- 271 -
Learning curriculum: maximising collaborative preparation
•
A number of features of the clinical domain inhibit closer working relationships between staff of different professions and the inclusion of students in practice. These include a prevailing hierarchy within ward teams and between professional groups, the 'busyness' of the clinical arena and the 'spaces' occupied by different professions.
•
Medical and nursing staff adopt different archetypes, the former as ‘functional visitors’ and the latter as ‘resident hostesses’, providing different models of practice which may inhibit collaborative potential
•
Staff can utilise the idea of ‘busyness’ to prioritise activity and may favour clinical developments over education of students.
•
‘Clinical blinkering’ is a strategy adopted to minimise contact with others and often excludes students from the ‘community of practice’
•
Models of practice based on enhancing knowledge of ‘experiential biographies’ may provide an effective model for promoting collaboration.
Data indicated a number of influences on the learning resources of the practice environment that influenced the opportunity for student participation in practice. Students were commonly alienated due to both inter and intra-professional hierarchies and different patterns of clinical working reduced the number of interprofessional contacts. However, the problem most commonly cited by students related to the 'busyness' of the clinical domain. Staff were confronted by multiple demands on their time and as a consequence education of students was often perceived to be relegated in importance or priority.
Roles adopted by medical and nursing staff based on patterns of practice and responsibility also differed notably. Whilst nursing staff were often restricted to specific clinical areas medical staff moved widely through different clinical areas. Consequently opportunity for contact and interaction were limited. Areas where contact was more prolonged and physical proximity was greater appeared to influence knowledge of ‘experiential biographies’, a feature that has been
- 272 -
suggested to facilitate the transcendence of restrictive role boundaries and increase trust, factors relevant to developing collaborative practices.
Conceiving doctors as medical functionaries, or ‘visitors’ has implications for the social engagements experienced by medical students in the clinical areas, in particular with nurses. If the utility of medical staff is viewed as their availability to carry out 'functions', and collaboration is based on immediacy of response and accessibility, medical students would appear to have little use or value to nursing staff in the clinical domain. Their observed,
'hanging around’ role offered little to care delivery and may even be described as impeding it. In a busy context there would seem little gain for staff in having medical students around which may explain their 'invisibility' and the adoption of ‘clinical blinkers’ to avoid contact.
Medical and nursing students both recognised that ‘busyness’ influenced the potential for intentional teaching time, however many nurses were willing to take additional tasks that were previously the domain of medical staff. The issue appeared to be explained in terms of not simply time availability but also in terms of personal or professional prioritisation. The ‘busyness
factor' conferred some advantage on staff as it allowed them to be selective about the roles or tasks upon which they focused.
Numerous factors evidently need to be considered in the development of education to promote collaborative practices. Attention must be paid not only to the knowledge held by students but also to the functional, social, and emotional roles adopted by students. The teaching and organisational factors which impinge on the process of learning and performance are evidently complex. However attention to the participative role of students and their social engagements provides a focus for future development of collaborative practices in health care.
- 273 -
9.5 Methodological conclusions •
The methodology adopted was appropriate for illuminating the clinical preparation of medical and nursing students for collaborative practices.
•
The methodological approach acted as a useful sensitising device for understanding student experiences
•
Limitations were inherent in the study but were acknowledged and minimised where possible.
The methodological approach adopted for this study has generated an extensive narrative on the role and context of the clinical experience as a preparation for collaborative practices. The qualitative, interpretive approach and specific data collection strategies adopted enabled students to provide their own accounts of learning experiences. The observational data enable this to be cross-referenced and contextualised within the clinical workplace. Documentary data provided and additional useful adjunct by indicating the planned curriculum against which other forms of data could be evaluated or interpreted.
The methodological approach the inherent reflexivity provided me with an understanding of the situation and context that I believe could never have been obtained using any other research methodology. The experience of being an observer in practice for example, often left me feeling alienated and exposed in a way that appeared to parallel some of the accounts of student interviewees. As a consequence I have tried to be open and reflexive in reporting both my feelings and experiences so that the reader can distinguish between what is data and what is artefact of the research process. The personal and emotional exposure required in such data analysis has I believe made me more sensitive to the challenges which confront students in practices and indicated challenges for the qualitative researcher that are not so prevalent in more positivistic paradigms. The methodological section included description in detail that I hope will benefit the learning of others adopting similar research strategies. Consistent with the methodological learning that occurred, and the rigour that was a fundamental requirement of
- 274 -
this study, is the recognition of the limitations of the study for directing future developments which are briefly considered.
This study into preparation of medical and nursing students for collaborative practice has illuminated the complexities of the ‘situated learning’ context and developed some conceptual ideas to direct future educational development. However consistent with the reflexive process I have recognise several limitations in the study:-
•
The research findings and conclusions, whilst adding to the body of knowledge about the clinical education of medical and nursing students, are based on a single case study and cannot be explicitly generalised beyond this one case. However in an interpretive form of study dealing with complex and uncontrolled or manipulated situations 'transferability' rather than 'generalisability' (Lincoln and Guba, 1985) are used as a primary indicator of utility. As other researchers explore their own clinical context the validity of the findings might be founded on the resonance in, or extrapolation of these ideas to, other situations.
•
In a study of complex organisational situations it is not possible for a single researcher, no matter how thorough, to capture all the complexity of the situation. However one might argue that the level of complexity means that the total situation can never be understood, particularly if it is recognised that constructed reality is a dynamic process that is constantly changing. No matter how detailed the analysis, the situational context will have moved on in the period between data collection and interpretation and can therefore never be absolutely 'captured'.
•
The data was collected in two cultures, medical and nursing education. Data was collected in an arena with which nineteen years experience has made me familiar. Collecting data in one's own culture can be difficult. Assumptions are 'hidden' because so much is taken for granted. As Gluesing, (1995) recognises, 'No amount of awareness can keep one's own
native culture from subtly influencing perceptions.' (p: 33). However I also recognised that
- 275 -
studying a culture other than one's own presents problems of representation. No matter how well I have come to understand the underlying cultural axioms, behavioural norms and social systems present within medical education and practice I recognise that I remain an 'outsider' and as such can never truly speak as a 'native'. The methods chapter presented the details of the process of the study and my own particular perspective as a nurse in order to acknowledge the potential for cultural bias. However as far as possible the student informants are allowed to speak for themselves in the presentation of the findings.
•
Since the study was undertaken in a rapidly changing educational and organisational context with limited resources of time and money the practicalities had to be managed to fit within practicable limits. As such the geography of some of the clinical sites identified as providing the best examples of collaborative working and student inclusion were too geographically remote and would have demanded too much of my time and expense to make their inclusion feasible. However the use of different data sources which could be cross-referenced aimed to address potential gaps in the data.
Making these limitations explicit I consider provides an open frame of reference from which the preceding study scope, findings and conclusions may be judged.
9.3 Implications and recommendations The detailed description and interpretation of the clinical experiences of medical and nursing students has been directed by A need to understand the impact these experiences have on preparation for collaborative practices. This is based on a premise that greater understanding of how learning and practice are constituted at both an organisational, group and individual level will contribute to existing knowledge of the relationship between learning, participation and performance. The research study has added to this existing knowledge, emphasising the importance of participation in practice and consequently made a contribution to the
- 276 -
development of strategies that are consistent with the current ethos of service, which calls for more seamless care.
A model for education and practice The conceptual basis on which both interprofessional and clinical education is founded is questioned in the literature (Campbell & Johnson, 1999, Jolly, 1998). Representation of learning as progressive modes of engagement in a 'community of practice' provides some rationale for developments, which concur with the end-point, proposed in medical and nursing documentation that students should be 'fit to practice'. The process of facilitating participation in practice is outlined in the representational model overleaf (Figure 4).
Within this ‘centripetal participatory learning trajectory model’, the conceptual basis on which curriculum might be developed is founded on creating contexts which enable students to move towards fuller participation in the 'community of practice'. Teaching and learning curricula need to consider the move the student makes towards a 'being mode', or involved and integrated position in which they have a valued and valuable contribution to make to practice, with colleagues from their own and other professions. To acknowledge a criticism of nursing education students should be prepared to be qualified staff who can work with others rather than being prepared to be students in a relatively passive and hierarchically dominated position in the clinical structure.
- 277 -
Figure 4: The centripetal participatory learning trajectory: a representational model of the influences upon and proposed idealised process of student progression in relation to the community of practice.
- 278 -
The current situation identified in this study suggests that some students may gain qualified status without ever having really participated, to any significant degree, in the professional role to which they have gained membership. Collaboration with colleagues or indeed any interaction with those from other professions may have had little part in the educational, or learning process, of the two groups of professional newcomers under consideration in this study.
Utilising the model as a conceptual framework encourages attention to given to both the influences on student preparation for collaborative practices and the modes of engagement of practice that they should be encouraged to adopt as they progress to ‘fuller’ participative roles in the ‘community of practice’.
‘Teaching curriculum’: implications and recommendations •
Social organisation of programmes that maximise participation in the ‘community of
practice’ and facilitates movement through different modes of engagement. •
Clarification of the purpose of clinical education and the relationship between education and the service that students will be required to deliver after qualifying.
•
Educational research to identify the utility of uniprofessional clinical educational process in developing the capacity for collaborative practices.
•
Preparation of students for negotiating learning in the clinical domain and to this end curricular attention to interprofessional communication skills.
•
Allocation of a ‘home ward’ for students to facilitate both skills and relationship development.
•
Evaluation of models of multiprofessional clinical education facilitators to support clinical supervisors/ preceptors.
It is apparent from this study that participation, or explicitly modes and degrees of engagement in practice were a significant factor in the inclusion of students in the clinical role. Participation in a 'community' of practice’ provides the only learning experience in which collaborative
- 279 -
performance or practices can be directly realised. The representation of learning as a series of modes of engagement, which form a participatory trajectory and the movement of students towards a fuller role in the 'community of practice ' (See Figure 4, p: 277) offers both a conceptual rationale and a pragmatic direction for educational organisation and intervention. Future research should focus on understanding how teaching and learning curricula can best be developed to move students towards the 'being mode' of engagement in which they can realise directly collaborative practices, or the challenges faced in their performance.
The study highlights the paucity of interprofessional contact experienced by students of both medical and nursing professions. In the medical programme the problem appears to be exacerbated by the duration, pattern and location of placements which provide little opportunity for medical students to know or become known to staff in the clinical areas.
An interesting finding from the study was the reported disparity in clinical learning opportunity and inclusion in team between teaching and district general hospitals. Students related this factor primarily to throughput although some reported greater hierarchical divisions in the teaching hospital. This finding mirrors a similar description reported over 25 years ago (Atkinson 1974) and therefore warrants further attention, particularly in light of the increased demand for sites in which students can gain clinical experience.
In the nursing programme contact with medical staff appears to be limited by hierarchy.
‘Unwritten rules’ suggest that staff speak primarily across stratified levels, these stratifications relating most commonly to seniority. One area for further research would be to ask the important questions around how and why some students can successfully integrate into a clinical team or negotiate their own learning needs whilst others cannot. What qualities enable students to transcend the hierarchical divide and overcome the 'unwritten rules'?. Research might be undertaken to explore the relative significance of experience, background, personality and conditional context. Cross-comparison of the medical and nursing contexts provides contrasting media against which findings relating to such factors might be interpreted.
- 280 -
This study has also raised questions about the purpose of the clinical experience. If it is about gaining technical expertise then one might argue that greater structure and co-ordination is required so that students spend more time in planned learning situations and less 'hanging
around' or acting as a 'pair of hands'. If it is about developing the capacity to perform a full role then students need to have learning experiences that are designed to move them along the learning trajectory which creates gradually ‘fuller participation’ in the 'community of practice'.
Rather than research based on cognitive processes or conceptual structures, the focus of future research may be on the kinds of social engagements that provide meaningful contexts for collaboration to take place. If students are perceived as 'legitimate peripheral participants' within the model proposed by Lave and Wenger then goals and levels of engagement should facilitate increasing levels of role performance.
In the medical programme particularly, observed students had little opportunity to perform beyond a sequence of delegated tasks until their pre-registration period when they were part of the staffing establishment. Although they were ‘legitimate’ in the sense that they had a 'right' be present their ‘peripherality’ restricted any meaningful social engagement that would permit collaboration in practice.
If the clinical experience is perceived as a primary opportunity for collaborative development then greater emphasis should be given to the relationship and inclusion of students in the clinical workplace. The trends in education towards self-direction may enhance the potential of students to negotiate their own learning. More research however is warranted to evaluate the relationship between self-directed learning strategies and the development of collaborative potential. The ability to negotiate personal learning needs appeared to be an important feature in addressing personal educational needs. However students received little formal education in this area. Whilst both medical and nursing students had didactic and experiential sessions on communicating with patients neither syllabus overtly explored issues of communicating with other staff.
- 281 -
Clinical supervision or mentorship was a major contributor to the inclusion of students in clinical teams. However clinical staff adopting or being allocated such roles are often confronted by multiple pressures relating to care delivery, management responsibilities or research commitments and consequently increased resources to support clinical learning of both staff and students and facilitate engaged role performance amongst students are required. This might take the form of ‘clinical educational facilitators’.
In response to recognition of problems in delivering appropriate support to nursing students on placement, one NHS Trust recently implemented new support posts. These posts focused on a number of factors including mentorships practical assessment, developing the learning environment, teaching in practice, clinical skills acquisition and clinical link lecturers roles (Anonymous, 2000: 6). Initiatives proposed for developing support included 'a home' trust, student welcome packs, induction days, monthly support groups and clinical link lecturer groups. These address many of the problems identified in this study, however the recommendation arising from this study would be that such facilities should be multiprofessional.
The development of ‘clinical educational facilitator’ roles to promote the learning of both staff and students acknowledges the intimate and inseparable relationship between learning and performance. Such facilitators could offer support for clinical staff involved in education and promote interaction between students of different professions and between students and qualified staff. This would respond to Savage & Playdon's, (1995) suggestion that the demands of the educational role have become too wide to be sustained by clinicians.
Students identified that the multiple pressures on individuals to perform supervisory roles limited support. Additionally these roles were uniprofessional and as such did not bring together students from different professions. If learning through clinical experience is to be given overt recognition for the valuable learning and practising opportunities it provides, then more formalised organisational structures should be created to support this.
- 282 -
This study also illuminates the importance of relationships in supporting collaborative development. Whilst nursing students perform in a relatively communal context their interaction with medical staff was often limited. Greater emphasis must be placed on creating such contacts. In the medical curriculum the development of relationships is inhibited by numerous factors, including a heavy emphasis on knowledge acquisition, learning based on tasks, staff attitudes to teaching and the organisation of attachments, which are frequently short and geographically diffuse. Students require a breadth of experience which limits the opportunity for prolonged periods in single units. One solution may be to allocate individual students to a 'home
ward'. This could be a ward to which students could have free access for the duration of their programme. If students required specific skills, knowledge, access to patients they could return to these wards as required. This prolonged contact with single units provides a greater likelihood that students can know and become known to clinical staff in such areas.
Finally whilst this study has highlighted some of the issues relating to promotion of collaborative development it has also raised a question regarding the emphasis on interprofessional education as the primary route forward for developing collaboration. As Barr et al., (1999a) indicated, there is a danger that the proposition that interprofessional education cultivates collaboration is 'treated as self-evident truth.' (p: 11). There are numerous teaching, assessment, role and organisational strategies that could be adopted which will facilitate the potential for collaborative development often in uniprofessional contexts.
An implication for education from this study is therefore that the goal, delivery of seamless service to patients, should be the over-riding director of educational and learning strategy and can be achieved in a number of different ways. This is preferable to a perhaps rather misplaced assumption that if interprofessional education is logistically, financially, or culturally unfeasible then collaborative development cannot remain a significant curriculum goal.
- 283 -
‘Learning curriculum’: implications recommendations
•
Exploration of the influence of different working patterns and organisational pressures on the development of collaborative working and learning.
•
Evaluation of different clinical working patterns in relation to collaborative development
•
Interprofessional staff development to promote enhanced understanding of different professional perspectives and raise awareness of promoters and inhibitors of collaborative working and learning
•
Illuminate behaviours adopted by clinical staff, e.g. ‘clinical blinkering’, which currently exclude students from the ‘community of practice’.
•
Development of the construct of ‘community’ rather than ‘team’ as clinical organisational unit
In this study a number of environmental factors have been identified which appear to influence learning and practice relationships. These include the working patterns or 'professional spaces' adopted by staff, the hierarchy and the 'busyness' of the clinical areas. Areas where staff have closer relationships, often based on physical proximity or social interaction were reported to be generally more inclusive and collaborative. This highlights the importance of considering the factors that facilitate such relationships and then provides the challenge to demonstrate whether advocating collaborative practices is service rhetoric or commitment is available to make such changes. The litmus test may be the willingness to invest resources in the development of such environments.
Evidence was identified of a process in practice of 'clinical blinkering'. Students and more subordinate staff were often almost ‘invisible’ to qualified staff, creating barriers to social engagements. This action warrants further exploration, however it may act as both a survival mechanism for staff in a chaotic working environment and a divisive strategy in terms of developing a culture of inclusivity and collaboration.
- 284 -
The identification of such features of practice indicate that it may be worth considering alternative approaches to the organisational promotion of collaboration. The literature on the nature of collaborative working outlined in Chapter 2 indicated that 'the team' was the primary unit of organisational functioning. However a notable characteristic of teams is their exclusivity, or frequent professioncentrism, which potentially has an inhibitory affect on both continuity of care and collaboration. An alternative conceptualisation of the unit of organisation of clinical care may be provided by organisational systems founded on the promotion of a concept of
'community'.
Peck, (1987) defines a 'community' in terms of groups of individuals who have learned how to communicate honestly with each other, are committed to others within the community and have exposed their personhood to others rather than hiding behind a professional or work-role façade. For the purpose of developing collaborative contexts Peck proposes an important characteristic that defines community, that of 'inclusivity'. In the literature evidence of professional exclusivity was identified in the structure of teams (Cott, 2000, Cable et al., 1999), alienating lower status members of staff. This contrasts with Peck's, (1990) conceptualisation of communities,
'True communities,… if they want to remain such, are always reaching to extend themselves. The burden of proof falls upon exclusivity. Communities do not ask "How can we justify taking this person in?" Instead the question is "Is it at all justifiable to keep this person out?" In relation to other groupings of similar size or purpose, communities are always relatively inclusive.' (p: 61). Whilst Peck's arguments are based on a spiritual level of development, which may seem obtuse to an analysis of group behaviour for collaborative practices, his analysis of community
- 285 -
dynamics has resonance with work on the development of the 'learning organisation (Senge, 1990)' 97 . Senge proposes that organisational transformation requires a reintegration of 'systems
thinking' in order to develop an understanding of 'connectedness to the whole'. Senge argues that this requires a recognition and a need 'to continually expand our awareness and
understanding, to see more and more of the interdependencies between actions and our reality.' (p: 170).
The concept of community, rather than team provides an alternative way of looking at the group dynamics in clinical areas. Whilst it may to some extent appear a semantic division with considerable overlap existing between the ideas of ‘team’ and ‘community’, the former is identified as having a degree of professional exclusivity and the latter, as defined by Peck, is founded on ‘inclusivity’. Clinical areas are busy and often chaotic environments containing large groups of staff many of whom appear to reside outside the 'team' . Organisations emphasise the importance of team, however it may be that if emphasis was focused on development of a sense of community then more inclusive constructs might be generated.
Patient care : implications and recommendations
•
Patient centrality should be retained as the primary purpose of developing collaborative practice
•
Practices should be developed which promote more inclusive relationships and encourage patients to participate in decisions on the care processes
This study did not set out to directly consider the role of the patient but it acknowledges the centrality of the patient in developing collaborative care as a fundamental requirement. As
97
Peck’s identification of the characteristic of contemplation as a feature of communities also allies with West's (1999) subsequent identification of the importance of 'reflexivity', the ability for team members to stand back and critically examine themselves, their performance and their processes and make appropriate changes.
- 286 -
discussed in the previous section teams can often be exclusive and it may be that the patient will be excluded from multiprofessional teams. Thus it is important to consider the approach adopted.
Westberg and Jason (1993) propose that collaborative relationships between students and their teachers provides a model for collaborative relationships with their patients. Whilst there is little evidence to support this, and research in this area may provide a useful justification for future educational development, it seems a tenable assumption to make. Evidence was provided in this study of lack of continuity in patient care in certain areas and such scenarios as described in this study may provide useful triggers in exploring the need for collaboration with students.
Students also reported that whilst a ‘team’ in some form may be apparent in clinical areas,(the ward round provides an exemplar of this), the patient may well be excluded. If the centrality of the patient need is retained the emphasis becomes less of a pursuit of collaborative practices, but rather one of delivering appropriate care to the patient. As Barr et al., (1999b) indicate, the challenge is to identify the conditions under which collaboration operates and is appropriate rather than a pursuit of unquestioned collaboration which may be neither efficient nor effective in achieving organisational and individual goals.
- 287 -
Research method: implications and recommendations •
Qualitative methods should continue to be used to explore the complexity of collaborative practice and social engagements, which have complex social, moral and emotional attributes
•
Qualitative interpretative method provides a useful sensitising device and may also be a valuable educational tool for clinicians who use them.
•
Action research may provide a bridge for enabling staff to address some of the context specific factors which inhibit collaboration in the clinical domain
•
Quantitative methods may be the most appropriate tool for further evaluation of some of the findings arising form this study
This study has made it clear that qualitative research can be a powerful tool in exposing the many facets of the learning and working environment. It has illuminated features of the participative role of students, their engagement in practice and qualities that enhance collaborative potential. It has also identified organisational, professional and personal features in which learning and collaborative development is embedded. Organisations are filled with internal contradictions and conflicts offering many different meanings for conditions and events which occur and in which groups work and learn. Collaboration as a single concept is only one facet of the process of care delivery. However the qualitative approach adopted has attempted to provide a way of understanding processes situated within a larger social, cultural, historical and organisational context. As such this approach I consider is well suited to looking at practices situated in context.
The study was a product of both myself as the researcher and the subjects who participated in the study. As an observer in the clinical areas I gained insight into the isolation of being on a ward but outside 'the team'. Whilst this was not an experience totally like that of the medical students whom I was observing, it provided me with an understanding of the effects of
‘peripherality’, that I could never have obtained using any other research methodology. The
- 288 -
method adopted therefore provided both direct observational and personal experiential material from which the study developed.
The study has also highlighted areas for research that would more suitably pursued through other methodological routes. For example having recognised the modes of engagement it may be possible to attempt methods to quantify the collaborative potential of students who have engaged to different degrees in the three modes of 'seeing', 'doing' or 'being'. Alternatively having identified some of the factors that appear to inhibit collaboration action research may be a useful strategy to facilitate change in specific context.
The important lesson is that ultimately the research method must be appropriate for purpose. The contention of this study is that the approach adopted has addressed the aims listed at the outset. This was to provide a detailed account of clinical learning amongst medical and nursing students in order to compare and contrast the different bases of collaborative development and to provide a conceptual and pragmatic basis on which to develop future educational initiatives.
9.4 Summary The concept of collaboration and developing the potential for collaboration amongst newcomers to health care evidently has important implications for the future of service delivery and for the nature of professional groups. Considerable attention has been given to developing formal educational initiatives between different groups however less focus has been upon the nature of the collaborative role adopted by students in the clinical domain.
This study has illuminated some of the issues, which may influence collaborative development and consequently provides a ‘benchmark’ interpretation of the different curricular and organisational effects, which might be considered in enhancing this development. At the same time it recognises the need for consistency between educational preparation, service delivery and patient needs. There is a need to continuously monitor and evaluate strategies for
- 289 -
promoting collaboration whilst giving attention to the wider social, cultural and political trends which are also influential on the nature and delivery of health care and professional education. Educational and organisational strategies may be uniprofessional or interprofessional, however the over-riding focus should be that they deliver responsive and sensitive care that is appropriate to patient needs.
- 290 -
REFERENCES Abbott, A. (1988), The System of Professions: an Essay on the Division of Expert Labour, Chicago, Chicago University Press. Adamson, B., Kenny, D. and Wilson-Barnett, J. (1995), ‘The impact of perceived medical dominance on the workplace satisfaction of Australian and British Nurses’, Journal of Advanced Nursing, 21, 1, 172-183. Adler, P. and Adler, P. (1998), ‘Observational techniques’, in Denzin, N. and Lincoln, Y. (eds.), Collecting and Interpreting Qualitative Materials, Thousand Oaks, Sage. Allen, D. (1996), ‘The Shape of General Hospital Nursing: The Division of Labour at Work’, PhD Thesis, Nottingham, University of Nottingham. Allen, D. (1997), ‘The nursing-medical boundary: a negotiated order?’, Sociology fo Health and
Illness, 19, 4, 498-520.
Allport, G. (1942), 'The Use of Personal Documents in Psychological Science'. Bulletin 49, New York, Social Science Research Council. Altheide, D. (1987), ‘Ethnographic content analysis’, Qualitative Sociology, 10, 1, 65-77. Alt-White, A., Charns, M. and Strayer, R. (1983), ‘Personal, organizational and managerial factors related to nurse-physician collaboration’, Nursing Administration Quarterly, 8, 8-18. Annandale, E., Clark, J. and Allen, E. (1999), ‘Interprofessional working: an ethnographic case study of emergency health care’, Journal of Interprofessional Care, 13, 2, 139-150. Annandale, S., McCann, S., Nattrass, H., Regan de Bere, S., Williams, S. and Evans, D. (2000), ‘Achieving health improvements through interprofessional learning in south west England’, Journal of Interprofessional Care, 14, 2, 161-174. Annells, M. (1997a), ‘Grounded theory method, part 1: within the five moments of qualitative research’, Nursing Inquiry, 4, 120-129. Annells, M. (1997b), ‘Grounded theory method, part 2: options for users of the method’,
Nursing Inquiry, 4, 176-180.
Anonymous (2000), ‘Meeting the Challenge’, Edlines. RCN Newsletter for Nurses Working in
Education, Summer 2000, 6.
Argyris, C. and Schon, D. (1974), Theory in Practice. Increasing Professional Effectiveness, San Francisco, Jossey-Bass. Armiger, B. (1977), ‘Ethics of nursing research: profile, principles, perspective’, Nursing
Research, 26, 5, 330-336.
Ash, E. (1994), ‘The personal-professional interface in learning: towards reflective education’, Journal of Interprofessional Care, 6, 3, 261-271. Atkins, J. and Walsh, R. (1997), ‘Developing shared learning in multiprofessional health care education: for whose benefit?’, Nurse Education Today, 17, 319-324.
- 291 -
Atkinson, P. (1973), ‘Worlds apart. Learning environments in medicine and surgery’, British Journal of Medical Education, 7, 218-224. Atkinson, P. (1974), ‘'Centre' and 'periphery': Further analysis of learning environments in the Edinburgh Medical School’, British Journal of Medical Education, 8, 234-240. Atkinson, P. (1977), ‘Professional segmentation and students' experience in a Scottish medical school’, Scottish Journal of Sociology, 2, 71-85. Atkinson, P. (1981), The Clinical Experience. The Construction and Reconstruction of Medical Reality, Farnborough, Hants, Gower Publishing Co. Ltd. Atkinson, P. and Delamont, S. (1977), ‘Mock-ups and Cock-ups: The Stage Management of Guided Discovery Instruction’, in Woods, P. and Hammersley, M. (eds.), School Experience, London, Croom Helm. Audit Commission (1992), ‘Homeward Bound: A new course for community health’, London, HMSO. Baggs, J., Phelps, C. and Johnson, J. (1992), ‘The association between interdisciplinary education and patient outcomes in a medical intensive care unit’, Heart and Lung, 21, 1, 18-24. Baggs, J. and Schmitt, M. (1988), ‘Collaboration between nurses and physicians’, Image, 20, 145-149. Baker, C., Wuest, J. and Stern, P. (1992), ‘Method slurring: the grounded theory/ phenomenology example’, Journal of Advanced Nursing, 17, 1355-1369. Bandura, A. (1972), ‘Modeling Theory: Some Traditions, Trends and Disputes’, in Parke, R. (ed.), Recent Trends in Social Learning Theory, New York, Academic Press. Banta, D. and Fox, R. (1972), ‘Role strains of a health care in a poverty community’, Social Science and medicine, 6, 607-722. Barnard, A. and Dunn, S. (1994), ‘Issues in the organization and structure for clinical education for undergraduate nursing programs’, Journal of Nursing Education, 33, 9, 420-422. Barr, H. (1996), ‘Ends and means in interprofessional education: towards a typology’,
Education for Health, 9, 3, 341-352.
Barr, H. (1998), ‘Competent to collaborate: towards a competency-based model for interprofessional education’, Journal of Interprofessional Care, 12, 2, 181-187. Barr, H. (2000), ‘New NHS, new collaboration, new agenda for education’, Journal of
Interprofessional Care, 14, 1, 81-86.
Barr, H., Freeth, D., Hammick, M., Koppel, I. and Reeves, S. (1999a), ‘Evaluating Interprofessional Education: A United Kingdom Review for Health and Social Care’, London, The British Educational Research Association and the United Kingdom Centre for the Advancement of Interprofessional Education. Barr, H., Hammick, M., Koppel, I. and Reeves, S. (1999b), ‘Evaluating Interprofessional Education: two systematic reviews for health and social care’, British Educational Research Journal, 25, 4, 533-544. Barr, O. (1997), ‘Interdisciplinary teamwork: consideration of the challenges’, British Journal of
Nursing, 6, 17, 1005-1010.
- 292 -
Beattie, A. (1995), ‘War and peace among the health tribes’, in Soothill, K., Mackay, L. and Webb, C. (eds.), Interprofessional Relations in Health Care, London, Edward Arnold. Becker, H., Geer, B., Hughes, E. and Strauss, A. (1961), Boys on White, Chicago, University of Chicago Press. Belbin, M. (1993), Team Roles at Work, Oxford, Butterworth Heineman. Benner, P. (1984), From Novice to Expert. Excellence and Power in Clinical Nursing Practice, Menlo Park, California, Addison-Wesley. Benner, P. (ed.) (1994), Interpretive Phenomenology. Embodiment, Caring, and Ethics in Health and Illness, Thousand Oaks, California, Sage Publications. Benney, M. and Hughes, E. (1984), ‘Of sociology and the interview’, in Bulmer, M. (ed.), Sociological Research Methods. An Introduction (2nd Edition), New York, Macmillan. Bevis, E. and Watson, J. (1989), Toward a Caring Curriculum: A New Pedagogy for Nursing, New York, National League for Nursing. Bezzina, P., Keogh, J. and Keogh, M. (1998), ‘Teaching primary health care: an interdisciplinary approach’, Nurse Education Today, 18, 36-45. Bjork, I. (1997), ‘Changing conceptions of practical skill and skill acquisition in nursing education’, Nursing Inquiry, 4, 184-195. Bondy, K. (1983), ‘Criterion-referenced definitions for rating scales in clinical evaluation’, Journal of Nursing Education, 22, 9, 376-382. Branch, W. and Pels, R. (1994), ‘The value of medical students critical incident reports’, Forum. Braye, S. and Preston-Shoot, M. (2000), ‘Keys to Collaboration’, in Davies, C., Finlay, L. and Bullman, A. (eds.), Changing Practice in Health and Social Care, London, Sage. Brown, T. (1982), ‘An historical view of health care teams’, in Agich, G. (ed.), Responsibility in
health care, Dordrecht, Holland, D. Reidel Publishing Co.
Bruner, J. (1966), Towards a Theory of Instruction, Belknap, Cambridge, Massachusetts. Bullimore, D. (1998), Study Skills and Tomorrow's Doctors, Edinburgh, WB Saunders. Burgess, R. (1984), In the Field: An Introduction to Field Research, London, Allen and Unwin. Busby, A. and Gilchrist, B. (1992), ‘The role of the nurse in the medical ward round’, Journal of Advanced Nursing, 17, 3, 339-346. Cable, S., Dunkley, J., Ker, J. and Matthews, A. (1999), ‘Audio-recording 'critcal incidents' - piloting a methodology for evaluating multiprofessional health care practice’, Dundee, University of Dundee. Calman, K. (1993), ‘Hospital doctors training for the future. The report of the working group on specialist medical training’, London, Department of Health. Campbell, J. and Johnson, C. (1999), ‘Trend spotting: fashions in medical education’, British
Medical Journal, 318, 1272-1275.
- 293 -
Campos-Outcault, D., Senf, J., Watkins, A. and Bastacky, S. (1995), ‘The effects of medical school curricula, faculty role models, and biomedical research support on choice of generalist physician careers: a review and quality assessment of the literature’, Academic Medicine, 70, 7, 611-619. Carpenter, J. (1995), ‘Interprofessional education for medical and nursing students: evaluation of a programme’, Medical Education, 29, 265-272. Carter, H. (1994), ‘Confronting patriarchal attitudes in the fight for professional recognition’, Journal of Advanced Nursing, 19, 367-372. Charmaz, K. (1990), ‘"Discovering" chronic illness: using grounded theory’, Social Science and medicine, 30, 11, 1162 -1172. Chenitz, W. (1986), ‘Getting started: the research proposal for a grounded theory study’, in Chenitz, W. and Swanson, J. (eds.), From Practice to Grounded Theory. Qualitative Research in Nursing, Menlo Park, Addison Wesley. Christman, L. (1988), ‘A conceptual model for centers of excellence in nursing’, Nursing Administration Quarterly, 12, 4, 1-4. Cicourel, A. (1964), Method and Measurement in Sociology, London, The Free Press. Coles, C. (1990), ‘Elaborated learning in undergraduate medical education’, Medical education, 24, 14-22. Coles, C. (1993), ‘cited by’, in Lowry, S. (ed.), Medical Education, London, BMJ Publishing Group. Coles, C. (1998), ‘How students learn: the process of learning’, in Jolly, B. and Rees, L. (eds.), Medical education in the millennium, Oxford, Oxford University Press. Coluccio, M. and Macguire, P. (1983), ‘Collaborative practice: becoming a reality through primary nursing’, Nursing Administration Quarterly, 7, 59-63. Cormack, D. (1983), Psychiatric Nursing Described, Edinburgh, Churchill Livingstone. Cott, C. (2000), ‘Structure and meaning in multidisciplinary teamwork’, in Davies, C., Finlay, L. and Bullman, A. (eds.), Changing Practice in Health Care, London, Sage. Coulter, M. (1988), ‘The Needs of Family Members of Patients in Intensive Care Units’, Manchester, University of Manchester. Cribb, A. and Bignold, S. (1999), ‘Towards the reflexive medical school: the hidden curriculum and medical education research’, Studies in Higher Education, 24, 2, 195-209. Dachelet, C., Wemett, M., Garling, E., Craig-Kuhn, K., Kent, N. and Kitzman, H. (1981), ‘The critical incident technique applied to the evaluation of the clinical practicum setting’, Journal of Nursing Education, 20, 8, 15-31. Dacre, J. (1998), ‘Clinical work and teaching’, in Jolly, B. and Rees, L. (eds.), Medical Education in the Millennium, Oxford, Oxform Medical Publications. Davidson, L. and Lucas, J. (1995), ‘Multiprofessional education in the undergraduate health professions curriculum: observations from Adelaide, Linkoping and Salford’, Journal of Interprofessional Care, 9, 2, 163-176.
- 294 -
Davies, C. (2000a), ‘Care and the transformation of professionalism’, in Davies, C., Finlay, L. and Bullman, A. (eds.), Changing Practice in Health and Social Care, Sage, London. Davies, C. (2000b), ‘Improving the quality of services’, in Brechin, A., Brown, H. and Eby, M. (eds.), Critical Practice in Health and Social Care, London, Sage. Davies, C., Finlay, L. and Bullman, A. (eds.) (2000), Changing Practice in Health and Social Care, Sage, London. Dent, J. (In Press), ‘Ambulatory Care’, in Harden, R. and Dent, J. (eds.), A Practical Guide for Medical Teachers, London, Balliere Tindall. Denzin, N. (1970), The Research Act, Chicago, Aldine. Denzin, N. (1978), The Research Act. A Theoretical Introduction to Sociological Methods (2nd Edition), New York, McGraw Hill. Denzin, N. and Lincoln, Y. (eds.) (1994), Handbook of Qualitative Research, Sage, Thousand Oaks. Denzin, N. and Lincoln, Y. (1998), ‘Introduction: Entering the field of qualitative research’, in Denzin, N. and Lincoln, Y. (eds.), Collecting and Interpreting Qualitaive Materials, Thousand Oaks, Sage. Department of Health (1997), The New NHS: Modern, Dependable, London, HMSO. Department of Health (1998a), A First Class Service. Quality in the New NHS, London, HMSO. Department of Health (1998b), Modernising health and social services: Promoting independence, improving protection, raising standards, London, Department of Health. Department of Health (1999a), ‘Making a Difference, Strengthening nursing, midwifery and health visiting contribution to health and healthcare’, London, Department of Health. Department of Health (1999b), Our Healthier Nation. A Contract for Health, London, HMSO. Department of Health (2000), A Health Service of all the talents: Developing the NHS workforce, London, Department of Health. Devereux, P. (1981a) 'Essential elements of nurse-physician collaboration', Journal of Nursing Administration, 11, 5, 19-23 Devereux, P. (1981b) 'Does joint practice work?', Journal of Nursing Administration, 11, 6, 3943 Devereux, P. (1981c), ‘Nurse-physician collaboration: nursing practice considerations’, Journal of Nursing Administration, 11, 9, 37-39. Dey, I. (1993), Qualitative Data Analysis, London, Routledge. Dingwall, R. and McIntosh, J. (1978), ‘Teamwork in theory and practice’, in Dingwall, R. and McIntosh, J. (eds.), Readings in the Sociology of Nursing, Edinburgh, Churchill Livingstone. Dolan, B. (ed.) (1993), Project 2000: Reflection and Celebration, Scutari, London.
- 295 -
Dolmans, D. and Schmidt, H. (1996), ‘The advantages of problem-based curricula’, Postgraduate Medical Journal, 72, 851, 535-538. . Drew, N. (1993), ‘Reenactment interviewing: a methodology for phenomenological research’,
IMAGE: Journal of Nursing Scholarship, 25, 4, 345-351.
Dumelow, C., Littlejohns, P. and Griffiths, S. (2000), ‘Relation between a career and family life for English hospital consultants: qualitative, semi-structured interview study’, British Medical Journal, 320, 1437-1440. Dunn, S., Stockhausen, L., Thornton, R. and Barnard, A. (1995), ‘The relationship between clinical education format and selected student outcomes’, Journal of Nursing Education, 34, 1, 16-24. Edward, C., Roberts, A. and Small, J. (in press), ‘A perspective on shared teaching in ethics’, in Glen, S. and Leiba, T. (eds.), Multiprofessional Learning for a Nurse. Breaking the Boundaries, London, Macmillan. Elkjaer, B. (1999), ‘In search of social learning theory’, in Easterby-Smith, M., Burgoyne, J. and Araujo, L. (eds.), Organizational Learning and the Learning Organization, London, Sage. Ely, M., Vinz, R., Downing, M. and Anzul, M. (1997), On Writing Qualitative Research. Living by Words, London, Falmer Press. Evans, J. (1994), ‘The role of the nurse manager in creating an environment for collaborative practice’, Holistic Nursing Practice, 8, 22-31. Feiger, S. and Schmitt, M. (1979), ‘Collegiality in interdisciplinary health teams: its measurement and its effects’, Social Science and Medicine, 13A, 217-229. Field, P. (1989), ‘Implementing change in nurse education’, Nurse Education Today, 9, 290299. Field, P. and Morse, J. (1985), Nursing Research: The Application of Qualitative Approaches, London, Croom Helm. Field, R. and West, M. (1995), ‘Teamwork in primary health care 2: perspectives from practices’, Journal of Interprofessional Care, 9, 2, 123-130. Financial Times Business (1999), Directory of Hospitals and NHS Trusts 1999/2000, London, Financial Times Business. Finlay, L. (2000a), ‘The Challenge of Working in Teams’, in Brechin, A., Brown, H. and Eby, M. (eds.), Critical Practice in Health and Social Care, London, Sage. Finlay, L. (2000b), ‘Safe haven and battleground: collaboration and conflict within the treatment team’, in Davies, C., Finlay, L. and Bullman, A. (eds.), Changing Practice in Health and Social Care, London, Sage. Firth-Cozens, J. (1987), ‘Emotional distress in junior house officers’, British Medical Journal, 295, 533-535. Fish, D. and Purr, B. (1991), ‘An evaluation of practice-based learning in continuing professional education in nursing, midwifery and health visiting’, Project Paper 4, London, English National Board. Flanagan, J. (1954), ‘The Critical Incident Technique’, Psychological Bulletin, 51, 4, 327-358.
- 296 -
Foucault, M. (1973), The Birth of the Clinic, London, Tavistock. Foucault, M. (1975), Discipline and Punish, New York, Vintage Books. Fowkes, F. (1982), ‘Medical audit cycle’, Medical Education, 16, 228-238. Fox, R. (1979), Essays in Medical Sociology: journeys in the field, New York, John Wiley and Sons. Freeth, D., Meyer, J., Reeves, S. and Spilsbury, K. (1999), ‘Linking interprofessional education to user benefit: of drops in the ocean and stalactites’, Advancing Clinical Nursing, 3, 127-135. Freeth, D. and Nicol, M. (1998), ‘Learning clinical skills: an interprofessional approach’, Nurse
Education Today, 18, 455-461.
Freeth, D. and Reeves, S. (1999), ‘Interprofessional Training Ward: Pilot Phase’, London, City University. Freire, P. (1970), Pedagogy of the Oppressed (Revised Edition 1996 Edition), London, Penguin. Freire, P. (1994), Pedagogy of Hope. Reliving Pedagogy of the Oppressed, New York, Continuum. Fromm, E. (1976), To Have or To Be?, London, Abacus. Fromm, E. (1993), The Art of Being, London, Constable. Geertz, C. (1988), Works and Lives: The Anthropologist as Author, Cambridge, Polity Press. Gelmon, S., White, A., Carlson, L. and Norman, L. (2000), ‘Making organizational change to achieve improvement and interprofessional learning: perspectives from health professions educators’, Journal of Interprofessional Care, 14, 2, 131-146. GMC. (1993), ‘Tomorrow's Doctors. Recommendations on Undergraduate Medical Education’, London, General Medical Council. GMC. (1997), The New Doctor, London, General Medical Council. GMC (1999), ‘The doctor as teacher’, London, General Medical Council. GMC (2000), ‘Revalidating Doctors. Ensuring standards, securing the future. Summary’, London, General Medical Council. Gerrish, C. (1986), ‘The newly qualified staff nurse's perception of the transition from student to trained nurse’, Manchester, University of Manchester. Gillam, S. and Irvine, S. (2000), ‘Editorial. Collaboration in the New NHS’, Journal of
Interprofessional Care, 14, 1, 5-7.
Glaser, B. (1978), Advances in the Methodology of Grounded Theory. Theoretical Sensitivity, Mill Hill, The Sociological Press. Glaser, B. (1992), Emergence vs. forcing: basics of grounded theory analysis, Mill Valley, The Sociology Press.
- 297 -
Glaser, B. and Strauss, A. (1967), The Discovery of Grounded Theory. Strategies for Qualitative Research, London, Weidenfeld and Nicolson. Glen, S. (1999), ‘The demise of the apprenticeship model’, in Nicol, M. and Glen, S. (eds.), Clinical Skills in Nursing. The Return to the Practical Room?, Basingstoke, MacMillan. Gluesing, J. (1995), ‘Fragile Alliances: Negotiating Global Teaming in a Turbulent Environment’, PhD Thesis, Michigan, University of Michigan. Goldfracht, M., Van-Raalte, R., Sifroni, A. and Itzchak, B. (2000), ‘Multiprofessional continuing medical education - Israeli experience (Abstract 2I/3)’, Horizon Scanning in Medical Education: 2020 Vision, , Association for Medical Education in Europe Conference, Ben Gurion University of the Negev, Beer Sheva, Israel Goleman, D. (1997), Emotional Intelligence, New York, Bantam Books. Gough, P., Maslin-Prothero, S. and Masterson, A. (1993), ‘A reflection on issues of practice’, in Dolan, B. (ed.), Project 2000. Reflection and Celebration, London, Scutari. Greenwood, J. (1984), ‘Nursing research: a position paper’, Journal of Advanced Nursing, 9, 77-82. Guba, E. and Lincoln, Y. (1981), Effective Evaluation: Improving the Effectiveness of Evaluation Results Through Responsive and Naturalistic Approaches, San Francisco, Jossey Bass.
Haas, J. and Shaffir, W. (1982), ‘Ritual evaluation of competence: the hidden curriculum of professionalization in an innovative medical school program’, Work and Occupations, 9, 131154. Haas, J. and Shaffir, W. (1984), ‘The 'fate of idealism' revisited’, Urban Life, 13, 63-81. Hall, J. and Stevens, P. (1991), ‘Rigor in feminist research’, Advances in Nursing Science, 13, 3, 16-29. Hallet, C., Williams, A. and Butterworth, T. (1996), ‘The learning career in the community setting: a phenomenological study of a Project 2000 placement’, Journal of Advanced Nursing, 23, 578-586. Hammersley, M. (1992), What's wrong with Ethnography? Methodological Explorations, London, Routledge. Hammersley, M. and Atkinson, P. (1983), Ethnography: Principles in Practice, London, Tavistock. Hanks, W. (1991), ‘Foreword’, in Lave, J. and Wenger, E. (eds.), Situated Learning: Legitimate Peripheral Participation, Cambridge, Cambridge University Press. Harden, R. (1986), ASME Medical Education Booklet No 21. Approaches to Curriculum Planning, Dundee, Dundee Association for the Study of Medical Education. Harden, R. (1998a), ‘AMEE guide No.12: Multiprofessional education: Part 1 - effective multiprofessional education: a three-dimensional perspective’, Medical Teacher, 20, 5, 402-408. Harden, R. (1998b), ‘Change - building windmills not walls’, Medical Teacher, 20, 189-191.
- 298 -
Harden, R., Crosby, J. and Davis, M. (1999), ‘AMEE Guide No.14: Outcome-based education: Part 1 - An introduction to outcome-based education’, Medical Teacher, 21, 1, 7-14. Harden, R., Davis, M. and Crosby, J. (1997), ‘The new Dundee curriculum: a whole that is greater than the sum of the parts’, Medical Education, 31, 264-271. Harden, R., Laidlaw, J., Ker, J. and Mitchell, H. (1996), ‘AMEE Medical Education Guide No. 7. Task-based learning: an educational strategy for undergraduate, postgraduate and continuing medical education, Part 1’, Medical Teacher, 18, 1, 7-13. Harding, G. and Gantley, M. (1998), ‘Qualitative methods: beyond the cookbook’, Family Practice, 15, 1, 76-79. Harris, D. (1998), ‘Assessment’, in Peyton, J. (ed.), Teaching and Learning in Medical Practice, Rickmansworth, Herts, Manticore Europe Ltd. Hawkins, J. (ed.) (1986), The Oxford Reference Dictionary, Clarendon Press, Oxford. Headrick, L., Wilcock, P. and Batalden, P. (1998), ‘Interprofessional working and continuing medical education’, British Medical Journal, 316, 771-774. Henneman, E. (1995), ‘Nurse-physician collaboration: a poststructural review’, Journal of Advanced Nursing, 22, 359-363. Henneman, E., Lee, J. and Cohen, J. (1995), ‘Collaboration: a concept analysis’, Journal of Advanced Nursing, 21, 103-109. Henson, M. (1991), ‘Reflection in clinical teaching: an analysis of reflection-on-action and its implications for staffing residents’, Medical Teacher, 13, 227-231. Hewstone, M. and Brown, R. (1986), ‘Contact is not enough: an intergroup perspective on the 'contact hypothesis'’, in Hewstone, M. and Brown, R. (eds.), Contact and Conflict in Intergroup Encounters, Oxford, Blackwell. Hill, J., Rolfe, I., Pearson, S. and Heathcote, A. (1998), ‘Do junior doctors feel they are prepared for hospital practice? A study of graduates from traditional and non-traditional medical schools’, Medical Education, 32, 19-24. Horder, J. (1995), ‘Interprofessional education for primary health and community care: present state and future needs’, in Soothill, K., Mackay, L. and Webb, C. (eds.), Interprofessional Relations in Health Care, London, Edward Arnold. House of Commons Health Committee (1999), ‘Third Report: Future NHS staffing requirments’, London, HMSO. Howard, J. and Byl, N. (1971), ‘Pitfalls in interdisciplinary teaching’, Journal of Medical
Education, 46, 9, 772-781.
Howkins, E. (1995), ‘Collaborative Care: an agreed goal but a difficult journey’, in Cain, P., Hyde, V. and Howkins, E. (eds.), Community Nursing: Dimensions and Dilemmas, London, Arnold. Howkins, E. and Allison, A. (1997), ‘Shared learning for primary health care teams: a success story’, Nurse Education Today, 17, 225-231.
- 299 -
Hudson, B. (1999), ‘Overcoming organisational barriers’, in Willams, G. and Willson, S. (eds.), The collaborative imperative: Overcoming the barriers in health and social care (St Catherine's Report No.66 Edition), Cumberland Lodge, Windsor, The King George IV and Queen Elizabeth Foundation of St. Catherine. Hudson, B. (2000), ‘Inter-agency collaboration - a sceptical view’, in Brechin, A., Brown, H. and Eby, M. (eds.), Critical Practice in health and Social Care, London, Sage. Hudson, H. (1997), ‘Seminar on Multiprofessional Education’, NBS News, Edinburgh. Hughes, D. (1988), ‘When nurse knows best: some aspects of nurse/doctor interaction in a casualty department’, Sociology of Health and Illness, 10, 1, 1-22. Hughes, E. (1984), The Sociological Eye, London, Transaction Books. Hutchinson, S. and Webb, R. (1989), ‘Teaching qualitative research: perennial problems and possible solutions’, in Morse, J. (ed.), Qualitative Nursing Research. A Contemporary Dialogue (Revised Edition), Newbury Park, Sage. Huxham, C. and MacDonald, D. (1992), ‘Introducing collaborative advantage’, Management
Decision, 30, 3, 50-56.
Hycner, R. (1985), ‘Some guidelines for the phenomenological analysis of interview data’, Human Studies, 8, 279-303. Hyman, H. (1954), Interviewing in Social research, Chicago, University of Chicago Press. Jasper, M. (1995), ‘The potential for the professional portfolio for nursing’, Journal of
Advanced Nursing, 4, 249-255.
Jasper, M. (1996), ‘The first year as a staff nurse: the experiences of a first cohort of Project 2000 nurses in a demonstration district’, Journal of Advanced Nursing, 24, 779-790. Johnson, N. (1992), ‘Collaboration - an environment for optimal outcome’, Critical Care
Nursing, 15, 3, 37-43.
Jolly, B. (1998), ‘Historical and theoretical background’, in Jolly, B. and Rees, L. (eds.), Medical education in the millennium, Oxford, Oxford Medical Publications. Jones, M., Siraj-Blatchford, J. and Ashcroft, K. (eds.) (1997), Researching into Student Learning and Support in Colleges and Universities, Kogan Page, London. Kahn, R. and Cannell, C. (1957), The Dynamics of Interviewing, New York, John Wiley and Sons. Kalisch, B. and Kalisch, P. (1977), ‘An analysis of the source of physician-nurse conflict’, Journal of Nursing Administration, 7, 1, 51-57. Kaplan, R. (1996), The Ends of the Earth, New York, Random House. Keen, E. (1975), A Primer in Phenomenological Psychology, New York, Holt, Reinhart and Winston Inc. Kerlinger, F.N. (1986), Foundations of Behavioural Research (3rd Edition), New York, Holt, Rinehart and Winston.
- 300 -
Kilmann, R. and Thomas, K. (1977), ‘Developing a forced-choice measure of conflicthandling behaviour: the MODE instrument’, Educational and Psychological Measurement, 37, 309-325. Knowles, M. (1975), Self-Directed Learning: A Guide for Learners and Teachers, Chicago, Follett. Koerner, B. and Armstrong, D. (1984), ‘Collaborative practice care cuts cost of patient care: study’, Hospitals, 58, 10, 52-54. Koerner, B., Cohen, J. and Armstrong, D. (1985), ‘Collaborative practice and patient satisfaction’, Evaluation and the Health Professions, 8, 299-321. Koerner, B., Cohen, J. and Armstrong, D. (1986), ‘Professional behaviour in collaborative practice’, Journal of Nursing Administration, 16, 39-43. Kolb, D. (1984), Experiential Learning: Experience as a Source of Learning and Development. Krathwohl, D. (1985), ‘From Discovery to Confirmation. Building the Chain of Reasoning’,
Social and Behavioural Science Research, San Francisco, Jossey Bass.
Kriel, J. and Hewson, M. (1986), ‘Conceptual frameworks in preclinical and clinical textbooks’, Medical Education, 20, 94-101. Kyle, M. (1995), ‘Collaboration’, in Snyder, M. and Mirr, M. (eds.), Advanced practice nursing. A guide to professional development., New York, Springer Publishing Company. Lave, J. and Wenger, E. (1991), Situated Learning: Legitimate Peripheral Participation, Cambridge, Cambridge University Press. Lawton, D. (1983), Curriculum Studies and Educational Planning, London, Hodder and Stoughton. Leathard, A.E. (1994), Going Inter-professional. Working Together for Health and Welfare, London, Routledge. Leinster, S. and Dangerfield, P. (1996), ‘Obstacles to real change in medical education’, Education for Health, 9, 1, 25-30. Lincoln, Y. and Guba, E. (1985), Naturalistic Inquiry, Newbury Park, Sage Publications. Lloyd-Jones, M. and Akehurst, R. (1997), ‘Clinical placements for student nurses and midwives: An evaluation of costs and practices.’, ScHARR, Universtiy of Sheffield, ScHARR Occasional Paper N.97/1. Lofland, J. and Lofland, L. (1984), Analysing Social Settings. A Guide to Qualitative Observation and Analysis (2nd Edition), Belmont, California, Wadsworth Publishing Co. Lofland, J. and Lofland, L. (1995), Analyzing Social Settings. A guide to qualitative observation and analysis (3rd Edition), Belmont, Wadsworth. Lowry, S. (1993), Medical Education, London, BMJ Publishing Group. Loxley, A. (1997), Collaboration in Health and Welfare. Working with Difference, London, Jessica Kingsley Publishers.
- 301 -
Lynaugh, J. and Bates, B. (1973), ‘The two languages of nursing and medicine’, American
Journal of Nursing, 73, 66-69.
Mackay, L. (1990), ‘Nursing: Just another job?’, in Abbott, P. and Wallace, C. (eds.), The Sociology of the Caring Professions, London, Falmer. Mackay, L. (1993), Conflicts in Care: Medicine and Nursing, London, Chapman and Hall. Mackay, L., Soothill, K. and Webb, C. (1995), ‘Troubled times: the context for interprofessional collaboration’, in Soothill, K., Mackay, L. and Webb, C. (eds.), Interprofessional Relations in Health Care, London, Edward Arnold. Macleod Clark, J., Maben, J. and Jones, K. (1997a), ‘Project 2000. Perceptions of the philosophy and practice of nursing: preparation for practice’, Journal of Advanced Nursing, 26, 246-256. Macleod Clark, J., Maben, J. and Jones, K. (1997b), ‘Project 2000: perceptions of the philosophy and practice of nursing: shifting perceptions- a new practitioner?’, Journal of Advanced Nursing, 26, 161-168. Maines, D. and Charlton, J. (1985), ‘The negotiated order approach to the analysis of social organisation’, in Faberman, H. and Perinbanayagam, R. (eds.), Foundations of Interpretative Sociology: Original Essays in Symbolic Interaction Studies. Supplement 1, Greenwich, Conneticut, JAI Press Inc. Marriott, A. (1991), ‘The support, supervision, and instruction of nurse learners in clinical areas: a literature review’, Nurse Education Today, 11, 261-269. Marton, F. and Saljo, R. (1976), ‘On qualitative differences in learning’, British Journal of
Eduactional Psychology, 46, 4-11.
Mason, E. and Parascondola, J. (1972), ‘Preparing tomorrows health care team’, Nursing
Outlook, 20, 11, 728-731.
Mason, J. (1996), Qualitative Researching, London, Sage. Mathias, P., Prime, R. and Thompson, T. (1997), ‘Preparation for Interprofessional Work: Holism, Integration and the Purpose of Training and Education’, in Ovretveit, J., Mathias, P. and Thompson, T. (eds.), Interprofessional Working for Health and Social Care, Basingstoke, Macmillan Press. May, K. (1986), ‘Writing and evaluating the grounded theory research report’, in Chenitz, W. and Swanson, J. (eds.), From Practice to Grounded Theory. Qualiatative Research in Nursing, Menlo Park, Addison Wesley. May, N. and Veitch, L. (1998), ‘Working to learn and learning to work: placement experiences of Project 2000 nursing students in Scotland’, Nurse Education Today, 18, 630-636. Mays, N. and Pope, C. (2000), ‘Qualitative research in health care: assessing quality in qualitative research’, British Medical Journal, 320, 50-52. Mazur, H., Beeston, J. and Yerxa, E. (1979), ‘Clinical interdisciplinary health team care: an educational experiement’, Journal of Medical Education, 54, 9, 703-713. McCarey, M. and Mires, G. (in press), ‘Interprofessional teaching programme on normal labour for midwifery and medical students’, in Glen, S. and Leiba, T. (eds.), Multiprofessional Learning for a Nurse. Breaking the Boundaries, London, Macmillan.
- 302 -
McKenna, G. (1995), ‘Learning theories made easy: cognitivism’, Nursing Standard, 9, 30, 2528. McMichael, P. and Gilloran, A. (1984), Exchanging views: course in collaboration, Edinburgh, Moray House College. McMichael, P., Molleson, J. and Gilloran, A. (1984), Teaming up to problem-solve, Edinburgh, Moray House College. Melia, K. (1979), ‘A sociological approach to the analysis of nursing work’, Journal of Advanced
Nursing, 4, 57-67.
Melia, K. (1987), Learning and Working. The Occupational Socialization of Nurses, London, Tavistock Publications. Melia, K. (1996), ‘Rediscovering Glaser’, Qualitative Health Research, 6, 3, 368-378. Miller, C., Ross, N. and Freeman, M. (1999), ‘Shared Learning and Clinical Teamwork: new directions in education for multiprofessional practice’, London, English National Board for Nuring, Midwifery and Health Visiting. Mires, G., Williams, F., Harden, RM., Howie, P., McCarey, M. and Robertson, A. (1999), ‘Multiprofessional education in undergraduate education can work’, Medical Teacher, 21, 3, 281285. Morse, J. (1999), ‘Qualitative methods: the state of the art’, Qualitative Health Research, 9, 3, 393-406. Mowat, H. and Mowat, D. (2000), ‘Spiritual maturity and collaboration: a challenge for multiprofessional education’.(Personal Communication). Mulrow, C. and Oxman, A. (eds.) (1994), Cochrane Collaboration handbook (Updated 1997), The Cochrane Collaboration. Update Software, Oxford. NBS. (1999), ‘Preceptorship in Action. A Guide’, Edinburgh, National Board for Nursing, Midwifery and Health Visiting for Scotland,. National Joint Practice Commission (1981), Guidelines for establishing joint or collbaorative practice in hospitals, Chicago, Neely Printing Co. Inc. Newble, D. (1998), ‘Assessment’, in Jolly, B. and Rees, L. (eds.), Medical education in the millennium, Oxford, Oxford Medical Publications. Newble, D. and Jaeger, K. (1983), ‘The effect of assessments and examinations on the learning of medical students’, Medical Education, 17, 165-171. Norman, I., Redfern, S., Tomalin, D. and Oliver, S. (1992), ‘Developing Flanagan's critical incident technique to elicit indicators of high and low quality nursing care from patients and their nurses’, Journal of Advanced Nursing, 17, 590-600. Oliver, R. and Endersby, C. (1996), ‘The Process of Assessment’, in Oliver, R. and Endersby, C. (eds.), Teaching and Assessing Nurses, London, Balliere Tindall. Opie, A. (1997), ‘Thinking teams thinking clients: issues of discourse and representation in the work of health care teams’, Sociology of Health and Illness, 19, 3, 259-280. Orr, J. (1987), ‘Why shouldn't we be clever?’, Nursing Times, 83, 35, 24.
- 303 -
Orr, J. E.(1990), ‘Sharing knowledge, celebrating identity: community memory in a service culture’, in Middleton, D. and Edwards, D. (eds.), Collective Remembering, Sage, London. Orton, H. (1981), Ward Learning Climate, London, Royal College of Nursing. Øvretveit, J. (1993), Co-ordinating Community Care. Multidisciplinary Teams and Care Management, Milton Keynes, Open University Press. Parsell, G. and Bligh, J. (1998), ‘Educational principles underpinning successful shared learning’, Medical Teacher, 20, 6, 522-529. Patel, V., Evans, D. and Kaufman, D. (1990), ‘Reasoning strategies and the use of biomedical knowledge by medical students’, Medical Education, 24, 129-136. Paterson, B. (1997), ‘The negotiated order of of clinical teaching’, Journal of Nursing
Education, 36, 5, 197-205.
Peck, M.S. (1987), The Different Drum, London, Arrow. Peckham, M. (1998), ‘Future health scenarios and public policy’, in Marinker, M. and Peckham, M. (eds.), Clinical Futures, London, BMJ Books. Pittilo, R. and Ross, F. (1998), ‘Policies for interprofessional education: current trends in the UK’, Education for Health, 11, 3, 285-295. Playdon, Z.-J. (1999), ‘How can we achieve equity in interprofessional working’ (Conference paper), Working together: noble ideal or practical reality, ENB Research and Development Conference, 24 November 1999, One Great George Street, Westminster, London, English National Board for Nursing, Midwifery and Health Visiting. Polanyi, M. (1967), The Tacit Dimension, New York, Doubleday. Pomeroy, V. and Philp, I. (1994), ‘Healthcare teams: an interdisciplinary workshop for undergraduates’, Medical Teacher, 16, 4, 341-346. Pope, C., Ziebland, S. and Mays, N. (2000), ‘Qualitative research in health care: analysing qualitative data’, British Medical Journal, 320, 114-116. Porter, S. (1995), Nursing's Relationship with Medicine: a Critical Realist Ethnography, Aldershot, Avebury. Poulton, B. (1996), ‘Effective multidisciplinary teamwork in primary health care’, London, Royal College of Nursing. Prescott, P. and Bowen, S. (1985), ‘Physician-nurse relationships’, Annals of Internal
Medicine, 103, 127-133.
Prescott, P., Dennis, K. and Jacox, A. (1987), ‘Clinical decision making of staff nurses’,
Image: Journal of Nursing Scholarship, 19, 2, 56-62.
Raya, A. (1990), ‘Can knowledge be promoted and values ignored? Impications for nursing education’, Journal of Advanced Nursing, 15, 504-509. Redfern, S. and Norman, I. (1994), ‘Validity through triangulation’, Nurse Researcher, 2, 2, 41-55.
- 304 -
Reeves, S. and Pryce, A. (1998), ‘Emerging themes: an exploratory research project of an interprofessional education module for medical, dental and nursing students’, Nurse Education Today, 18, 534-541. Richardson, S., Dohrennend, B. and Klein, D. (1965), Interviewing. Its Forms and Functions, New York, Basic Books Inc. Rogers, A. (1992), ‘Marguerite Sechehaye and Renee: a feminist reading of two accounts of a treatment’, International Journal of Qualitative Studies, 3, 3, 245-251. Ross, F. and Mackenzie, A. (1996), Nursing in Primary Health Care. Policy into Practice, London, Routledge. Rowntree, D. (1987), ‘The Purposes of Assessment’, in Rowntree, D. (ed.), Assessing Students: How Shall We Know?, London, Kogan Page Ltd. Royal College of Nursing (1964), ‘A Reform of Nurse Education: First Report of a Special Committee on Nurse Education (Platt Report)’, London, Royal College of Nursing. Savage, P. and Playdon, Z.-J. (1995), ‘Whither the educational supervisor?’, British Journal
of Hospital Medicine, 54, 5, 192-193.
Schatzman, L. and Strauss, A. (1973), Field Research. Strategies for Natural Sociology, Engelwood Cliffs, New Jersey, Prentice Hall. Schon, D. (1983), The Reflective Practitioner. How Professionals Think in Action, New York, Basic Books. Schon, D. (1987), Educating the Reflective Practitioner, San Francisco, Jossey-Bass Publishers. Scottish Executive (1999), Learning Together. A Strategy for Education, Training and Lifelong Learning for the National Health Service in Scotland, Edinburgh, Scottish Executive. Senge, P. (1990), The Fifth Discipline. The Art and Practice of the Learning Organization, London, Century Business. Silverman, D. (1993), Interpreting Qualitative Data. Methods for analysing talk, text and interaction, London, Sage. Silverman, D. (1998), ‘The quality of qualitative health research: the open-ended interview and its alternatives’, Social Sciences in Health, 4, 2, 104-118. Silverman, D. (2000), Doing Qualitative Research. A Practical Handbook, London, Sage. Skilbeck, M. (1984), School Based Curriculum Development, London, Harper Row. Smith, A. and Russell, J. (1993), ‘Critical incident technique’, in Reed, J. and Proctor, S. (eds.), Nurse Education: A Reflective Approach, London, Edward Arnold. Smith, P. (1992), The Emotional Labour of Nursing, Basingstoke. Snadden, D. and Thomas, M. (1998), ‘The use of portfolio learning in medical education’, Medical teacher, 20, 3, 192-199. Soothill, K., Mackay, L. and Webb, C.E. (1995), Interprofessional Relations in Health Care, London, Edawrd Arnold.
- 305 -
Sorrell, J. and Redmond, G. (1995), ‘Interviews in qualitative nursing research: differing approaches for ethnographic and phenomenological studies’, Journal of Advanced Nursing, 21, 1117-1122. Spence, D. (1994), ‘The curriculum revolution: can educational reform take place without a revolution in practice?’, Journal of Advanced Nursing, 19, 187-193. Steering Group for Multiprofessional Education (1998), ‘Multiprofessional Education’, Dundee, University of Dundee. Stein, L. (1967), ‘The doctor-nurse game’, Archives of General Psychiatry, 16, 699-703. Stein, L., Watts, D. and Howell, T. (1990), ‘The doctor-nurse game revisited’, Nursing Outlook, 38, 6, 264-268. Stern, P. (1985), ‘Using grounded theory method in nursing research’, in Leninger, M. (ed.), Qualitative Research methods in Nursing, Orlando, Grune and Stratton. Strauss, A. (1993), Continual Permutations of Action, New York, Aldine de Gruyter. Strauss, A. and Corbin, J. (1990), Basics of Qualitative Research. Grounded Theory Procedures and Techniques, Newbury Park, Sage. Strauss, A. and Corbin, J. (1998), Basics of Qualitative Research. Techniques and Procedures for Developing Grounded Theory (2nd Edition), Thousand Oaks, Sage. Strauss, A., Schatzmann, L., Ehrlich, D., Bucher, R. and Sabshin, M. (1963), ‘The hospital and its negotiated order’, in Friedson, E. (ed.), The Hospital in Modern Society, New York, Free Press. Styles, M. (1984), ‘Reflections on collaboration and unification’, Image: Journal of Nursing
Scholarship, 16, 21-23.
Svensson, R. (1996), ‘The interplay between doctors and nurses - a negotiated order perspective’, Sociology of Health and Illness, 18, 3, 379-398. Szasz, G. (1969), ‘Interprofessional education in the health sciences’, Millbank Memorial Fund
Quarterly, 47, 449-475.
Taylor, J. (1993), ‘Education can never be neutral - teaching for subversion’, Nurse Education Today, 13, 69-72. Thomas, J. (1984), ‘Some aspects of negotiated order in maximum security prisons’. Symbolic Interactionism 7, Fall, 213-231. Tope, R. (1996), Integrated interdisciplinary learning between health and social care professions. A feasibility study, Aldershot, Avebury. Towle, A. (1991) Critical thinking: the future of undergraduate medical education. , London, King's Fund Centre. Towle, A. (1992), Outpatient teaching at St.Bartholomew's Hospital Medical College, Mimeo, SBHMC. Towle, A. (1998), ‘Education for health needs in 2000 and beyond’, in Jolly, B. and Rees, L. (eds.), Medical Education in the Millennium, Oxford, Oxford Medical Publications.
- 306 -
UKCC. (1986), Project 2000: New Preparation for Practice, London, United Kingdom Central Council for Nursing, Midwifery and Health Visiting.. UKCC (1999), ‘Fitness to Practice’, London, United Kingdom Central Council for Nursing, Midwifery and Health Visiting. University of Dundee Medical School (1995), ‘Dundee Undergraduate Medical Curriculum’, Dundee, University of Dundee. University of Dundee Medical School (1997a), ‘Dundee Undergraduate Medical Curriculum, Phase 3 - Year 4, Handbook 1997/8’, Dundee, University of Dundee. University of Dundee Medical School (1997b), ‘Study Guide Handbook’, Dundee, University of Dundee. University of Dundee Medical School (1999), ‘The Dundee Curriculum’, Dundee, University of Dundee. University of Dundee School of Nursing and Midwifery (1997), ‘Document B1. Diploma of Higher Education in Nursing’, Dundee, University of Dundee. University of Dundee School of Nursing and Midwifery (1998), ‘School of Nursing and Midwifery Strategy 1998-2003’, Dundee, University of Dundee. Wahlstrom, O. and Sanden, I. (1998), ‘Multiprofessional training ward at Linkoping University: early experience’, Education for Health, 11, 2, 225-231. Walby, S., Greenwell, J., Mackay, L. and Soothill, K. (1994), Medicine and nursing. Professions in a changing health service, London, Sage. Waterworth, S. and Luker, K. (1990), ‘Reluctant collaborators: do patients want to be involved in decisions concerning care?’, Journal of Advanced Nursing, 15, 971-976. Watson, H. and Harris, B. (1999), ‘Supporting Students in Practice Placements in Scotland’, Glasgow, Glasgow Caledonian University, Research commissioned by the National Board for Nursing, Midwifery and Health Visiting. Watson, S. (1998), ‘The support that mentors receive in the clinical setting’, Bradford Hospitals Trust, University of Bradford. Weiss, S. (1983), ‘Role differentiation between nurse and physician: implications for nursing’, Nursing Research, 32, 3, 133-139. Weiss, S. and Davis, H. (1985), ‘Validity and reliability of the Collaborative Practice Scales’,
Nursing Research, 34, 299-305.
West, M. (1999), ‘Communicating and teamworking in healthcare’, NT Research, 4, 1, 8-17. West, M. and Slater, J. (1996), ‘Teamworking in primary health care: a review of its effectiveness’, London, Health Education Authority. Westberg, J. and Jason, H. (1993), Collaborative Clinical Education. The Foundation of Effective Health Care, New York, Springer Publishing Co. Whale, Z. (1993), ‘The participation of hospital nurses in the multidisciplinary ward round on a cancer-therapy ward’, Journal of Clinical Nursing, 2, 155-163.
- 307 -
While, A. (1994), ‘Competence versus performance: which is more important?’, Journal of
Advanced Nursing, 20, 525-531.
WHO (1986), ‘Leadership for health for all: the challenge to nursing: a strategy for action’, Geneva, World Health Organization. Whyte, W. (1982), ‘Interviewing in field research’, in Burgess, R. (ed.), Field research; a sourcebook, London, Allen and Unwin. Wicks, D. (1998), Nurses and Doctors at Work. Rethinking Professional Boundaries, Buckingham, Open University Press. Wolcott, H. (1990), Writing Up Qualitative Research, Newbury Park, Sage. Wolcott, H. (1994), ‘Confessions of a 'Trained' Observer’, Transforming Qualitative Data. Description, Analysis and Interpretation, Thousand Oaks, Sage. Wolfhagen, H., Gijselaers, W., Dolmans, D., Essed, G. and Schmidt, H. (1997), ‘Improving clinical education through evaluation’, Medical Teacher, 19, 2, 99-103. Wondrak, R. (1989), ‘A uniform bunch’, Nursing Times, 85, 22, 58-59. Woodward, C. and Ferrier, B. (1983), ‘The content of the medical curriculum at McMaster University: graduates evaluation of their preparation for postgraduate training’, Medical Education, 17, 54-60. Woolley, S. and Costello, S. (1988), ‘Innovations in clinical teaching’, Curriculum revolution: Mandate for change, New York, National League for Nurses. Young, K. (1981), Discretion as an implementation problem: a framework for interpretation, London, Heinemann Educational Books. Zerubavel, E. (1979), Patterns of Time in Hospital Life, Chicago, Chicago University Press. Zwarenstein, M., Atkins, J., Barr, H., Hammick, M., Koppel, I. and Reeves, S. (1999), ‘A systematic review of interprofessional education’, Journal of Interprofessional Care, 13, 4, 417-424. Zwarenstein, M. and Reeves, S. (2000), ‘What's so great about collaboration?’, British
Medical Journal, 320, 1022-1023.
- 308 -
APPENDICES Appendix 1: Overview of medical and nursing programme The Medical Programme The Dundee Medical Curriculum was introduced in 1995 in response to General Medical Council (GMC) recommendations for undergraduate medical education (General Medical Council, 1993). The curriculum document was subsequently revised and a number of features relevant to the development of collaborative practice made more explicit (University of Dundee Medical School, 1999). This Appendix provides a brief overview of the broad structure of the curriculum. The review is supplemented by published papers that make specific reference to developments in medical education in the Faculty (Harden et al., 1999, Harden, 1998a, Harden et al., 1997, Harden et al., 1996).
Curriculum Structure and Content
Developers of the Curriculum proposed that, 'A curriculum should be viewed not simply as an aggregate of separate subjects but rather as a programme of study where the whole is greater than the sum of the parts.' (Harden et al., 1997). The coherence of the curriculum is designed to be reflected in six key aspects (Table 9):-
Table 9: Six aspects underpinning the philosophy of the new Dundee Medical Curriculum (University of Dundee Medical School 1999: 3) •
Spiral curriculum working towards development of competences required of a junior house officer
•
Systems-based approach with themes running through curriculum
•
Core curriculum with special study modules
•
Educational strategies adopting elements of problem-based and community-based approaches to teaching and learning to encourage self-directed learning by students
•
Approach to assessment emphasising the overall objectives of the course
•
Organisation and management of curriculum and allocation of resources designed to support the educational philosophy
The curriculum comprises three phases with the emphasis in Phase 1 (Year 1) on normal structure, function and behaviour, Phase 2 (Year 2 & 3) on abnormal structure, function and behaviour and in Phase 3 (Year 4 & 5) on clinical practice. In addition a range of themes, are interwoven throughout the programme e.g. anatomy, child health, surgery, health promotion, ethics and clinical methods (Figure 5).
- 309 -
Figure 5: Spiral curriculum model adopted for Medical Programme (University of Dundee Medical School, 1999: 6)
- 310 -
The programme comprises a core component and a range of optional special study modules that allow students to study selected areas in greater depth, the total educational experience being integrated through an outcomes-based approach to education (Harden et al., 1999). Therefore, whilst different students can pursue areas of personal/professional interest, the composite elements of the programme are integrated both 'vertically' and 'horizontally' by twelve outcomes of learning (University of Dundee Medical School, 1999).
'Horizontal integration' of learning in Phases 1 & 2 is promoted by constructing different
subjects such as surgery, pathology, microbiology and epidemiology, around the 11 body systems, whilst 'vertical integration' is achieved through the spiral format utilising the interwoven themes previously mentioned. An integrated approach to learning is adopted in Phase 3 using a 'task-based learning strategy' through which students are faced with problems that will confront them as practising doctors (University of Dundee Medical School 1999: 1617). 'Task-based learning' strategy is described as a 'development of problem-based learning' (University of Dundee Medical School 1999: 16), through which students undertake defined 'tasks' and are expected to learn not only about the pathology of the problem identified but also the underlying science and 'generic competencies' such as communication and problem-solving (Harden et al., 1996) 98 . A review of medical course documentation indicates features of a medical curriculum that is student-centred and within which a 'mixed economy' of educational strategies, often involving problem-based and small-group work is adopted. The programme is based on a common core with additional optional special study modules, providing students with a degree of control over, or choice in, the content of their education. A number of shared learning activities are undertaken by medical and nursing students at different stages of the programme and some teaching is undertaken by qualified nurses. Some of these elements comprise compulsory or core components of the course whilst others are optional within special study modules. Shared activities are largely non-clinically based although students may undertake shadowing of qualified nurses in the clinical areas.
The Nursing Programme The nursing curriculum was introduced in 1997 following the Scottish Office award of the contract for Pre-Registration Nursing and Midwifery Education to the University. This three-year programme leads to an award of Diploma in Higher Education. This section provides an overview of the programme utilising documentary data from the curriculum document, course handbooks and student competency assessment booklets.
Curriculum Structure and Content
The curriculum developed for the nursing programme was influenced by a number of factors; the model of education adopted, the need for a modular programme, (to adhere to the Scottish Credit Accumulation and Transfer Framework), the challenge to create more self-directed and flexible methods of learning and a demand for the development of transferable skills, e.g. problem-solving, team working and communication skills (School of Nursing and Midwifery 1997). However perhaps of most significance in the context of this study was the following acknowledgement,
'In its successful bid for the provision of pre-registration nursing and midwifery education, the University of Dundee placed a high priority on the development of multi-professional education and training [and] the linkage of theory and practice' (University of Dundee School of Nursing and Midwifery, 1998: 1) 98
Review of the specific details of task-based learning make it difficult to differentiate it in any meaningful way from problem-based learning. Indeed the listings of 'tasks' are also defined as 'problems' in the document and are written in the latter rather than former terminology e.g. haematuria, swollen scrotum, cough. One might argue that using the term 'task' risks a reductionist approach to care
- 311 -
The curriculum model for the nursing programme utilised a ‘cultural/ situational analysis model’ (Skilbeck, 1984, Lawton, 1983) 'based on reconstructuralist or society-centred ideology'. The aim of the design was to provide a series of learning experiences that bridged the gap between the student and the prevailing culture with a view to improving the health of society. Thus it considered both internal factors such as strengths, weaknesses and values of the curriculum, School philosophies of nursing and education and available resources, and external factors such as the views of clinical experts, students and consumers, literature on education and health care and statutory and professional requirements and guidelines (Figure 6). The programme was based on a modular design that it is proposed in the curriculum document, allowed greater flexibility for programme change of individual modules without effecting the integrity of the overall pathway. The modular design it was also proposed could facilitate multiprofessional learning 'where a shared module or part of a module can be beneficial to both
parties without compromising the integrity of either programme'
The nursing curriculum provides for four different strands of nursing preparation; adult, mental health, child and learning disabilities (in addition to a midwifery programme, which parallels in many areas). The curriculum document outlines twelve learning outcomes for the adult pre-registration programme (Table 10): Table 10: Learning outcomes of the Adult Nursing Curriculum (University of Dundee School of Nursing and Midwifery, 1997: 41) • Recognise the physical, social and psychological implications of health, disease, disability and ageing on the individual, family, his friends and the community • Evaluate effect of social, political, cultural, spiritual, economic, educational and environmental factors on health care • Deliver competent, compassionate, high quality nursing having regard for individuals’ race, creed, culture, economic and social status •
Practice evidence-based nursing
•
Utilise relevant research in nursing practice
•
Justify the relevance of ethics to nursing practice
• Use appropriate communication skills in the development of effective/ therapeutic relationships with patients/ clients and their families and friends •
Assess the political and policy issues surrounding and influencing nursing practice
•
Apply the current legislation and respond to the changing influences governing health care
• Participate in the teaching and supervision of patients/clients & appropriate members of the caring team. • Appraise health-related learning needs of patients/clients. their families and friends and participate in health promotion and education • Participate as an effective team member within a multidisciplinary approach to the care of patients/clients
These outcomes are proposed to prepare students for supervisory clinical, teaching and managerial roles so as the student on qualification may provided 'holistic care to meet the
nursing needs of the adult at any point along the health illness continuum.' (p:40)
- 312 -
Figure 6: Development of student learning experiences (University of Dundee School of Nursing and Midwifery, 1997: 13)
- 313 -
The nursing curriculum also more overtly addresses the issue of collaboration with other professional and outlines principles of its educational strategy in this respect (Table 11):Table 11 : Principles of Nursing Multiprofessional Education Strategy (University of Dundee School of Nursing and Midwifery, 1997: 29-30) •
Shared learning experiences will not embarrass the integrity of the individual educational programmes of the professions taking part.
•
Each profession will maintain its own professional identity within the shared learning framework.
•
Each student shall experience multiprofessional education at various stages in the curriculum.
•
Identified areas for multiprofessional education shall pertain to areas of common relevance and interest.
•
The longer term perspective of multiprofessional educational initiatives embraces the spectrum of both clinical and social care, and the professions involved across such a spectrum.
•
The School wishes to facilitate multiprofessional initiatives through integrated learning resources centres on multiple sites. The constituents of such centres include clinical skills centres, libraries and other learning and teaching resources.
•
The School in conjunction with appropriate facilities will operate a strategic plan of development for multiprofessional initiatives, which safeguards quality and sets out standards and procedures for monitoring and evaluation of the overall initiative.
In addition to defined multiprofessional education initiatives the curriculum document also emphasises the role of the student as a member of a wider team,
'There will be an emphasis on the role of the student as a member of the multidisciplinary team during both theory and practice element of the programme.' (p: 81) The document acknowledges the importance of the relationship between students and lecturers and clinical staff in promoting the capacity for collaboration. School-based staff are required to undertake 'linking' responsibilities thus visiting and acting as a resource to students and clinical staff. Thus rather than a specific learning strategy the nursing curriculum recognises the influence of the prevailing culture between School and service area in which the student is placed for clinical experience,
'… the educational process […] is perceived as a collaborative one where the student develops knowledge, skills and attitudes through supportive relationships with lecturers and supervisors. The tripartite relationship is seen as being fundamental to the development of competent practitioners thoroughly accustomed to collaborative styles of working and learning.'(p: 20) The three-year programme for nursing education involves theory and practice composite modules in a range of clinical settings. Students undertake a common foundation period and move into a specialist branch component after eighteen months of the programme. The curriculum has made a heavy commitment to problem-based learning and makes frequent reference to the importance of developing multiprofessional education initiatives (within a defined series of guiding principles (Table 11). The largely prescribed programme of study limits choice of content selection. Practice placements are designed to be of over seven weeks in both community and hospital contexts and students can elect to return to certain wards in the latter stages of their programme. A defined clinical mentor, based in the area of placement, and a named 'link lecturer', based in the School support students in practice.
- 314 -
Appendix 2: Additional evidence supportive of the value of collaboration Relational statements derived from the literature to support the importance of collaboration in clinical practice (adapted from (Baggs & Schmitt, 1988): 149) 99 •
Increased collegiality leads to improved patient outcomes (Feiger & Schmitt, 1979),
A quasi-experimental study in long-stay care with randomly assigned patients to team care or 'usual' care. Over a one year period team care resulted in less overall decline across physiological, physical, social and emotional health outcomes
•
• Increased collaboration leads to improved quality of care, increased patient satisfaction, decreased need for physician supervision of nurses and increased nursing job satisfaction (National Joint Practice Commission, 1981, Devereux, 1981a, b, c)
A model of collaborative practice developed based on five essential factors: communication, competence, accountability, trust and administrative support. In demonstration projects this involved introducing 100% registered nurse staffing, primary nursing, joint practice committees (comprising nurses and physicians), nurses encouraged to make individual decisions, integrated patient records and joint patient care review. Reported data is highly anecdotal but physicians and nurse in 'model' units felt that patient care had improved. Cost implications were also considered to be minimal.
•
• Collaboration in acute care hospital units leads to decreased costs, increases patient satisfaction and better professional relationships (Koerner et al., 1986, 1985, Koerner & Armstrong, 1984) •
Project set up on pattern of that described in NJPC project described above, in acute care unit
• Primary nursing, critical care practice, open communication, administrative work support and standardised policies and skills lead to increased collaboration (Alt-White et al., 1983)
Study of organisational and managerial factors suggested to contribute to collaboration, though questions asked in study are unavailable and statistical significance to support some of claims is questionable. Organisational factors correlating with collaboration included primary nursing and critical care unit practice i.e. high staff-patient ration; managerial factors correlating with collaboration were open communications process, administrative support for work and standardisation of policies and skills
•
• Increased competition or accommodation (as opposed to collaboration) in problem-solving leads to decreased efficiency and effectiveness (Prescott & Bowen, 1985)
Interview data collected from nurses and physicians in 90 units in 15 hospitals. Questionnaires also distributed. Competitive tactics involved postponing or nor implementing medical orders, complaining to nursing administration of involving family or patient in disputes. Accommodation often involved nursing deference or passivity in relation to medical orders (similar to 'doctor-nurse game') to a degree that could place patient in jeopardy
•
•
Lack of collaboration leads to nursing stress (Weiss, 1983)
Structured 'dialogue sessions' with groups of nurses over 20 month period. Two of three most stressful factors indicated for nurses were discrimination in health care relationships and failure of physicians to value nurse communications. Weiss & Davis, (1985) carried out similar group dialogues with physicians and consumers over same period and reported that these dialogues appeared to have enhanced traditional beliefs rather than fostered a belief in collaboration
•
• Separate educational processes for nurses and physicians leads to decreased communication and decreased communication leads to decreased co-operation and poorer performance (Lynaugh & Bates, 1973) •
Opinion not evidence-based
• A dominance/deference pattern between physicians and nurses leads to decreased communication (Kalisch & Kalisch, 1977)
Statement based on an analysis of literature on communication and wider social changes e.g. role of women in society
•
99
Whilst Baggs and Schmitt derive the statements from a wealth of studies the published papers which underpin the statements are of highly variable quality, making detailed review of findings problematic
- 315 -
Appendix 3: ‘Keys’ to collaboration Keys to collaboration (Braye and Preston-Shoot, 2000: 144-154) •
Vision - vision exists, or is developed, at organisational, professional or individual level to move around the system with the perspective of those others who are involved, rather than retaining a single, fixed perspective on a problem or situation. This meta-vision then allows reflection on roles, perspectives and possibilities.
•
Power - imbalance in power between purchasers and providers, between professional groups and between qualified staff and students is well recognised, incorporating a range of factors including knowledge, education, status, gender, financial reward and class. Problematic when internalised by stakeholders within the system resulting in 'internalised oppression' and consequently restricted practices (often by self as well as the system). Thus issues of power must be confronted and changed through legal mandates, policy directives, resources and skills. Unless issues, which emphasise power differentials, are addressed, then services evolving as required will not be feasible due to misplaced power along organisational or professional lines 100 .
•
Introduction of difference - this is the recognition of the ever-changing nature of health care and user needs and developing a commitment to constantly strive for 'something different'. At a personal level this requires constant unlearning and relearning of practices and value assumptions underpinning services delivered and relationships formed. At professional/practice level it involves promotion of collective action by users and professionals in order to maximise arrangements, which limit participation in health care (and within the context of this study learning). At an organisational level it involves constantly striving to create policies and practices that empower individuals, practitioners and users to enhance the service delivered.
•
Creating a holding environment - involves development of environments and cultures which encourage 'analysis, reflection and discussion rather than denial of complexity.' Requires the recognition
of tensions, practice dilemmas, and conflicting agendas and consequently demands the development of a culture within which stakeholders feel secure. May involve personal reflection on own thoughts, feelings and actions in addition to those of other professions or organisations and therefore requires consideration of the 'vision' and 'power' keys identified earlier.
•
First- and second-order change - requires recognition of difference between two types of change. Much organisational change focuses on the solution of problems (first order change) but leaves traditional power structures and relationships untouched. Recurrence of the problem or resistance to intervention results in more of the same. Second-order change requires more fundamental evaluation considering power differentials, cultural norms, organisational structures and encouragement of challenge to the service. Second order change demands reconsideration of shifting perspective and shifting relationships to accommodate new organisational arrangements.
•
Partnership - requires all parts of the system to be engaged. Partnership involves organisations, professions, groups and individuals working together to jointly plan. The term implies mutual learning and trust and values difference in development of agreements on aims, principles and procedures. Partnership also implies equality, a feature that lacking in the traditionally hierarchical arena of health care.
•
Visibility - implies a culture of openness, recognising and dealing with differences that exist. It also indicates the need for visible support for collaboration through consistent and overt policies, systems and relationships. It requires open commitment and support for the possibilities of what can be achieved.
•
Distinction between task and process - highlights need to focus not simply on the task to be achieved but the processes that facilitate that achievement. It recognises that group structures and relationships need to be developed and maintained. Requires freedom for experimentation in order to develop solutions appropriate to context, process and task.
100
Braye and Preston Shoot are recognising a problem that was reported by (Dingwall & McIntosh, 1978) almost quarter of a century ago and has not yet been resolved. Thus whilst power equalisation may remain a key to collaboration its redistribution remains elusive.
- 316 -
Appendix 4: Differences between studentship and apprenticeship
Differences between studentship and apprenticeship (Dolan, 1993: 4)
Studentship
Apprenticeship
Rationale
Command of disciplines
Learn routines
Benefits
To student
To service
Purpose
Understanding
Getting job done
Learning
Intellectual
Play a role
Content
Selective
Complete
Thinking
Conceptual
Task
Competence
Transferable skills
Limited repertoire of behavioural skills
Student responsibility
High
Low
Student attitude
Questioning
Passive
Mistakes
Inevitable
Sign of failure
- 317 -
Appendix 5: The conditional matrix used to analyse the learning context
- 318 -
Appendix 6: Critical incident interview framework Framework for critical incident interviews. Interviews were preceded by discussion of purpose of the study and review of students clinical experiences as an ‘icebreaker. The framework was for prompts and structure of data, rather a sequence of questions to be strictly followed.
UNIVERISTY OF DUNDEE SCHOOL OF NURSING AND MIDWIFERY Collaborative working/ Learning Study Critcal Incident Interview Recording Sheet
Student Name: Placement/ Attachment
Year/ Set
Medical /Nursing
Date
1. Date of Incident (approx.) 2. Students view of productive or counterproductive learning/ working experiences and why
3. Description of incident: a Who was involved in the incident?
b Location of incident
c Events leading up to the incident?
4. Additional information
- 319 -
Appendix 7: Unstructured interview guide The interview guide acted as a prompt particularly in early data collection, however it was not pursued in nay particular order and efforts were made to allow interviewees to talk about issues that they considered relevant rather than topics/ questions prescribed by me.
UNIVERISTY OF DUNDEE SCHOOL OF NURSING AND MIDWIFERY Collaborative working/ Learning Study Interview Guide •
Outline clinical experiences to date (icebreaker)
•
Describe features of best and worst clinical experiences
•
Explore student perspectives on perceptions of own profession in relation to delivery of high quality patient care.
•
Explore student perspectives on perceptions of other professions in relation to delivery of high quality patient care.
•
Discuss influences on their roles or functions in practice e.g. educational, organisational, personal Course organisation - clinical, classroom, hospital, community Educational preparation - preparation for roles expected to perform and anticipated will have to perform Demographic influences on experiences/ relationships e.g. age, gender, background Relationship with clinical team -inclusivity of other staff members, inclusivity of students Contacts with students/ staff of own and other professions Public perception of teamworking in hospitals and role of patient in care management/ delivery
- 320 -
Appendix 8: Strategies for recording observed data in the field The strategies described below proved useful in collecting unstructured data through field observations in situations where the environment was busy and potentially overwhelming in terms of knowing what features to record.
Strategies for recording observed data in the field (Wolcott 1994: 161-164)
Strategy one: Observe and Record Everything Whilst it is not possible to record everything, evidence of the observation process arises from what is recorded. This highlights recording habits and the expanse of gaze. It also recognises that readers may value a broad look around prior to focusing on the issues as a way of contextualisng and evaluating findings. Thus recordings were made of the style of ward, its layout, decor, organisation as well as the people in it. This may be of value for readers transferring the findings to their own clinical domain. It proved useful in picking up data on differences between medical and nursing spaces, some of which e.g. positioning of doctor and nurses desks which was not identified until the final data analysis. Personal feelings and experiences were also recorded which subsequently proved useful in analysing the experiences of students as newcomers to the ward. It also indicated the reflexivity inherent within the study.
Strategy Two: Observe and Look for Nothing - That Is Nothing in Particular The opposite strategy to recording everything is to record as if nothing commended greater attention than anything else and then only recording the ‘bumps’. This proved useful in the early stages of observation when I felt overwhelmed by the amount of data to record. Thus at times only key events were recorded. On one occasion the ward seemed to be running on ‘business as usual’ mode and only when a patient fell did different roles come into a sharpened focus for recording purposes.
Strategy Three: Look for Paradoxes The researcher also looks for contradictions or paradoxes within the field. For example, staff had suggested a commitment to the broad notion of student teaching and supervision of practice, but on numerous occasions students were simply left to their own devices in the clinical area. Attempting to explain this paradox highlighted an interesting line of inquiry for subsequent data collection relating to individual freedom, choice and clinical roles (See analysis chapter 3).
Strategy Four: Identify the Key Problem Confronting the Group This strategy proved central to the whole study. That is the problem confronted by the group of survival in the practice domain and the participation in practice from which they could learn. For example whilst student nurses were encouraged in the School to be independent self-directed learners their clinical acceptability was often most enhanced by acting as a highly compliant ‘pair of hands’. Hence they were confronted by a conflict between the advocated modes of learning and personal and professional development and the ‘fitting in’ in the practice setting.
- 321 -
Appendix 9: Exemplar of observational field notes
- 322 -
Appendix 10: Extract from field notes following transcription and grouping 3 forms of notation were used to organise field notes; methodological notes, (MN), observatiional note (ON) and theoretaical notes (TN) (after Lofland and Lofland, 1984) MN2: A ward assistant pushes past me several times and I tell her, ‘Kick me out of the way if necessary, I’m used to it’, (I’m seated in a doorway, my ‘secure ‘home’ position’), She laughs and says, ‘You’re supposed to say, ‘I’ve been kicked in better places’ (Humour developing a connectedness?). I feel more relaxed on this ward as everyone knows who I am as I have been introduced and they also have a vague understanding of my purpose i.e. looking at clinical education opportunities for students of all types as I was given a chance to outline the project. Perhaps I need to ensure this happens in future observation sites. ON9: The whiteboard is on the wall opposite my ‘home’ observation position, though on this ward there is only a single board. Patients are colour-coded red, blue or green depending on which consultant they are under. Perhaps an symbolic indicator that consultant has ownership of patient/ team leadership. ON10: Similar ward layout to other general ward with three bays and six side rooms all located around a central office/ services e.g. toilets, sluice etc. block. ON11: Staff observed on ward so far (after 40 minutes) = 13, all nursing; Nights: 1 SN, 1 EN, 1N/A, 1St/N, Year 2; Days: 2 SSNs, 2 SNs, 1 N/A, 2 StN, Yr1. & Yr 3, 1W/A and 1 palliative care researcher ON12: N/A and W/A hand out breakfasts whilst S/N and St/N Yr3 do drug round. St/N Yr1 helping patients go to toilet and S/N changing beds and helping patients with washing. A second drug round started by SSN, subsequent enquiries indicate that this is for different teams, red and blue i.e. drug rounds separated out and have different trolleys. TN1: Palliative care worker still around filling in forms and asks the W/A for something who replies, ‘I hope you’re not going to cause trouble’ (laughs) and she goes off and returns with and envelope which she hands over saying, ‘Don’t mention it, it will be added to your bill’. I s this a use of humour indicating that she is doing person a favour, a way of preserving her own esteem i.e. so she doesn’t feel she is subservient to palliative care person whilst acting in a supportive capacity? 7.50am ON13: Doctor walks through ward down a back corridor (through traffic) and S/N walks past me and smiles. Another S/N and St/N are still doing drug round but some drug is not available so S/N goes to borrow keys from nurse in charge, SSN - power of holding the keys as a symbol of seniority or organisational convenience. ON14: Phone starts to ring but this is ignored by student nurse who is on drug round and waiting for S/Ns return is standing nearest to it and it is finally answered by S/N. Is this issue of only certain people answering phone, students confidence or idea that as student do only one task at a time. ON15: Person, young male, in outdoor clothes arrives on ward carrying a rucksack. Dressed in shirt and tie, carrying copy of The Sun newspaper. I think he might be a medical student but newspaper seems to make me think otherwise (hierarchy of papers! - doctor-nurse, broadsheet/tabloid - Is this my own stereotype?). He goes into staff room and emerges a short time later wearing shirt and tie and hangs around the notes trolley with his hands in his pockets, evidently waiting for something. Nursing staff pass he him but do not acknowledge him. 8.00am ON16: Team of doctors arrive on ward. Three doctors huddle around the notes trolley whilst the surgical registrar talks to the SSN about various patients on the ward. They share a joke and laugh.
ON17: S/N comes and collects keys from SSN and then hangs around behind the group of doctors apparently waiting to start the ward round with them. The doctors walk off, all white coated (2 registrars, 2 JHOS - from badges, 1 unidentifiable, possibly a medical student as he looks quite young , appears awkward in the situation and looks relieved when one JHO hands him a folder ? medications - he hangs around at the back of the group. Doctors all visible at patient’s bedside in first bay. Curtain partially drawn across to obscure view of patient from ‘through traffic’. Some discussion within group, whilst medical student hangs at back. He walks forward as curtains are drawn right around curtains (See Lawler’s work on ‘Behind the Screens’ for ideas).
- 323 -
Appendix 11 Categories generated from early analysis of data
Data Categories 1. Learning by seeing and being/ Role modelling 2. Feeling Valued 3. Variable Clinical Experience 4. Busyness of Clinical Environment 5. Characteristics and Role As Student 6. Comparison of training to own (nurses) 7. Task Oriented Learning 8. Contact With Other Professions 9. Doctor-Nurse Characteristics, Roles and Relationships 10. Teamworking Qualities 11. Inter-staff Communication 12. Patient Exclusion
- 324 -
Appendix 12: Steps of multiprofessional education
- 325 -
Appendix 13: Examples of ‘core clinical problems’ in the medical programme
- 326 -
Appendix 14: Outline of ‘Partnerships in Learning’ module
- 327 -
Appendix 15: Exemplar of study guide from medical programme
- 328 -
- 329 -
- 330 -
Appendix 16: Extract from competency assessment booklet in nursing programme
- 331 -
Appendix 17: Bondy’s levels of competence as used in nursing programme
- 332 -
Appendix 18: Types of multiprofessional teamworking
Types of Multiprofessional Teamworking (Miller et al, 1999)
•
Integrated working - a highly collaborative form of working with evidence of shared vision, philosophy and responsibility. Contributions were expected of all relevant team members in problemsolving and decision-making, and role boundaries and skill enactment were flexible to ensure continuity of care. Efforts were made to share knowledge and information, acknowledge professional concerns and understand the role of others. Joint practices included joint note-keeping, assessment, monitoring, evaluation and therapeutic intervention.
•
Fragmented working - a less collaborative form of working with lack of shared vision and philosophy and with responsibility for problem-solving and decision making and action confined to uniprofessional groups. Communication was brief and based primarily on information giving rather than sharing and understanding of roles of others was superficial. Role boundaries were actively protected and specific skills and knowledge remained in domain of individual professions.
•
Core and periphery working - a core collaborative group with other team members who were more peripheral, shared vision and philosophy only evident in the core group. The core group demonstrated similar patterns to the integrated group with flexible role boundaries, shared skills and knowledge and communication between team members. The level of engagement of the peripheral group in these activities was more superficial with some peripheral group members actively protecting their professional roles.
- 333 -
Appendix 19: Publications, Presentations and Awards An important element of the PhD process is professional development of the student into the research community. As evidence of the process of development in over the duration of the period of study (1997-2000) publications, national and international presentations and awards relevant to the subject area are listed below:-
Publications Cable, S (in press) 'The Context: Why the current interest?', in Glen, S. and Leiba, T. (eds.), Multiprofessional Learning for a Nurse. Breaking the Boundaries, London, Macmillan Cable, S (in press) 'Multiprofessional education', in Harden, RM. and Dent, Leiba, T. (eds.), in Harden, R. and Dent, J. (eds.), A Practical Guide for Medical Teachers, London, Balliere Tindall. Cable, S., Ker, J., Dunkley, P. and Matthews, A. (accepted subject to minor amendments) Understanding multiprofessional health care practice using audio-recorded critical incidents - a pilot study', Medical Education.
Presentations Cable, S. (2000) Situated learning - dimensions of medical and nursing students' clinical preparation for multiprofessional practice. Association for Medical Education in Europe Conference, Beer Sheva, Israel, August 2000 Cable, S. (1999) Audio-recording critical incidents - piloting a methodology for evaluating multiprofessional health care practice. Association of Medical Education for Europe Conference, Linköping, Sweden, August 1999. Cable, S. (1999) The conditional matrix as a tool for the contextual analysis of the preparation of medical and nursing students for multiprofessional working (Poster), Association of Medical Education for Europe Conference, Linköping, Sweden, August 1999. Cable, S. (1998) Lessons from the workplace: preparing students for effective interprofessional working, Clinical Skills Network Conference, Bristol, November 1998. Cable, S. (1998) How we work together: Lessons for educators and practitioners (keynote address), Northern Nurse Practitioner Association, Lancaster, September 1998. Cable, S. (1998) Interprofessional education and practice: the future of nursing in collaborative relationships. 2nd European Region Conference of the Commonwealth Nurses Federation, Malta, March 1998.
Awards Cable, S. (1999) Exploration of multiprofessional educational developments with a University of Linköping Faculty of Health Sciences, Travel award from National Board for Nursing, Midwifery and Health Visiting for Scotland, General Nursing Council for Scotland (Education) Fund 1983. Cable, S.Ker, J., Dunkley, P. and Matthews, A. (1998) Audio-recording critical incidents piloting a methodology for evaluating multiprofessional health care practice. Research award from National Board for Nursing, Midwifery and Health Visiting for Scotland, General Nursing Council for Scotland (Education) Fund 1983.
- 334 -
Page
Figure 1: Development of student learning experiences (University of Dundee School of Nursing and Midwifery, 1997: 13)
Page
Figure 2: Spiral curriculum model adopted for Medical Programme (University of Dundee Medical School, 1999: 6)
Page
Documentary analysis Medical programme - undergraduate curriculum document1, medical student handbooks for seven attachments, medical student study guide for years 4 and 5, Nursing programme - pre-registration curriculum document, competencies and assessment of practice booklet for years 1 to 3, school strategy document Faculty - position papers relating to multiprofessional education
Interviews
Critical incident interviews - 22 interviews, 14 nursing students, 8 medical students generating 75 critical incident descriptions: Duration 30-40 minutes per interview In-depth interviews - 16 interviews, 9 nursing students, 7 medical students: Duration 60-90 minutes
Reflective Diary
Observation
Teaching hospital - general surgical ward: 12
visits, 35 hours; general medical ward: 12 visits, 31.5 hours, A & E, 8 visits, 21 hours. District general hospitals - general surgical ward, 8 visits, 28 hours; general medical ward: 9 visits, 28.5 hours. Opportunistic - midwifery (DGH) 5 visits, 18 hours, cottage hospital 3 visits, 7 hours. Total 57 site visits, 169 hours
Figure 1: Concurrent data collection process and details of data sources using 3 forms of data collection
Page
Learning Curriculum
Centripetal Participatory Learning Trajectory 'Seeing'
'Doing'
'Being'
'Community of practice'
Teaching Curriculum
Figure 3: The centripetal participatory learning trajectory: a representational model of the learner’s developing participatory role in the ‘community of practice’
Page
Assertiveness (attempting to satisfy own concerns)
A s • s e r t i v e
Competing
• U n a s s e r t • Avoiding i v e Unco-operative
•
Collaborating
•
Accommodating
Compromising
Co-operative
Co-operativeness (attempting to satisfy the other party's concerns
Figure X: Two dimensional model of interpersonal problem-solving behaviour (Weiss and Davies 1985: 299)
