Editorial: Nurse education: time to get it right
The support of pre-registration students in the practice setting and the facilitation of their learning has been a topical issue for at least the last two decades, both nationally and internationally. The ways theoretical and practical components are combined, the most effective method of teaching and assessing practical skills, who is best placed to undertake this and what characterizes a positive and supportive learning environment are just some of the issues. There is a developing literature on these diverse aspects of nurse education and its impact on clinical nursing. However, inherent in this literature are a number of fundamental assumptions that (i) we know what constitutes a good practice-learning environment and (ii) the current theory/practice split-model of education is effective.
I aim in this editorial to challenge these assumptions by, first, mapping out the factors contributing to why the practice-learning environment has become such a political arena and, second, asking what it is that students say is important for the facilitation of their learning. Finally, I make some suggestions for a strategic approach to the commissioning and conduct of healthcare education research.
The practice environment – the political issues
Lambert and Glacken (2005), in a review of the literature related to practice placement support roles, indicate that providing a supportive environment for students is important. But what do we mean by a supportive environment? Issues such as a dedicated and appropriately trained mentor, staff who understand the curriculum, a welcome ‘ambience’, good role models, staff interested in teaching and the integration of theory and practice all seem important. Lambert and Glacken state that ‘learning through placement experience is often deemed more meaningful than that received in the classroom’. Furthermore, Napthine (1996, cited in Nolan 1998) argues that ‘the quality of nursing education is dependent upon the quality of a student's clinical experience. Clinical experience is central to the development of nursing practice skills’. But how do we know all these things? And perhaps more importantly, what is the strength of this evidence? We will return to this issue later.
A theory/practice model has been the primary pattern for nurse education nationally and internationally. In England, all curricula are based on a 50% theory/practice split. Changes in the curricula over the last two decades have further emphasized the perceived importance of the practice environment for learning. But we know from Melia's (1987) early work in this area that students can sometimes struggle to negotiate the different worlds of service (practice) and education (theory). So, is it time to start thinking ‘out of the box’ with respect to the way in which nurse education is organized? I would suggest that what we have at the moment is an inherited legacy. In contrast, what is needed is robust evidence to underpin the decisions, which the nurse educationalists make for organizing the curricula.
In addition to the principle of educational reform, the goal to recruit and retain more nurses (Department of Health 1998, 1999, 2000a–c) has been a further significant driver for the investment in the development of pre-registration curricula. These reforms of nurse education have resulted in greater emphasis being placed on the amount and quality of clinical experience. It would seem that a good practice-learning environment has become the panacea for recruitment and retention problems, the promotion of life-long learning and the integration of theory and practice.
However, the promotion of a good practice-learning environment is dependent upon the availability and commitment of suitably qualified staff. Paradoxically, some of the policy initiatives driving the practice-learning environment into the spotlight have served to adversely impact on the support, which the students have received. For example, there is a significant ambiguity in the current climate over who is ultimately responsible for the facilitation of learning in the practice setting.
In this regard, Lambert and Glacken (2005) identify what I consider to be the crucial issue – who is responsible for this facilitation of learning in the practice setting? Prior to the restructuring of nurse education, this facilitation of practice learning was undertaken by staff nurses, charge nurses and clinical tutors. However, the transfer of all pre-registration education in England to the higher education (HE) sector in the mid-1990s heralded a change in the perceived responsibility for teaching and learning in the practice setting. Responsibility shifted from ‘service’ (the NHS) to ‘education’ (HE institutions). But higher education did not receive any additional funding and I suggest, as a result, the support of students in practice became a neglected area.
The practice environment – what is important for students?
So, we now appear to be in an era that recognizes the value of high quality-facilitated learning in the practice setting. But what exactly are the dimensions of this quality learning experience? May and Veitch (1998) suggest six factors, which affect students’ learning in the practice setting:
- • Students’ preparation for the practice placement;
- • Mentors’ preparation for their role;
- • Clear understandings of the tutor/lecturer role;
- • Formal opportunities for reflection;
- • Well-established assessment processes;
- • Students’ strategies for maximizing their practice learning.
From an educationalist's perspective, these factors appear to make sense. However, how do we know for sure that these are the relevant issues and if not, how do we find out? This leads us on to consider the third and final dimension to this commentary – the need for a coherent strategy for education research in nursing and healthcare.
The practice environment – a strategy for research
Clark (2005) calls for a more robust evidence base for education practice. She argues that:
whilst most of us will teach evidence-based practice because clinicians are increasingly expected to defend their clinical decisions and actions, the same does not appear to be true for education practice. When was the last time you heard a lecturer referring to the evidence base of their approach to teaching and learning? How can research studies that tend to be small scale, short term and undertaken on a single site provide the evidence base required for an evidence-informed culture?
Drawing on the work of Rafferty and Traynor (1997), she goes on to suggest that nurse educators consequently have to rely on this small-scale work until more systematic evidence emerges. However, how do we arrive at a place that can generate this systematic evidence? I would suggest that, as with nursing research in general, there is no strategy giving direction to the nurse education research agenda. So how can we develop such an agenda?
Clark (2005) argues that to ‘provide education that is both effective and sensitive to the needs of students and other stakeholders, healthcare educators must continue to contribute actively to the education research agenda’. With reference to the work of Long and Johnson (2002), she makes some suggestions for the shape of such a research agenda, which could include more large-scale research studies, multi-site/multi-institutional research, longitudinal research and more collaborative research. Such collaboration could be across disciplines and international boundaries.
As a body, nurse educationalists must shape this into a coherent agenda, which drive education research and identify robust evidence to underpin the education practice. On my list of research, priorities would be a raft of work exploring the factors that most effectively promote learning in the practice setting. This work would involve many of the issues already identified here such as:
- • Identifying the characteristics of a supportive learning environment;
- • Evaluating different models of theory/practice combinations;
- • How can we enable students to negotiate the different worlds of service and education?;
- • Evaluating the effectiveness of practice support roles;
- • What is the best way to prepare students for practice placement?;
- • What is the most effective way to educate and support mentors?;
- • What is the role of the lecturer?;
- • Do the current pre-registration education models prepare students for the role of the contemporary Registered Nurse.
Despite its ‘long and noble tradition’ (Thompson & Watson 2005), nursing is in danger of losing its way. Escalating financial pressures currently being exerted on health services will continue to emphasize and exacerbate the recruitment and retention problems in nursing, both nationally and internationally (Wickett & McCutcheon 2002). Nurses are a precious and finite resource. If ever there was a time to get the training of nurses’ right, then the time is now. The profession and the patients for whom we care urgently deserve it. I would like to urge dialogue between governments, nursing bodies and HE establishments to devise a strategic approach to the generation of a strong evidence base, which would form the foundation for future educational reform.