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Education in the clinical context: establishing a strategic framework to ensure relevance Author Henderson, Amanda, Fox, Robyn, Armit, Lyn
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Education in the clinical context: Establishing a strategic framework to ensure relevance
Amanda Henderson, RN RM ICUCert BSc GradDipNsgEd MScSoc PhD Nursing Director (Education), Princess Alexandra Hospital, Woolloongabba, Queensland. Robyn Fox, RN RM AgedCareCert GradCertMgt GradCertHRM DNE BEdStud MNsgLdrship Nursing Director (Education), Royal Brisbane & Women’s Hospital, Herston, Queensland. Lyn Armit, BABehavSc RN GradDipHealthEd MHSc Nursing Director (Education), Gold Coast Hospital, Southport, Gold Coast, Queensland.
Education in the clinical context: Establishing a strategic framework to ensure relevance
Quality contemporary practice relies on nurses to provide health care within an embedded nexus of clinical, professional and organizational learning that leads them through a career trajectory that encourages lifelong development. Within complex health service environments this is fraught with difficulties. Enhancing practice is multifaceted requiring not just education for the acquisition of skills and abilities but time and space for reflection on experience within the clinical context. This ultimately leads to professional knowledge development. Queensland Health has developed a Nursing and Midwifery Staff Development Framework to assist nurses in structuring their experiences in the practice setting to enable their professional goals. Learning is guided within this framework through its collective modus operandi, that is, the development of teams that overlap to identify and progress the educational agenda; resources to develop consistent relevant learning material that incorporates evidence obtained through practices and the literature; and educator and clinician networks across health services throughout the State, and furthermore, links with the tertiary sector to assist in marketing, applicability and synergy with further education.
Education in the clinical context: Establishing a strategic framework to ensure relevance
Supporting teaching, researching and health service improvement is essential for the future workforce if they are to provide a quality health service. While this is universally acknowledged it is increasingly recognised that establishing structures and processes for the development of staff that are timely, relevant and readily adopted by staff in their practice is fraught with difficulties (Lundgren & Houseman, 2002). For practicing nurses within clinical settings establishing and maximising gains through contemporary practice is recognised by Queensland Health as essential for a quality service. Leadership in education strives to provide staff development that enables a quality workforce. Educators, in particular, possess a particular obligation to facilitate learning that will advance professional growth (Thorne, 2006).
Similar to other organisations that have responded to contemporary needs, Queensland Health has developed innovative frameworks for delivering post-registration clinical education that best meet the needs of the clinicians and the organisation (Mockett, Horsfall & O’Callaghan, 2006). The intent of this paper is to describe the structure and processes that have been established within Queensland Health, to provide staff development to approximately 20,000 nurses across the State of Queensland, Australia. In particular, the significant ‘drivers’ that ensure continuing education addresses the knowledge and skills to progress clinical agendas, an imperative for efficiency and cost-effectiveness in the workplace, are discussed (Barriball, While & Norman, 1992).
The ‘drivers’ of the structures and processes that are intrinsic to the modus operandi of the Queensland Health Nursing and Midwifery Staff Development Framework (Queensland Health, 2007) include: recognition of a number of teams that overlap to identify and progress the educational agenda; resources to develop consistent relevant learning material that incorporates evidence obtained through practices and the literature; and educator and clinician networks across health services throughout the State, and furthermore, links with the tertiary sector to assist in marketing and applicability, and synergy with further education provided in institutions of higher education. Nursing registration is the beginning level of practice for registered nurses and a pathway for the continuous development of clinicians ensures maintenance of standards and professional growth. Arguably, these structures and opportunities for nurses are similar to medicine where upon registration doctors are supervised and linked into continuous learning programs within specific fields of practice.
Queensland Health recognises that education in the clinical context is core business. It is recognised that nurses continually ‘buddy’, preceptor and mentor nurses within the workplace (Malloch & O’Grady, 2006). In their endeavour to promote a systematic approach to life long learning in the workplace, Queensland Health has developed the Queensland Health Nursing and Midwifery Staff Development Framework (Queensland Health 2007). The Framework provides learning and development opportunities in a coherent and structured format through guiding all classifications of nurses in the progress of their practice in the workplace (refer Figure 1).
INSERT Figure 1
Lifelong learning is a commitment to the development of knowledge and social capital. To this end the framework recognises the nexus of learning that includes individual, clinical, organisational and professional development. The effective integration of the nexus of learning ensures the sustainability of learning for staff, as motivation is enhanced (Stapleton, Henderson, Creedy, Cooke, Patterson, Alexander, Haywood & Dalton, 2007) together with ensuring relevance of learning to the needs of patients and the organisation. A fundamental component within the framework recognises that an individual staff member needs to acquaint themselves with the organisation and the premises upon which clinical practice and continuous learning is based.
A learning organisation continually expands its capacity to create its own future by being committed to encouraging its staff to develop themselves (O’Shea, 2002). Organisational learning refers to knowledge and skills required by nurses to function effectively in areas to achieve specific organisational aims and objectives. At its fundamental level, this can include education on the Queensland Health Code of Conduct (Queensland Health, 2006) or the performance management system of the organisation. It also involves an understanding of culture including the values, norms and behaviours necessary to work as part of the team in the delivery of patient care. An understanding of the organisation is imperative if the complexities and demands of work are to be successfully negotiated to provide learning and professional development opportunities for staff. Recognition of the importance of the organisation and the values integral to its operation is the basis of successful leadership that facilitates continuing professional development.
In the broadest sense, a nurse’s ongoing self development, based on individual and personal goals, falls into the professional sphere of learning. More specifically, this sphere includes the learning the nurse engages in relative to broader nursing professional issues and trends. Examples in this area include: resolving ethical issues relating to practice (application of the ANMC Code of Ethics), decisions regarding scope of practice (application of QNC Scope of Practice Framework for Nurses and Midwives), participation in professional groups, and consideration of how nurses and the profession participate in shaping state and national policy development. A significant proportion (if not all) professional learning stems from clinical learning, as nursing practice does not occur in a vacuum, for example, ethical questions (central to many professional issues) arise from providing care in the clinical setting.
Clinical learning refers to the clinical knowledge and skills specified by the organisation as being essential prerequisites to demonstrate acceptable standards of practice in the delivery of patient care. For the individual units, the service profile and models of service delivery identify the required areas of clinical practice. As recognised, this occurs within a context of organisational and professional learning.
Each registered and enrolled nurse is required to practise safely and competently as described in the Queensland Nursing Council (QNC) Scope of Practice Framework for Nurses and Midwives (Queensland Nursing Council 2005, p.4):
The scope of nursing practice is that which nurses are educated, competent and authorised to perform. The actual scope of an individual nurse’s or midwife’s practice is influenced by the context in which they practice, the client health needs, level of competence, education and qualifications of the individual nurse or midwife and the service provider’s policies.
In the clinical environment, nurses continually attain knowledge and skills relevant to their practice situation. Therefore, the practice of a new graduate is quite different from an experienced registered nurse within the same clinical area. The requisite clinical skills through which the new graduate or new nurse entering the area needs for career progression is clearly specified in the operational map tailored for each clinical area. The implementation of continuing education is governed by these individual, clinical, professional and organisational needs (Griscti & Jacono, 2006).
The framework acknowledges the integration of organisational, professional and clinical learning. The career development of nursing staff is based on this nexus as presented in the framework (Queensland Health, 2007). It is a development pathway reflective of a continuum of practice. That is to say, a nurse will - at any given time - be at a point on a continuum of beginning to advanced practice in a particular work context (Benner, 2001). As the work practice context changes the nurse may move to a point of beginning practice in a different specialty. The career development path needs to match the practice level of the individual nurse. Synergies between individual and organisational goals can be difficult to attain (Lawton & Wimpenny, 2003) therefore a systematic approach to this progression can
be helpful. Participants’ progression through the framework is assisted through the recognition of stages, namely, orientation, transition, and continuing development. These stages provide sequence and clarity to staff progression.
Orientation is the process by which new employees are provided with knowledge and understanding of their district and QH as a state-wide organisation - including its mission, strategic objectives and scope of operations. During orientation, staff are made aware of the policies and protocols of the organisation and work unit. Staff are acquainted with responsibilities, workplace, clients, and co-workers and provided with the opportunity to consolidate the knowledge and skills required to fulfil job responsibilities.
Orientation is an essential human resource management strategy, as it can influence the employee’s subsequent attitudes toward the entire organisation. Orientation should make the staff member feel welcome, safe, valued and excited about their new workplace. Orientation programs are instrumental in the adoption of values - an essential component of organisational learning. About this stage the staff member enters the period of transition.
Transition has been defined as the period of learning and adjustment in which the new staff member acquires the skills, knowledge and values required to become an effective member of the health care team.
When a new staff member commences in a new setting / environment / role, there is a period of time before they feel confident and competent with the various aspects of the role such as knowledge, skills and/or attitudes that are required for the position. This period is known as transition, and support during this period is crucial. Nurses requiring transition support may include any nurse who is: moving to a new practice setting; or possesses new qualifications relating to a specialty post-graduate course.
It has been identified that transition support is an integral part of workforce planning, and that there is a direct relationship between the implementation of programs and the retention of nursing staff (Leigh, Calbert, Lee & Douglas, 2005). The transition process enables the nurse to effortlessly transfer to the new work environment and aids consolidation of their existing skills, knowledge, attitudes and values to the new practice setting, resulting in better client outcomes.
The transition process component of the framework does not represent a fixed period of time. The length of time it takes an individual to complete the transition process is determined by both the nurse’s entry behaviours, as well as achieving competency standards which are set by individual health facilities and/or departments. Individual ward areas generally have a trajectory of clinical skills that specify learning needs for their area. This also assists the nurse integrate into the organisational culture. This is an important consideration given that nurses’ perception of assimilation and adjustment can relate to their feeling of ‘getting to know the system’ (Fox, Henderson & Malko-Nyhan, 2005).
Throughout the transition process, developmental milestones are specified and utilised as markers to monitor nurses’ progress. The teaching and learning support for the transition
process uses both formal and informal support systems such as practice partners, buddies, mentors, facilitators and preceptors. The formal programs provided by staff to provide this support to other staff is acknowledged in the lower section of the Operational Map (refer Appendix 1). The integration through partnering with team members is an essential aspect of learning in the clinical environment (Henderson, Winch & Heel, 2006).
Continuing and Ongoing Education
Education during this period facilitates the development of nurses beyond the transition process. Advanced clinical, leadership, management, education, research knowledge and skills are developed. Accordingly, staff are prepared to mentor, support and facilitate career progression through succession management. Partnerships and collaboration with institutions of higher education are also particularly important at this stage. Such learning that occurs between the work environment and higher institutions is arguably interactive, and used to encourage staff to reflect and build upon their practice. Improved outcomes are associated with such learning that is meaningful to practice (O’Brien, Freemantle, Oxman, Wolf, Davies, & Herrin, 2003).
The modus operandi of the framework
This model distinguishes itself through clearly articulating and aligning individual needs with educational programs, in particular prioritising organisational needs and establishing systems whereby these core needs become the basis of learning. The value of the framework is maximised through learning that is consistent and relevant to the clinical context. As the organisation supports the learning of the nurse then its relevance through engaging in
contemporary clinical practice is assured. The successful functioning is dependant on teams, resources and networking.
A number of teams assist in enabling the operation of the framework. Encouraging educators, clinicians and managers to work together toward a common goal breaks barriers, improves understanding and improves educational delivery processes (Leigh, Calbert, Lee & Douglas, 2005).
Firstly, a local ward based team comprising the nurse unit manager, nurse educator and senior clinical staff meet to determine those skill sets required by staff that are integral to care delivery in the local unit. The value of education is recognised and supported through allocation of resources for this local leadership team to meet. This is imperative as they ensure that processes are aligned, for example, in-service sessions, rostering and allocation of workloads with preceptors, so that staff can readily partake in learning in the structured clinical environment.
Secondly, a specific education team develops the program, that is, the learning suites that are appropriate to the requisite skills sets; and modes of delivery, namely, self-directed education, in-service sessions, tutorials and workshop study days to facilitate access and maximise learning for staff. This local team responsible for planning the conduct of education and requisite assessment comprises an experienced nurse educator, ward based clinical facilitators, and clinical nurse consultants. Liaison with the nurse unit managers also occurs at this time.
Queensland Health has developed a number of educational resources specifically to be used to support the transition process. Within the Transition to Practice Nurse Education Programs a suite of modules relevant to practice have been developed that can be accessed by all QH staff across Queensland. Transition to Practice Nurse Education Programs are contemporary, clinically focused learning modules that have been designed to provide the nurse with learning experiences to acquire the necessary knowledge and skills to begin to function effectively in an area of specialisation in nursing.
A core set of modules has distinct advantages that include:
a clear minimum standard for practice in relation to skills that are reviewed at a designated three year period (similar to curriculum review); and a moderation group around the assessment criteria.
consistency across a broad geographical area; and also has provision for staff who move around Queensland Health facilities to ‘pick-up’ where they ‘left-off’ therefore reducing duplication and potential disinterest in pursuing workbased learning.
effective use of time and resources of educational staff across QH as not every facility needs to be developing its own suite of modules.
material that is contemporary as appropriate teams that include Nurse Practitioners, Clinical Nurse Consultants contribute to the development of modules. Findings from the research literature where relevant are also incorporated into modules.
The continuing support for financial resources and for updating and conducting programs, and also the marketing and embedding of the program in rostering practices is supported by nursing leadership teams across Queensland – at a broad State-wide level and a local unit/ward level.
To progress these initiatives a group of Nursing Directors (Education) from across Queensland Health meet regularly. These Nursing Directors participate in Area Health Service meetings that are attended by Directors of Nursing across a range of Districts. The collaboration of the teams and networks is recognised as an investment in social capital, that is, closely knit groups who teach and educate others through a commitment of time and patience (Gopee, 2002). This ultimately strengthens the culture of life-long learning.
The role of collaborative processes between clinical and academic settings in the continuous development of nursing staff is pivotal (Mockett, Horsfall & O’Callaghan, 2006). In Australia, when nursing moved from the apprentice style teaching to the academic setting the role of the hospital in education was not clearly explicated. Implicit in the shift was the importance of ‘clinical learning’ in undergraduate and postgraduate courses. Clinical experiences in the form of placement as ‘supernumerary’ has been accepted practice for the undergraduate program. However, post-registration education has been adopted in highly variable forms and partnerships. While there has been recognition that the nursing profession
requires a rigorous academic preparation coupled with appropriate clinical experiences to ensure competent skilled clinicians, the interface between the tertiary and clinical settings has not always been clearly communicated or articulated in the post graduate arena.
When developing partnerships that enable continuous learning the contribution of clinicians, industry based educators and tertiary partners needs to be clearly articulated to promote learning (Henderson, Twentyman & Heel, 2007). The value of the suite of modules developed, is that, through partnership and negotiation with tertiary partners nursing staff upon completion of the program receive credit for post-graduate education pertinent to clinical skills and abilities. Clinical learning is therefore recognised as a legitimate step toward knowledge development and ultimately career progression.
While the hospital component of the modules facilitates the advancement of clinical skills, knowledge, attitudes and problem solving, further academic pursuits are enabled through the tertiary sector. The university component while not limited to, does provides opportunities such as: extension of knowledge, influence of the political system and policy, and provides a space for nurses embarking on further studies to explore diverse application and other possibilities in clinical practice.
This structured pathway when clearly articulated to staff at the time of their orientation, and detailed in staff development pathway booklets provides staff with clear directions about educational opportunities that are available to them within Queensland Health. Depending on nurses’ skills, interests and aptitudes the career pathways are variable.
Learning is complex. Through the recognition of the nexus of learning, that is, supported in the clinical setting, staff arguably feel encouraged to maximise possibilities for career development. This is commensurate with learning organisations that develop a culture of openness and trust (Senge, 1990). Nurses when offered a range of learning opportunities that assist in making their work more meaningful are more likely to remain in the organisation. The organisation therefore benefits from this expert knowledge that is then communicated and shared with the future workforce.
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