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“Dewey (1938) stated that all genuine education comes through experience. Certainly, in practice-based professions such as the health care professions, clinical experience should be the basis for learning. To extract learning from experience, we need to create meaning from our experiences as we interact with and react to, them. We cannot allow any experience to be taken for granted; once we do so, actions become routine and habitual, we stop noticing and enter into a rut” (Stuart 2007).
Critically discuss this quotation by focusing on the complexity of learning in practice, the complexity of supervisory process and the end goal of creating a competent practitioner.
Table of Contents
It is in the interest of both the university and the clinical areas to ensure that newly qualified nurses are perfectly competent to take on the responsibilities of their new jobs. The big question is; which area should play the best part in ensuring that this feat is accomplished? Conversely, could it be a perfect balance between the two domains? Considering the changing face of nursing education to keep up with modern times, it is also useful to contemplate the challenges that students and educators, both academic and clinical are faced with. In order to establish if the goal of producing a competent practitioner is reached, it is important to determine what exactly constitutes a competent practitioner. As a final thought the concept of competency shall be pondered to see if it is sufficient to produce competent professionals when today’s employers demand high standards and excellency of care.
The changing nature of nursing
Countless times nursing has been referred to as both an art and a science. Clearly, this is to delineate that it is a combination of both academical knowledge and practice skill. Through the years nursing education has shifted from hospital training (skills) to higher education (academic) namely university baccalaureates, masters and also doctorates (Wilson, 2008). Jarvis (2005) explains that this change is occurring because nursing is undergoing a process of professionalization (professionalism). Another important change is that, whereas the student nurses before were all young recruits nowadays the classroom is a mixture of ages either due to mature students entering nursing or due to continuing education (Jarvis, 2005). These adult learners may thus have different learning needs. The fact that nursing has distanced itself from the medical model, in favour of a holistic, patient centered approach, it has also inevitably changed the way nurse education is planned and delivered nowadays. Alongside the study of anatomy and physiology, nurse educators had to include the nursing process and humanistic subjects like the concept of care, psychology, sociology and ethics.
Meurier, Vincent & Parmar (1997) maintain that this process was necessary for nursing to become an autonomous profession that has research underpinning its practice. Evidence based practice became a means of gaining credibility with both clients and other professions. Greater autonomy has been given to nurses locally by the issuing of the nursing warrant. However, autonomy also translates into increased accountability. Patients abroad are now personally suing individual nurses when they are thought to be personally responsible for errors. Never before has it been more important to produce competent, efficient and effective nurses in order to avoid costly litigations and avoidable patient suffering and harm. The emphasis is now on which type of learning is best at producing competent nurses, theoretical, academic or possibly a mixture of both.
The great debate
One of the main objectives of this assignment is to critically discuss the quote provided. In this quote Dewey is said to put great emphasis on the role that experiences plays in providing a genuine education. Experience is defined in the Longman (2010) dictionary as “knowledge or skill that you gain from doing a job or activity”. Experience is an important component of practice development (Lyneham, Parkinson & Denholm, 2009). However, nursing is not only about doing but also about thinking.
In the quote provided, Dewey’s seems to be subjective when he omits to recognize the role that theory plays in the learning process. However Dewey, in his own book states that “the belief that all genuine education comes about through experience does not mean that all experiences are genuinely or equally educative” (Dewey, 1998, p. 13). Knowles, Holton III, & Swanson, (2005) believed that many Dewey’s ideas were misinterpreted through the years and emphasised the importance of direct quoting. Hence, to evaluate properly Dewey’s quote, one must assess it in the whole context not just a short quote. Peplau (1988, p. 13) asserts that the art and science aspects of nursing should always be kept “interconnected if not inseparable”. This statement suggests that experience and academical knowledge, should complement each other in order to achieve optimal learning. The clinical environment is a rich learning ground full of learning opportunities. On the other hand, this knowledge can be in a tacit form and hard to translate into words. Eraut (2004) maintains that when these situations arise, the practitioner needs to find alternate ways of unlocking and sharing this knowledge. Reflection, which is widely taught in nursing curriculae nowadays may be a means of articulating knowledge that is embedded in practice (McBrien, 2006). Thus, this is an example of theory complimenting experiential learning. Furthermore, without nursing developing its own theoretical body of knowledge the quest for professionalization would have been unreachable. In order to advance the nursing profession and provide the tools to increase the body of knowledge, critical thinking and research modules have been added to the nursing curriculae. This enabled nursing to move away from the dominancy of other professions and empowered nurses to be able to make their own competent decisions based on well researched evidence.
Clinical experience includes also the practicing of skills, which are primarily learnt through role modelling strategies and perfected through repetition thus increasing competence. Consequently, habitualisation runs the danger of becoming a ritualistic practice when it is taken for granted and done without thought (Stuart, 2007). Heath and Freshwater (2000) regard proficiency in skill, achieved through repetitive practice as positive. They explain that nurses will require less thought whilst performing procedures and their attention may be dedicated to answering the patient’s questions or observing his behaviour. However, practice without reflection truly risks becoming a rigid, habitualised and ritualistic vicious circle.
Experience is not just about performing skills well and in good timing. It is also an opportunity to be faced with different clinical situations and challenges that equip the nurse with the necessary knowledge to deal with similar situations in the future. A report compiled by the Department of Health (1999) entitled Making a difference outlined that many newly qualified nurses lacked the necessary skills to function as confident and competent practitioners in their new professional roles. Therefore, although nurses might possess the academical knowledge to pass their final exams, they lacked the experience to operate confidently on the wards. Another shortfall was that newly qualified nurses were observed to lack the critical thinking skills necessary to function in the increasingly complex clinical environment (Aronson, Rosa, Anfinson & Light, 1997). Many argue that this is the result of the shift from hospital based training to university centered education, creating the theory practice gap phenomenon (Evans, 2009). In the following paragraphs, the theory practice gap and means of reducing it shall be discussed.
Theory- Practice Gap
In the past, nurses had more clinical hours than study hours as part of their nurse education. Furthermore, the students of the past were counted as part of the nursing compliment. This may explain why they found the transition from a student to qualified nurse less problematic. However, this kind of training sucked the students into a circle of ritualistic practice concentrating on efficiency rather than effectiveness. In contrast today’s student is provided with all the theoretical knowledge to ensure that practice is guided by evidence thus shifting the balance onto effectiveness. Wilson (2008) explains that teaching should not just be the imparting of facts but that students must learn how to adapt this information to each unique clinical setting. Therefore, it is empirical to bridge the gap between what is known and what is practiced.
The gap between theory and practice is not something of the present and will persist through the ages. Haigh (2009) considers this gap to be important as it portrays nursing as a “vibrant and dynamic profession” (p. 1). Notwithstanding this, the theory practice gap has inspired theorists to introduce learning models in the clinical environment and mostly included the participation of a clinical supervisor (Beinart, 2004 and Lynch, Hancox, Happell, & Parker, 2008). Furthermore, no model has managed to eradicate the theory practice gap (Baxter, 2007). Whichever model may be used, the importance of having a clinical supervisor with exceptional qualities must not be overlooked.
An advantage of the local nursing scene is that although the Institute of Nursing has now become a faculty, its basis is still within the general hospital. The significance of this is not only that the two domains are not physically separated, but that also academical staff and other resources such as the library are easily accessible. However other measures are also necessary in order to amalgamate theory and practice. The areas of reflection and clinical supervision as a means of reducing the gap shall be discussed in the following paragraphs.
Reflection and learning
Schön (1983) in his book regarding the reflective practitioner states that reflective practice enables a person to learn from both his actions and experiences. Jarvis (2005) maintains that the role of a teacher may include facilitating reflective practice for practitioners in order to “crystallize” the ideas generated in practice. Moreover, Schön established that nurses reflect upon their actions and through this, knowledge about practice is generated as opposed to just the application of knowledge to practice. Rolfe (1997) supports this statement by asserting that reflective practice is a systematic and thoughtful process that allows nurses going about their daily work to make sense of their practices. Reflection is a means of identifying areas that need improvement. However, reflection should also take place in instances that went well to identify the key principles that contributed to success. Surgerman, Doherty, Garvey and Gass (2000) point out that if reflection is taken away from practice, the practitioner might not be able to learn from these experiences.
Unfortunately staff shortages and the overcrowding of wards often leave little time for nurses to think (Weaver, Warren & Delaney, 2005). However, this should not be an excuse not to engage reflective practice. Reflection on action may be more suitable and should be greatly encouraged amongst supervisees as a means of making sense of practices being undertaken. This form of reflection was also used by Florence Nightingale as a means of generating knowledge from practice and the start of evidence based practice (McDonald, 2001). Another way would be to organise group reflections. The group may include a mixture of supervisors and supervisees in order to facilitate discussion and the sharing of knowledge (Lee, 2009). The process of reflection is also very useful in helping students and qualified staff alike to develop critical thinking skills. Further on, a problem solving attitude may be instilled, which is a valuable tool for the nurses in their career (Jarvis, 2005) thus leading to the development of a competent practitioner. The generation of ideas from reflection is not sufficient. The greatest challenge is to put these ideas into practice. Clinical supervisors can be an asset in helping students to engage reflective practice whilst helping them articulating and implementing the ideas generated.
Wong and Lee (2000) define the roles of clinical supervision as to help students develop their clinical skills, help to bridge theory and practice and assist students with their socialisation into nursing. McBrien (2006) states that clinical supervision acts as an extension of classroom teaching. In other words, the clinical supervisor works alongside the university to maximize the educational activity gained from the ward experience. In the wards, the supervisor, helps to safely monitor students, whilst they practice what they have learned in the classroom thus bridging the afore mentioned gap. Supervisors may teach supervisees by being good role models, and help novice students acquire knowledge through emulating their behaviour. As supervisees progress the supervisor must then give greater freedom to the student whilst challenging their practices in order to develop their reflective and critical thinking skills. Supervisors must be well prepared and supported (Lynch, Hancox, Happell, & Parker, 2008). Furthermore, their practices have to be grounded in evidence as supervisees at this stage will healthily challenge what the supervisor is imparting.
Supervision takes up different forms in different hands “depending on the intent and emphasis of the supervisor” (Johns 1996, p.1142). Staff shortages, overcrowding and high patient turnover may result in ward nurses looking at students in an inappropriate manner, especially if supervision was forced on them. Consequently, they may look at students as a burden, an extra duty or a waste of their free time. Moreover, they may view them as an extra pair of hands which can be easily manipulated to do their every bidding. McBrien (2006) warns that faced with such negative attitude student nurses may be inclined to abandon their learning objectives in order to fit in. Furthermore, nurses may be hostile and uncooperative towards their colleagues who are trained clinical supervisors who take on students for supervision in their wards.
The clinical supervisor thus has an important role in creating an environment conducive to learning on the wards. This should include measures to make students feel welcome and accepted by the rest of the ward staff in order to safeguard the student’s self esteem and potential for learning (Franke, Garssen, & Huijer Abu-Saad, 1995). Moreover, good relationship is of utmost importance in obtaining the desired goals in the supervisory process. The relationship between the supervisor and the supervisee is the key for successful clinical supervision (Lynch, Hancox, Happell, & Parker, 2008 and Sloan, 1999).
The above points strongly indicate that clinical supervisors have to be willing and dedicated to undertake the teaching role in the ward. Supervisors must undergo specialised training. However, in order to move a further step, full collaboration with the academic body has to be in place. Sloan (1999) stated that on-going training for supervisors helps them to construct their own supervision models, to develop interpersonal skills and facilitate supervisory support besides others. One training module is not enough to last a life-time, hence update courses and meetings should be held yearly. By this means not only knowledge is updated but also an opportunity for the sharing of ideas is provided. Introducing regular meetings with the academic supervisor ensures not only a bridging of the theory practice gap but also that the desired student goals are made clear and achievable.
Unfortunately, the number of nursing students by far outnumbers the amount of clinical supervisors who have been formally trained. This lack of supervisors may be the result of the absence of a good reward system such as monetary or professional. Alternatively, the quality of supervision might deteriorate with its introduction. This can be due to applicants applying for the rewards, rather than a keen interest in supervision. In this event, a rigid vetting process and performance appraisal should be introduced. The concept of collaborative learning has been explored by Jeffries (2005) as a means of compensating for the lack of supervisors. The main advantages were an increased sense of teamwork, student bonding and richer discussions. However, Evans (2009) points out those students who are less eager to participate may hide within these groups thus limiting the development of their potential. Moreover, large groups may contribute to certain students getting away with not performing duties that they might consider not to their liking (Evans, 2009).
An important role that the clinical supervisor must play, which is sometimes overlooked is the development of self awareness. Heath and Freshwater (2000) maintain that the supervisor must help the student to develop an awareness of self, and an acceptance of responsibility for one’s own actions. Thus the supervisor must instil the concept of accountability, which greatly contributes to the development of a competent practitioner. Todd & Freshwater (1999) assert that through this process the supervisee becomes less dependent on the clinical practitioner because an internal supervisor is developed. Hence, the supervisee develops a professional conscience whilst becoming more capable to assume more responsibility for one’s own learning. When this is achieved, the seed of life-long learning is planted ensuring that the supervisee will continue to self direct learning even after graduation. Jarvis (2005) states that if this had to be universal for all students, continuing education programmes could be drastically reduced.
Weaver, Warren and Delaney (2005) explain that nursing care affects a range of health care outcomes namely; mortality, morbidity and costs. For this reason, an emphasis is now being placed on high quality care, avoidance of errors, cost effectiveness and elimination of wastages. A competent practitioner is someone who is able to conduct tasks safely on their own. Moreover, competency is defined by the Nursing Council of New Zealand, (2008, p.12) as, “the combination of skills, knowledge, attitudes, values and abilities that underpin effective performance as a nurse”. Conversely, Lofmark, Smide, & Wikblad, (2006) state that competency must be achieved in all areas and not just in clinical and technical skills. Furthermore, it is difficult to find a person who is competent in all areas. Having stated all this, a doubt arises, whether being a competent practitioner is enough to meet these growing healthcare demands.
Nurses are faced daily with items that are out of stock, staff shortages and unexpected and unplanned occurrences. In these situations, knowledge and standard practice are not sufficient to meet healthcare demands. Heath and Freshwater (2000) explain that a nurse that goes beyond the competent phase not only can demonstrate greater technical proficiency but is also able to correct and adapt her actions according to the unfolding situations. Benner (1984) asserts that for competent practice to become proficient, a qualitative change must occur. Benner, Tanner, & Chesla, (2009) believe that some nurses may never develop beyond the competent stage. Given the complex clinical situations that every single nurse is faced daily on the wards, this transition should be avidly cultivated. Improvisations and solutions must be effected in order to ensure that patients still receive good quality care. Drawing up on past experiences, knowledge new or old and utilizing reflection and problem solving skills are a means of coming up with new solutions. The clinical supervisor is an invaluable asset in helping the supervisee to make this transition. This can be done by being a role model, providing meaningful experiences that can be utilized in future practice as well as supporting the supervisees in developing their own problem solving skills.
A universal responsibility
Although an emphasis has been made that the clinical supervisors should be formally trained, every single nurse in the clinical setting should take an interest in the education of student nurses. These same students will in the future become nursing colleagues and further on nursing administrators and lecturers. Making sure that they receive the best possible education is a means of safeguarding the future of nursing. On a more egoistical note, these same students will be the nurses in the wards taking care of us and our loved ones. Therefore, ensuring that they develop their full potential is a guarantee of receiving excellent quality care to the highest standards.
It has been established that experience and theoretical knowledge both play a pivotal role in the formation of competent practitioners. The phenomenon of the theory practice divide occurs, when academical knowledge is not successfully adapted into the working environment to achieve meaningful practice. In order to bridge these gaps important assets were identified namely clinical supervision, experience and the use of reflection. Clinical supervision is a challenging area of nursing that should involve specific training and utmost dedication. Collaboration with the academical supervisors ensures that the goal of achieving competent practitioners is achieved. However, exceptional practice should be the ultimate goal that should be shared by all clinical practitioners in order to safeguard the future of nursing.
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