Enhancing Learning in a Specialist Environment: Development of a Tool for Nursing Students

Enhancing Learning in a Specialist Environment: Development of a Tool for Nursing Students

I am a qualified nurse, qualified to care for Paediatric Patients and have been qualified since 2017, I have been in my current role since qualification and plan to extend my role to further support students within the settings, who are aiming to complete a nursing degree to become registered practitioners. Whilst mentoring students, I plan to encourage and assist them in forming an understanding of the role of nurses in the United Kingdom (UK) such that they understand and gain competencies, which will aim to lead them to registered qualification. The role of a nurse is described and regulated by a professional body, the Nursing and Midwifery Council (hereafter referred to as "NMC") and contains specific standards within "The Code" of conduct that express the roles and responsibilities of a nurse (NMC, 2018a). The NMC and the representing body the Royal College Of Nurses (hereafter referred to as "RCN") depict throughout their literature (such as the Code) that a nurse must continue to expand upon his/her professional development (NMC, 2018b, RCN, 2019a). As part of professional development for qualified nurses, the NMC states that nurses have a responsibility to complete a training course that enables the extension of their role from "registered to practice in this country" to being "registered to mentor" and educate students on the Nursing course (during practice placements, in the working environment), through completion of the "Standards to Support Learning and Assessment in Practice" Course, or SLAiP (NMC, 2008).

As a qualified nurse, I wish to complete this course as part of my continuing professional development to permit me to educate (within my scope of practice) and assess student nurses in practice prior to their qualification. The requirement to achieve this responsibility has come from the NMC (2008) which states “registered nurses must attend a post-registration course that follows a framework set out by the NMC”. The domains that make up the NMC framework are applicable within the context of learning and development, and subsequently provide opportunities for nurses and midwives to develop other roles within healthcare, including supporting student practitioners (NMC, 2008).

This assignment will critically analyse a resource formulated to assist students on a specialist high dependency unit in an inpatient paediatric setting. The resource developed is a shift planner aimed to support and facilitate Domain 1 and Domain 2 of the assignment brief (Establish Effective Working Relationships and Faciliation Of Learning), in relation to the current student assessment book, as depicted by the Nursing and Midwifery Council (NMC). I have developed this resource to help integrate students into the practice area by giving them knowledge of their caseload, offering prompts for cares needed by the patients allocated to myself (a mentor) and the student working with me, it will assist me in assessing the student in knowing that they are able to "plan care". The planning checklist and handover permits the student to have patient details that they otherwise would not have access to, as students are not permitted to have full handover sheets in my place of work. The assignment will begin with an explanation of the tool and how I intend it to be used, it will then go on to critically analyse the tool by addressing the competing influences that may impact on its' use. Following this, I will consider how this will affect me as a mentor, how I am able to teach and assess and will then compare the above to analyse if my tool will benefit the students who have access to it. I aim to be able to integrate the opinions of students, comparing learning theory and using current evidence base to finally conclude points to summarise.

The resource (Appendix 1) has been developed as a means of documenting and as an observation tool to be used in place of a handover sheet with a care planning aspect to support student learning. It has been developed for students to use on a daily basis, to support them in nursing skills and developing autonomy. It has been suggested by Seifert and Sutton (2009) that students benefit in a new environment when they have access to an environment specific resource, relevant to the working environment alongside support from a mentor with specific knowledge, which this resource aims to do to facilitate learning (applicable to appropriate nursing domains).

This resource is a planning checklist to be utilised by students in place of a handover sheet, I feel that there is a specific need for the ward setting to have this type resource for students that they are permitted to use to store information on. The resource aims to allow students to develop an understanding of the child’s care needs, by detailing key pieces of information about the child and their needs. Having a comprehensive understanding of patient need is described as an essential part of care by the NMC who discuss that nurses (including student nurses) must offer time to patients to develop this to promote patient care (NMC, 2018). Stated by Hemingway et al. (2018) "nurses need to engage with individuals and ensure that they focus their practice on the health needs of the groups they serve" and this is relevant to students and nursing mentors having an understanding of need.

Information understanding and sharing (for the purpose of discussion this is referred to in relation to students, but is applicable to all nurses and the wider multidisciplinary team) is described as essential by nursing bodies, namely the NMC (section 5.4 of the Code) and RCN, such that it is done in a safe manner (NMC, 2018c, RCN, 2019b). The sharing of information is necessary to protect patients and their needs, discussed by Dyer (2009) who stated that care delivery "may be hindered and patient outcomes affected if information is not shared appropriately", this is extended to the students in a placement area. In addition to this, it is essential to consider that information is shared in a professional way, only to be shared when it is necessary; this is to ensure that nurses and allied health professionals are not in breach of the setting's confidentiality policy. As discussed earlier, professional nursing bodies, the NMC and RCN detail that it is imperative that confidentiality standards are not breached, to protect patients and their personal information. The aforementioned bodies express that is essential that students (not just their mentors or registered colleagues) have a good understanding of patients' medical needs, histories and current concerns that has lead to the inpatient stay, such that they are able to partake in providing safe patient care (Lewis and Kelly, 2018). However, it is entirely necessary this information must only be shared in a relevant and professional manner so that the patient and their details are protected (HM Government, 2018).

Ervin's (2008) research regarding understanding key information suggests that having visual aids may benefit students in effective management of a caseload (alongside a qualified nurse, a mentor). Although this reference is dated, it is supported by (Alvarez, 2014) who agrees with Ervin in stating that aid sheets and other supporting documents/visual tools, which include direction are necessary to help facilitate learning and planning, particularly where individuals may not have prior experience in a particular setting. Contrary to this, it may be suggested that having such a tool does not prompt a student to use his or her intuition to consider patient need and plan cares (National Research Council, 2000), and may mean that the student may become reliant on the produced tool, this may affect their developing autonomy. The sheet has twelve depicted sections for up to four children on one nurse's caseload (in this case, the nurse is acting as the student's mentor), such that they are able to document clearly for each patient in a structured format with an additional section for other notes relating to history and current issues. Williams (2001) states that students are likely to find this formal structure useful and refers to constructive and problem-based learning theory models which state that structured support "facilitates the development of nursing students' abilities to become self-directed in learning ", this is supported by Spooner et al (2018) who explored the use of supplementary handover tools and found that by using a tool to record information, more information was able to be retained. I believe that the tool will be useful for students to ensure that they have more familiarity with the new ward environment that they may not have been to before, it is important that students are further understanding as we are a specialist unit with highly dependent children.

The columns are blank so that it can be adapted to different patients; as it is intended for single day/use and states that it must be discarded following the completion of a shift, this is to remain in consideration of confidentiality policy, supported by the NMC. The resource is required within my setting as students are not permitted to have full handover sheets due to a previous breach of data protection and it is imperative that we strive to protect patients at all time (NMC Code), it is also to be used as a "tick sheet" style resource to ensure that essential care needs are complete. Due to the nature of the area of practice and as students are not allowed full handover sheets, their understanding and knowledge may be limited in relation to how they are able to plan care as they do not immediate access to all the information. As above, Lewis and Kelly (2018), the NMC and the RCN state that patient details are essential to providing patient centred care, as it may be that students in our area are disadvantage by not having this information. The resource is reliant on the mentor to inform the mentee with details about the patient; as the information is not available to them via the handover sheet medium. The resource aims to eradicate this barrier to care planning by allowing the student to form understanding of the caseload and subsequently plan patient care using the checklist under the direct supervision of a mentor.

The resource, as depicted above, aims to not only store information, but to also ensure that essential care factors are noted and considered by the student, by giving a prompted list of factors that should be considered by the nurse and student when organising care. As the student will be recording the information independently, it should be written within their scope of understanding and it is hoped that this will challenge the student to ask about areas of where understanding is lacking (in this case, where they may have blank boxes on the tool sheet). When the student has been within the setting for a prolonged period it may be that they may develop an unconscious understanding and start referring to the resource less as their knowledge of care needs develops, moving through the four stages of competence (Kuldas et al, 2013). The need for such a resource is supported by previously mentioned Lewis and Kelly  (2018) and further by Jamshidi et al (2016) who state that students may feel overwhelmed with complex patient care and may benefit from prompting tools as the of the ward may be overwhelming.

Learning theories have been considered in relation to how this tool is able to be applicable to students with different learning styles. Pioneer in behaviourist learning theory, John Watson (1913) (researched by McLeod, 2017) suggested that by "explaining at the outset what it is that people will learn will encourage them to achieve" based on a stimulus response, in this instance the "stimulus" is completing a successful placement and achieving set criteria as depicted in student's placement book (within the domains). The tool developed aims to help develop skills which will facilitate the achievement of a successful placement. Insight theory was also considered, as if students are given the tool to be able to facilitate development of understanding, by being given insight, then they are more likely to achieve (Barber, 2002).

Following review, the resource has been found to be best suited for students who are "activists" (who learn best from activities where they can be engrossed in immediate events) and "reflector" (people who collect data and review in summary) styles as the way in which a student is able to document information and relay this onto the necessary nursing care. Consequently, this may mean that it is likely to be less effective for those who consider themselves "theorists" or "pragmatists". Learning theories, methods and subsequent student needs have been applied and taken into consideration when developing the tool. It is understood that students are not likely to all share the same learning style (Advanology, 2019) and that is where I think there may be a problem in developing a tool as it is hard to facilitate all kinds of learners. Regardless of learning style, it is hoped that the use of direction and prompt will be beneficial for all students in practice. Studies show that it is likely that teaching styles delivered by mentors will need to be reviewed for each student, such that they become best adapted to a particular student, is likely to be needed, as is possible for students can change learning styles as they progress through a course/over time, this is known as multimodal learning teaching will be adjusted to suit what is required (Leve, E, KL, 2015). The benefits to this include being able to refer back to the resource to assess development and understanding, to see if a student is progressing, this also related back to the stages of competence as discussed earlier.

When developing this resource, I was mindful to consider the specific needs of the patients cared for the ward. I offered the resource to some students who used and evaluated the resource after using it for one thirteen hour shift. Two students used the resource, which is a small sample size, but I feel that the response from them is important I assessing the usefulness of my resource. Student A (a third year student) suggested that the resource may not be comprehensive enough and felt making her own notes would be more beneficial than the formal structure as she felt there wasn’t enough space for the information to be documented And that the sections were too stringent and didn’t leave scope for variation. Student B was a first year student and she said that she appreciated the prompts that the tool offered as she was unfamiliar with the ward and hadn’t worked in a placement setting before. She said that she would benefit from the tool, as long as she had time to fill it in and if she was given a full handover, alongside a mentor, otherwise she was worried that she may miss vital information. She also said that she worried about the understanding of the mentor in comparison to herself, as her "knowledge of different conditions or medications" will differ greatly from the mentor's.

My concern with assessing this tool is that I do not feel that I have been able to gather a comprehensive review of the tool as the students I approached did not used it for a prolonged period. I feel that as a mentor assessing the tool's effect, whether positive or not, I would need to observe over a longer period of time and observe use in the clinical area. It would also be beneficial to review it again in a few weeks, when the students have become accustomed to and are competent in using it. In doing this I could follow up the observation by tackling any concerns that arise and further adapt the tool to suit. I also feel that there may be a barrier to implementation as I was only able to ask two students to review it and it may be that additional barriers are encountered in communicating the change (RCN, 2019c). I feel that with further expansion and roll out of the tool, it would be better evaluated.

This resource will enhance teaching by prompting students to follow a plan of care and by encouraging them to consider important parts of care specific to the children in the ward setting. By the end of the placement on the Ward it is hoped that a student will be more able than they were and will be more likely to use their own intuition to plan care, therefore less reliant on formal checklist. Historic information may not be recorded on the sheet, as there is limited capacity for space, this may meant that students remain inhibited in not having a handover as they will not have all the information. However, it will remain available as a prompt to ensure care needs are fulfilled. This method of teaching has been theorised by Engelmann (1991) and reviewed with Carnine (2016) who refer to educating via direction and instruction where a student is guided and educated, that I hope the tool offers to students. The tool facilitates the cording of information, but does not tell how to obtain that information, that would involve additional basic training to be taught by the mentor to the student, however, it is also hoped that the student would enter the placement setting with some understanding of how to obtain information such as PEWS, height and weight that should have been taught at the university prior to the placement commencing.

I feel that this resource is best suited for first and second year students as it is expected that third year the students should have more understanding and therefore be more autonomous within their work in a placement setting. However, it may be a resource that the third year student uses when getting used to the ward, if it isn’t an area they’ve been to before, and such have limited understanding.

The resource has been developed in using a pedagogic approach, with some direction given by means of prompt (the headings provided). It encourages the student to fulfil cares in a timely manner, by prompting the student to document different items on which to form the basis of care. The resource is a planning list which will be used by students, it has previously been stated which will challenge students to ask questions about the care provided and will prompt in place of a paper handover. Paper handovers do support understanding of patient need, instead they show history and may include some current cares, this was discussed above, in regard. Following review of the resource it has demonstrated that it is not entirely comprehensive and is largely reliant on a student's individual ability and will to record information during handover. If a student is reluctant to use the tool, or has a disability that affect their ability to record information, it may be that reasonable, adjustments may be needed to facilitate these needs.

Without the resource, it is generally assumed that students do still learn to take notes regarding patient care, but it is hoped that with a structured planner, this information is stored in a safer, more organised way. T is hoped that mentors with go over the information recorded by the student on the resource sheet bad that information will be shared with the student but this is dependent on the mentor.

Following the responses of the students I would further like to develop the tool to suit their needs, but certainly feel that further research into additional theories would help me in adapting it to support one target audience, a first year student, as opposed to trying to make it suitable for all; response showed that it doesn’t suit that due to the varying capabilities of individual students. I had previously had concern with my resource in choosing the more necessary parts of care to put onto the sheet, knowing that I would have very limited space, it may be better to develop the tool into a prompt rather than somewhere to store historic information.

I believe that the resource will be useful within my area of practice and will be relevant to all patients we encounter. The mentor role in promoting development can be benefitted by relating back to the tool to ensure that the student's developing understanding and skill is improving. It also boasts the ability to offer direction where there may be concern, which may be a difficult conversation to have, but I feel that between the student documentation book and the tool, it will be possible to assist in the assessment of the student hoping to qualify. The NMC state that "As mentors you have the privilege and professional responsibility of helping students translate theory into practice, supporting the conversion of learning in the classroom into effective and safe practice in line with the Nursing and Midwifery Council’s Code (2015)" and I feel that the tool, with adaptation made as suggested will help to facilitate this.

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