Promoting Effective Learning In Nursing

The NMC Code of Conduct (2008) states that ‘We exist to safeguard the health and wellbeing of the public’. This is of vital consideration in all practice and also when approaching the challenge of teaching colleagues. The need to be accountable ‘for keeping knowledge and skills up to date through continuing professional development,’ NMC SLAIP (2008), is essential.

 Those on the registrar must keep updated and those aspiring to join the register must recognise that this is a commitment of registration. As the person providing teaching must be up to date it also implies that those being offered teaching have an obligation to attend and learn. In order for this to be successful it is important that learning takes place in an environment that allows conditions for promotion of education. It is also important to be sure that the information taught is relevant and of use, Spouse (2003) and individuals receiving training are assessed as to their understanding and competence to proceed with any skills learnt.

As I approach the ‘Slips course’ I am working on a very busy dialysis unit which is short of staff but has the advantage of the staff being experienced and working hard to maintain high standards despite great pressures of work load. The unit has recently introduced a new process of managing access with a change in the process used to cannulate the patients’ fistulas. This has come about following attending several meetings and realisation that this process is becoming the ‘gold standard’ and that we wish to provide this for our patients. The information available for this procedure is mostly reflective experiential information but I gained what I could researching and attending meetings and another unit and with the support of our consultant and manager we launched the change. I must facilitate the learning on the unit implement and evaluate it as required by the NMC standards 2008.

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The other members of staff need to have advice and encouragement to support this change and my formal teaching is to aid their knowledge to help them to feel confident with this new technique in practice. This is challenging because it is teaching a group of very experienced staff to carry out a process they are familiar with but introduce a change in current practice which they need persuading of the advantages. I believe in considering the needs and influence of the students I am ‘providing constructive support to facilitate transition’ as required by SLAIP(2008).

Looking at the Jenny Spouse (2003) comments about the mentor and the progress of the student it is important that they feel that the ‘learning is relevant and beneficial’ if they are to accept the changes and wish to accept them into practice.

‘All nurses must act as change agents and provide leadership through quality improvement and service development to enhance people’s wellbeing and experiences of healthcare.’ NMC 2010.

Some of the staff who had been comfortable and felt skilled and knowledgeable had felt deskilled and isolated by the fact that the processes were being altered. They needed the knowledge and confidence to continue to progress and Spouse’s comments(2003) ‘in successful mentor -student partnerships student’s were able to learn from their mentor and then practice independently under their mentor’s distant supervision’ were very relevant. This was easier to manage with trained experience staff who understood the bounds of safe practice and the main need here was to impart information and allow the staff to question, feeling confident their question would be sensitively and assuredly dealt with, to raise the confidence and inspire the motivation to make this change. I have identified that in order to teach my colleagues I must establish my own abilities and how to share the knowledge with my peer group effectively. ‘Each registered nurse has a duty to provide students with clinical support to help them question, analyse, reflect upon their practice and develop autonomy in decision -making to enable them become safe, caring, competent nurses’, An BORD Altarnais(2003), this guideline offers a goal to aspire to. To achieve this and offer learning this requires consideration of learning theory and I need to think about how this information was best shared. In this I must also consider equality and diversity of any learner thinking how to be fully inclusive to see any learner with learning difficulties is aided to benefit fully from teaching offered to aim to help all achieve their full potential, NMC SLAIP (2008).

I believe that the group I shall teach will respond to being empowered and I wish to facilitate their self direction. Knowles as cited by Smith (2002), believed that adults expect to take responsibility and therefore their learning must be allowed to promote this. Andragogy, Knowles explains believes that adults learn willingly when they see the relevance of the learning. For my teaching I believe that this approach is most suited to how the group will learn. We are making changes to our practice, that they know will benefit our patient group and as a team we are keen to promote any improvement, so motivation is high. Pedagogy is where learning is directed the learning is led to the outcomes with the teacher taking responsibility for learning. I believe that there must be some overlap of these ideas as even with andragogy any teaching must have an element of direction which leads the student but that they then take over to motivate their own learning on appreciating its relevance to them. As Carl Rogers cited in Smith (1999), states ‘…I’m grasping comprehending what I need and what I want to know.’

The learning will by its nature be a combination of cognitive and humanistic learning. Cognitive learning a process of, as J Hartley cited by Smith (1999 (2)), states ‘learning from inferences, expectations and making connections. Instead of acquiring habits, learners acquire plans and strategies, and prior knowledge is important’. Cognitive learning is the process that will prepare the staff being taught to independently carrying out the procedure and becoming safe practitioners, using previous experience to assess the process for each patient in their care.

Humanistic learning will be my method where the individual will be motivated to learn as they wish to improve the care they provide their clients. This considers the human as a being influenced by thoughts and feelings as well as experience. Quinn (2000) explains that the humanistic approach in learning emphasises the ‘teacher-student relationship and the classroom climate.’ Rogers cited by Quinn (2000) argues teaching ‘is a highly overrated activity , in contrast to the notion of facilitation.’ I would agree with this from my own experience learning being far more effective when presented in an inclusive encouraging manner and where a facilitator is skilled it can produce inspiration to further learning.

I have considered behavioural theory where ‘the cognitive and psychomotor elements’ are considered and as Smith (1999) discusses teaching in this manner usually has the outcomes where the teacher aims that ‘by the end of the session participants will be able to ….’, I would hope that as well as this that, teaching can offer more and that students will be motivated to consider the value of the teaching session and I found that the opportunity led to a discussion of their experiences and in pooling their knowledge. The teaching allowed a progression which increased learning and encouraged relevance.

The requirement to engage the student was considered and a PowerPoint presentation allowing those with visual memory aids to learning and also to allow those who may need to revisit the session a resource they can access. Those with auditory learning were served by the presentation which was given, followed by encouraging the group to reflect on their experience, discuss their anxieties, about the change in procedure. Reassurance was added explaining the theory and using this to back up statements allowed successfully progress to be made. Then to enhance the experience a practical demonstration, allowing those who particularly benefit from involving their motor skills, was given as to the handling of the needles and we all took part. The session taught was focused, but allow inclusion by asking questions of the group to satisfy that they understood, were engaged and most importantly felt competent and confident.

The learners in the group all had experience of needling so were able to relate well to the session and this enhanced the ease of teaching but allowed the subject to be considered in some depth. Spouse (2003) stated that ‘thinking about practice and contexualising it on an individual basis requires considerable practice and skill’ our session allowed recognition of skills gained, encouraged reflection of past practice and consideration of problems met to consider solutions. The reflection of practice demonstrated ‘the ability to analyse and reason’, as Dewey cited by Morton-Cooper (1993), states ‘is a quality of the educated’. The group all reported feeling more positive and the changes to practice are being implemented with constant deliberation as to the significance of issues raised. The opportunity to discuss shared experience was valuable and allowed each of us to consider the interpretation of others on issues met in practice. This then led us to consider further learning needs. The whole session was of value to each member following feedback and to also to myself. This works towards ‘fostering professional growth, personal development and accountability through supporting students in practice’ SLAIP (2008). I instigated the learning having recognised a learning need. Most importantly it brought us together as a team willing and determined to improve our practice to enhance the care of our patient group. This was particularly uplifting as there had been some resistance to change which was now identified as a fear due to lack of confidence which was addressed by the education of the group. I was willing to ‘act as a resource to facilitate personal and professional development of others’ SLAIP(2008). I believe that the concept of Kolb’s cycle as cited by Quinn (2000) perhaps demonstrates the achievements of the team having gained ‘concrete experience’ in the changed procedure they have ‘observed and reflected’ and with the knowledge gained ‘ integrated their observations into logical theories’ which they will now use to ‘actively experiment’ applying this knowledge to problem solve in their day to day working practice.

I was conscious in this teaching that in this group that we have established effective working relationships NMC (2008) and these are important for our successful implementation of enhanced practice. I recognised that for the learning to be established effectively I would have to continue to support and supervise the process until each member of the team was fully competent and that constant reassessment of the process would have to be carried out. The requirement of SLAIP (2008) to ‘provide ongoing and constructive support to facilitate transition’ being very necessary in this situation.

‘In successful mentorship … students were able to learn and then practice independently with mentor’s distant supervision’ Spouse (2003) this must be the aim of learning in practice.

It allowed a learning response in that the session had demonstrated some of the problems that had been meet in the proceeding weeks that changing practice before a formal session of teaching was commenced had led to resistance and unsettled feeling. Some of the group had been willing to go ahead with little comprehension of the need to proceed, while others had held back and then felt uncomfortable. This demonstrated that when mentoring it is vital to support people with change, provide excellent information and be aware that instant success may not be achievable and that this will require confidence building support and constant reappraisal of both the procedure and the team. Success only comes with mutual respect and these factors were all discussed and re-evaluated as part of our discussion.

‘Leadership -focuses on identification and articulation of the nurse’s role in partnerships and teams, professional responsibility, accountability and autonomy, and ethical frameworks for practice as well as personal and professional behaviour’ Mazhindu 2000. These are all aspects of leadership that I have considered and tried to ensure that I planned my teaching around these requirements taking responsibility for the information I impart, and encouraging the team to aspire to quality care using the techniques newly introduced. Roberts (2009) considers that confidence in a student is important in their ability to learn and recommends that educators consider the importance of fostering confidence in learners. So the teaching session was useful for the procedure being introduced, for the team and also for myself in evaluating my skills as a teacher and mentor.

A second teaching session required my teaching our health care assistants about the sterile technique and to enhance their knowledge. Under the ‘context of practice’ requirement to ‘initiate and respond practice developments to ensure safe and effective care is achieved and an effective learning environment is maintained’ SLAIP (2008) a session to teach the principles and test understanding of them was given. The teaching was initially intended to create a reaction and then to lead to reflection and consider the evidence offered to back up the methods of practice it was an informal event in response to observation of an episode not demonstrating best practice. The session was presented by carrying out a process in front of the learners for demonstration only making mistakes that they were encouraged to point out and to persuade them to think about the process and why certain activities are rigidly adhered to. It required an active role from the students encouraging them to consider how they carry out the procedure.The teaching demonstrated important concepts in nursing such as preparation, organisation, cleaning and personal hygiene. These skills are all fundamental to nursing care and basic. They are performed repeatedly on the unit but a realisation that full understanding or knowledge application as to the why may have been lost in repeated action suggested the need for a refresher session. The saving lives programme DOH (2007,) requires that these skills are always carried out to create a safe environment and audit is repeated performed to maintain standards. I tried here to ‘support students in critically reflecting upon their learning experience in order to enhance future learning’ SLAIP(2008).

The session promoted discussion and thought and allowed the recognition of the importance of this practice especially in the environment of the renal unit. This was designed to facilitate learning encouraging the ‘relating theory to practice and encouraging critical reflective skills’ as required by SLAIPS (2008). This session demonstrated leadership in that the recognition of the requirement of members of the team to learn the principles and refresh knowledge led to the session. Meeting the ‘defined learning needs’ of the team was very much the motivation for this teaching session as required for leadership SLAIP (2008). This session could, if not sensitively handled, be resented by staffs that are competent with the procedure taught, so it was important to express the value of reflection and discussion as to the process, the use of consumables and the theory behind each action. It was important that the session was introduced as a challenge offering support and encouragement. By carrying out poor practice purely for demonstration I offered myself up for criticism and in so doing introduced the discussion of best practice. The use of effective communication was very important to assure that the session was seen as a positive experience to enhance standards of care. In reflection I was nervous presenting this teaching session because it was looking at familiar procedures and may have been resented by the students involved but encouraging them to look at the theory behind practice involving them and allowing them to criticise the practice I demonstrated highlighted some of the practises I wished to eliminate from the unit. I believe that the situation succeeded in creating a realisation of the importance of practice being adhered to rigidly to promote prevention of infection. A disadvantage of this informal session was that I had not completed a literature search in advance and so a follow up to this would be to use our teaching notice board to present current evidence regarding sterile procedures. Our infection rates are very low but being complacent will not maintain this and so the refresher was of value. The assessing of the procedure will be ongoing as part of the audits in practice and these had been the motivation to carry out this teaching session.

Assessment must be carried out using criteria which are’ reliable and valid ‘Gronland et al (2002).With these factors in mind I prepare for a assessment session.

I am very aware that in assessing it is imperative that non- judgemental, impartial assessment is carried out taking in to account the stage of the individual in training, the level required and the standards to be attained.

 The task of assessment I completed was to assess the ability of a team member to accurately assess and record a MEWS score. Assessment is important as a means of looking at strengths and weaknesses. When weaknesses are recognised action can be taken to motivate improvement. My assessment required the assessment of practical skills and an accurate completion of the form requiring exact numerical clinical assessments such as temperature, o2 saturation, pulse blood pressure and requiring a specific number to be calculated which made assessment specific and measureable. Assessment requires judgements about achievement and for accurate assessment to be made the clearer the criteria for assessing are the more accurately and fairly a student can be assessed. The criteria for my assessment were exact in that specific numerical recordings were required and then the ability to record those on a chart and graph were required. My student achieved this with complete accuracy and her knowledge was then tested as to the relevance of these recordings and how to act and use them to assess if they were indicating the patient needing medical attention. Again this was assessed by numerical calculation a given number requiring specific action. This meant that any subjective assessment was minimised allowing a level to be gained by all students assessed in the same manner.

Norm referencing is a method of grading which relies on the assumption that an individual is assessed in the light of the normal achievements of that student group. The normal pattern of achievement is that most students will be in the centre of grading while just a few will be at the perimeters of the top and bottom. This allows grades to be distributed in the usual pattern but does not allow for unusual distribution of achievement. Criterion referencing has more reliable method of assessing a student against specific criteria which allow clear standards to be measured. James et al (2002), discuss that norm referencing can be unfair. They state that criterion referencing requires consideration of expected outcomes to learning and used with norm referencing to assure that assessment is the most effective way to reliably and consistently assess each student.

It is important to assess a student ‘according to the level and knowledge expected at each stage of their training’ RCN toolkit (2007). Constructive feedback will be needed for a student to progress with specific goals to achieve and time scales in which to achieve them. SLAIP (2008) requires that a mentor can ‘provide constructive feedback and assist in identifying future learning needs’. Hincliffe (1999) identifies characteristics of effective and ineffective teachers and factors effecting learning. Hincliffe encourages student feedback to always begin with the positive, avoid criticism in front of others and refer to weaknesses as points for consideration with clear goal setting. She recommends allowing the student time this is in fact a requirement of the NMC (2008) where students must work 40% of their time with their mentor and the sign off mentor must have in addition protected time one hour each week per student in the final period.

When assessing it is important to be aware of the work of Duffy (2003), regarding the studies on ‘Failure to fail’. Each individual mentor has, as Duffy demonstrates, responsibility to ensure that they are ‘professionally accountable for their judgements’. Duffy’s study highlighted those students who fail must be assessed early in placement and have written evidence as to their problems, acknowledge the issues and advise the academic institution as to concerns. The pressure to pass a student, on the borderline, in the event of not having documentation in place was demonstrated to be tempting. The support for a mentor failing a student is there but must be accessed as it is recognised as a problem where reliable assessment tools are not used. However it is important to be aware of the professional accountability of the mentor when making assessments.

SLAIP (2008) requires that a mentor must ‘be accountable for confirming that students have met or not met the NMC competencies in practice and as a sign off mentor confirm that students have met or not met the NMC standards of proficiency and are capable of safe and effective practice’. A sign off mentor must be on the same part off the nursing register as any student signed off by them. In order to be able to demonstrate that interviews, have been carried out at the appropriate times for during a placement and that any issues discussed with students are clearly documented with the goals set and action plans in place. This will require a summative evaluation taking into account their performance over a range of skills over a period of time. Any actions required by the student so that they enhance their learning to the relevant level must be dated and reviewed in the time scale set. In the event of a student failing it is important that they are aware of short falls in their abilities or attitudes to allow the opportunity to improve. Where a student is failing there must be clear evidence of the issues creating this conclusion. The guidelines to mentorship can be found in the NMC standards (2008) and the criteria which is mandatory is exactly that, this allows protection for both the mentor and the student and to see that the process is as level for each student as a process dependant on people can allow.

Ethical issues must be considered when teaching in a patient environment. Any patient involved in the process must be asked for their consent prior to any episode of teaching involving them. The learner must be supervised to maintain the safety of the patient and only when the student is competent to carry out a procedure safely can they be allowed to independently do so.

On reflection the completion of this course has been an enlightening experience considering the environment and personal skills needed to promote learning and the necessity of good working relationships. The need to recognise the accountability of contributions and assessment and particularly participating in self and peer review of my own learning and teaching abilities. I recognise, as I encourage others to too, we all still have much to learn.