PREPARING TO CARE. A study of personal qualities, values, and readiness to engage in caring work among health care students 20/3/2015 RESEARCH REPORT

Transcription

1 PREPARING TO CARE A study of personal qualities, values, and readiness to engage in caring work among health care students 20/3/2015 RESEARCH REPORT Funded by: Health Education Yorkshire and the Humber University of Hull in collaboration with:

2 PREPARING TO CARE: RESEARCH PROJECT FINAL REPORT Full Title: Preparing to Care: A study of personal qualities, values, and readiness to engage in caring work among students in pre-registration adult nursing, occupational therapy and physiotherapy at the Universities of Hull, York and York St John. RESEARCH TEAM University of Hull Professor Kathleen Galvin (Principal Investigator) Dr Mary Laurenson Dr Carole Wright (Research Associate) University of York Professor Karen Spilsbury Dr Elizabeth Hughes University of York St John Dr Jane Cronin-Davies Helena Johnson Acknowledgements The research team would like to extend their thanks and appreciation to all students, clinical educators and university staff who gave up their time to take part in this study. We would also like to thank Professor Helen Allan her support in the early days of this research. Any queries should be addressed to: Professor Kathleen Galvin k.t.galvin@hull.ac.uk Dr Mary Laurenson m.c.laurenson@hull.ac.uk

3 Background and Context EXECUTIVE SUMMARY In recent years an emphasis has been placed on the systematic failings of the NHS, as outlined in the Francis reports: Independent Inquiry on the Mid-Staffordshire NHS Foundation Trust (2010); and his public enquiry findings (2013). These reports generated national debate around the problems of care delivery and the culture within hospitals. The nursing workforce comprises over half (356,404) of the professionally qualified healthcare workforce in the NHS (644,583), whilst allied health professionals (physiotherapists and occupational therapists) make up about 12% (78,205) (HSCIC, 2015). As such, the nursing workforce is often subjected to criticism and negative publicity when care problems are reported. In particular negative inferences focus on frontline NHS healthcare staff, particularly nursing staff, and their perceived lack of compassion and caring values. To date, one of the Government s key solutions has been to transform healthcare education and training (DH, 2013a) with educational measures aimed at reforming healthcare and instilling the right values in healthcare professionals. Changes include three key short-term deliverables for nursing students: Ensure that selection into all new NHS funded training posts incorporates testing of value based recruitment. Introduce and evaluate pilots that give NHS-funded students hands-on care experience. Increasing the proportion of entrants to healthcare professional education who have had experience working in, and providing care in a care setting before they start their course (DH, 2013b, p. 14) The complexities surrounding caring as a concept are apparent at a number of levels; across practice, education, and disciplines, and also between nurses and patients themselves (Henderson, 2008; Watson, 2002). As such, common understandings and consensus remain elusive, with some scholars arguing that knowledge about caring is now constituted through description, i.e., everything that has ever been said about caring, and lists of associations (Paley, 2001). Using a lifeworld perspective, Galvin & Todres (2012) offer a knowledge foundation for caring that points to new experience near vocabulary to guide practice. Whilst others argue that it is the language of care that confuses and compounds the issue, and that caring for (direct bodywork) and caring about (a desire to help) are often used interchangeably (Cohen, 2015; Watson, 2012). Research Aim and Objectives The aim of the Preparing To Care project was to gain insights into the caring values of newly recruited health-care students; to explore whether/how these values changed during the course of their educational programme; and to ascertain their readiness to engage in caring work as qualified health professionals. The objectives were to: Assess the caring values of pre-registration student nurses Explore the transition of students values, and readiness to engage in caring work from year 1 to year 2, year 2 to year 3, and at the end of year 3. Gain an understanding of whether and how student values change during their educational programme Explore educators and clinical mentors views on student caring values, in order to provide multiple perspectives. Methods The Preparing To Care study, was carried out between April 2013 and February 2015, and used a mixed methods approach. Quantitative methods consisted of an online questionnaire

4 that measured student caring values, and also explored how academic and practice placement environments impacted on, and shaped student learning. Ten focus groups were conducted between May and July, 2014 to gain in-depth rich data. The sample consisted of first, second and third year pre-registration nursing students from the Universities of Hull and York and surveys were completed at two separate twelve month intervals September, 2013 and September A total of 514 surveys were completed. To explore the survey data in more depth, qualitative methods consisting of ten focus groups were conducted between May and July, A total of 51 participants took part in the focus groups comprising first, second and third year nursing students, practice placement mentors and lecturing staff. The analysis was conducted using a cross-sectional and comparative analysis to explore the survey data. Focus groups were audio recorded, transcribed verbatim, and thematic analysis was used to explore the data. Key Findings Student Caring Values Debates around caring as a concept (Henderson, 2008; Watson, 2002), and the language of care (Cohen, 2015), have been ongoing for some time, and point to important questions around instruments that are designed to measure caring ; the sensitivity of these measures; and whether they do indeed measure what they have been designed to measure. Nevertheless, the prevailing views at any one time have a profound influence on the education and training of nursing students (Watson, 2012, p. 14). For the purposes of this research it was necessary to obtain a baseline measurement of student values or their codes of behaviour, so as to ascertain whether and how they might change during the education process. The vast majority of students reported that they held what are perceived to be common values around caring, and our online survey shows they are apparent at recruitment, and do not change in any significant way at any point during their education and training programme. That is, most students share these common values around caring, and intend to operationalise and utilise them as reference points, both during their educational programme, and after qualification. Learning through Practice Placements Educational programmes for healthcare students and pre-registration nursing degree students comprise a 50/50 split of university and clinical practice experience, and comprise experiential learning opportunities for students to develop their clinical skills, competencies, critical thinking, problem solving and reflexive abilities during the learning period from novice to professional. The vast majority of students agreed they were welcomed to most of their placements, and met with their mentor during the first week. To progress to the next level of study, the completion of Continuous Assessment in Practice (CAP) documents are a requirement for all students. However, less than half of students strongly agreed that their mentors were aware of their assessment criteria (42%), with similar results for learning outcomes (44.5%). Some placements did not afford the scope to complete all the necessary assessment criteria for students, and this was recognised by community mentors in particular. To combat this, they had been proactive in forging links with other hospital departments, specialisms and nursing homes, so as they could facilitate student learning, and help them to achieve all their assessment criteria. In general students acknowledged that completing their CAP documents had been very difficult on at least one of their placements, but at the same time, this meant students were highly appreciative of practice mentors who had been helpful and enabled them to complete the documents. Continuous Assessment in Practice (CAP) documents were extremely important for students, and were the frameworks through which they navigated their placement journeys. Students used them to manage their placements and, in particular, their self-directed and autonomous learning. Self-directed learning was an intrinsic component of the CAP

5 document, and was valued as a contributory factor to developing communication skills and building confidence. Students also used self-directed learning when their mentors were busy, or when placements did not offer them the range of skills required to complete the CAP documents. Staff Workloads and Student Supernumerary Status Heavy workloads and a lack of available time for clinical educators was a major theme identified by both students and mentors themselves. These time pressures sometimes encroached on mentor responsibilities, which had a direct impact on a significant number of students who struggled to meet their required competencies. There was also a suggestion that mentors were compelled to negotiate their responsibilities within the time available to them, which often meant keeping up-to-date with student academic curriculums and assessment requirements could be pushed aside. For most mentors the general consensus was that more knowledge of student s academic learning would be helpful and benefit students, however, time constraints would limit the amount of extra information that could be sought out. Practice mentor time constraints were borne out further with 32% of first year, 25% of second year, and 26% of third year students reporting that practice mentors were usually too busy to take time to really listen to student problems or concerns. Most students found that spending time with their mentor was often a barrier they had to overcome, and could be made more difficult through disapproval from other members of staff. This situation was echoed by the majority of mentors, who agreed that carrying out their work responsibilities had become very difficult. This was attributed to the allocated time for students rarely being protected; the loss of dedicated ward-based practice teachers, a decrease in staffing levels and incorporating mentorship into band five and upwards The vast majority of students acknowledged the benefits of being part of a team, and having hands-on experience, and valued their supernumerary status, and contribution to the workplace. However, students also told us that they were often included in staff numbers. This was confirmed by some mentors as a problem apparent at ground level, as well as with higher management. Nevertheless, mentors often tried to protect students supernumerary status, which needs to be respected if placements are to enhance their learning and skills. Our online survey also reported that many students were reluctant to voice their concerns or challenge practice educators. 13% of first years disagreed it was safe to disagree openly with mentors, rising to 19% for second year and almost 25% of third year students. In order to manage their concerns, students, across all year groups, tended to reconstruct what they perceived as poor practice into a positive learning experience. As such, it contributed to their education in terms of how not to care for patients, and also highlighted a resilience that helped them to continue with their educational programme. It is notable, that although the Francis report advocates the reporting of poor practice and concerns, it seems that students are extremely uncomfortable about doing this, as they fear it will have a detrimental impact on their learning and assessment, and on their future career prospects. Supportive Environments Supportive relations in practice placement environments are crucial for student learning. Having designated mentors, ongoing contact, being made to feel welcome and part of a team, all contribute to a sense of belonging, and to positive and enhanced learning. Students reported that the majority of their placements were positive and supportive. Almost all students discussed how inspiring some of their placements and mentors had been. Qualities that were beneficial and contributed to high quality placement experiences were: a harmonious staff team, with friendly, welcoming and cooperative staff; who were helpful and made them feel part of a team; took an interest in their education and were knowledgeable; had an understanding of the assessment documents; provided opportunities for learning in a variety of settings; and ensured all their required competencies were met. Mentors were also asked about attributes that contributed to high quality mentoring, and generally agreed, that

6 being approachable, friendly, welcoming, setting out expectations, creating trust, and being knowledgeable were all necessary. However, mentors also agreed that structural reorganisation, changing work roles, and increased responsibilities were all barriers that could prevent them from carrying out their supporting roles with students. Our data revealed inconsistencies in practice placements, and students could expect to experience at least one negative and/or unsupportive placement during their educational programme. Our data also suggested a common perception amongst students that some nurses did not want to be mentors. This raises concerns, as it suggests unsupportive placement environments are more common than are acknowledged. The experience for students appears to be incongruent with written educational policy and what educators believe is happening within the learning environment. Focus groups with university link lecturing staff revealed that some placements can have up to ten students at any one time. That mentorship is no longer voluntary can be viewed, on the one hand as sharing out responsibility, but on the other the mandatory nature causes problems, such as increased work load, pressure, stress, feelings of resentment and resistance. This may be one of the factors that has a significant effect on student learning as well as on motivation and attrition. The majority of students had significant levels of resilience and were able to develop strategies early on in their learning to help them manage. Crucially, it appears that a good practice placement along with inspiring and high quality mentors, of which there were clearly many, were pivotal in compensating for and helping to counteract the effects of more negative practice experiences. In addition, the reconstruction of what students perceived as unsupportive environments into positive learning experiences acted as motivators for some students, and highlighted a resilience that contributed to continuation with educational programmes. For those students who were not able to develop these strategies, particularly first year students, difficulties in practice placements had increased their stress and had been a major factor for them to consider leaving their educational programmes. Supportive Learning in the Academic Environment Building supportive relations between students and academics are an inherent part of adult learning, and vital for supporting students throughout their academic journey, and for maximising retention. In addition, the modelling of caring throughout the teaching process illuminates the reciprocal nature of care ethics, which is particularly salient for students in the caring professions. The data shows that the vast majority of university teaching staff did practice anagogical teaching and respectful teaching. Over 90% of students from both universities reported that staff wanted to see them succeed. Students were informed of what was expected of them up-front, and the learning environment was generally a safe space to share ideas and opinions. However, students also identified inconsistencies in supportive teaching, with just over 20% disagreeing that praise was received, and 16% disagreeing that staff told them they had confidence in their ability to become good healthcare professionals. Half (50%) of all first year students reported that university staff told them what they were doing wrong rather than what they were doing right, with figures improving over the course of study to 37% of second year, and 36% of third year students. One third of all students also felt they could not predict how staff would treat them from one day to the next, which again appeared to impact more on first year students, at 38%. Most students, 85%, agreed at some level that staff took the time to make sure students understood what they were learning. Of those that disagreed, there was a marked difference across year groups, with 20% of first year students disagreeing. In addition, 34% of first year students disagreed that university staff recognised when they were having problems. Similar to the practice placement experience, much of students perceived lack of support stemmed from the time and availability of staff. Over a quarter (28%) of first and second year students reported staff were usually too busy to listen to their problems and concerns, and almost a third (31%) of first year students disagreed that staff were readily available. Adult

7 learners are expected to take responsibility of their own learning, but this can be detrimental if they are not coping and do not feel they can seek help. Teaching staff may believe students are failing to take responsibility for their learning, which can also create barriers between students and staff. Students need to be made aware that support is an integral component of the degree programme, and is there to facilitate their personal development. Course Content and Structure In the main, students were positive about their educational degree programme, and were able to connect and apply it to practice. Anatomy and physiology, communication, and clinical skills modules were particularly useful. Social science modules were also appreciated, but students felt they were only useful if teaching staff related and grounded subjects directly in health and healthcare. All students discussed teaching styles, with passion, knowledge, and humour valued qualities, along with staff who had the ability to make lectures interesting. Most students tended to be pragmatic about teaching styles, and for those lectures that students perceived as dry, they would follow self-directed learning to fulfil their educational needs. Having high numbers of students in classes could be detrimental to learning, with students being reluctant to speak up or ask for clarification on concepts that were not well understood. Students recognised the advantage of small group teaching, and how this aided them with confidence building, and providing peer support, and deeper levels of learning through discussion, debate and dialogue. Most students also had a preference for assessment through essays rather than exams, as this represented deeper and wider learning, and was more beneficial in the long-term. Time pressures and academic demands for students was a strong theme across all university and year groups. The academic and practice placement requirements of healthcare degrees are tightly packed, and not comparable to other degrees, and the timetabling of modules and assessments was sometimes problematic. More than 90% of students who took part in this study were female, with the majority aged over 21. As such, it is likely that a significant proportion of students also had financial, family and/or domestic commitments to factor into their learning. These constantly changing external factors can and do impact on heavy workloads and the demands of degree programmes, and some students struggled to manage these demands. Connecting University and Practice Placements As students progressed through the developmental stages they became more confident with their skills, and also at applying, and knowing how and when to apply them. Spending time with patients was very important to students, as it allowed them to forge relationships with patients, establish their individual needs and facilitated their being seen to care about them. Developments and new thinking that students brought to practice was often appreciated by clinical educators who saw it as a reciprocal relationship. However, new thinking was not always accepted by clinical educators, and students were sometimes compelled to manage and develop pragmatic strategies to deal with conflict that arose, in order to maintain positive relationships with clinical educators. Students also had to deal with the politics and media agenda around nursing, and sometimes found themselves having to defend attitudes that held degree and classroom educational nursing programmes were not as good as the old style school of nursing training. These attitudes were also held by a small number of practice mentors who participated in the study, with the main reasoning being that on-the-job training is more effective than classroom based learning. Connections were also maintained between university and practice placements through link lecturer staff. Here, some students were highly satisfied with the support and visits made by link lecturer staff, but in the main, this area was problematic. Link lecturers should lead on practice-based learning for students, and arranging tripartite meetings between students, clinical educators and university staff is a requirement. Most students in the focus groups did not have a tripartite meeting, and were often confused about link lecturer roles, what they

8 entailed, their importance, and who would perform it. No formal preparation was apparent for this role. Hull were in the middle of reorganising the role, which involved sharing responsibility between various teaching staff. Whilst this caused confusion for both students and staff, it was hoped that once roles were firmly established, confusion would be alleviated. Conclusion Findings from this study show pre-registration nursing students were satisfied with most aspects of their educational degree programme, and how it prepared them for their future career as registered nurses. It was apparent that the majority of students could expect to experience at least one negative practice placement. Although factors are complex and interrelating, our study suggests that in this study practice placement experiences were the primary area for decreasing motivation, and increasing attrition. However, the impact of negative placements were, in the main, balanced by the majority of practice placement mentors who provided high quality support, supervision and education. Most students were satisfied with the support they received in the university setting, but first year students were less satisfied than other year groups. Inconsistencies in support can and did have detrimental effects on student learning, and could lead to a decrease in confidence. The data also points to students requiring most support during their first year of study, which is also the most likely time for students to leave their course. The modelling of care ethics exists in two locations, those of universities and practice placements. Each area can nurture and teach caring values through example. The reverse is also true, and care needs to be taken not to model disinterest and uncaring values. However, this study demonstrated how resilient most students are, to the extent that their caring values do not change over time. What did appear to change over the course of educational programmes, were students expectations of what it was to nurse. In this sense, their expectations were adjusted accordingly and assimilated, which in turn led to their caring values becoming more sophisticated, particularly in learning how to care whilst spending decreased amounts of time with patients, and increased time in administrative duties, as well as learning how not to care for patients. Both the NHS and academia have witnessed re-organisation, with austerity cuts, added work-loads, and staff shortages, leading to work rich and time-poor conditions that can overwhelm staff. This situation clearly has an adverse effect on student learning. Whilst some of the figures reported by students are more pronounced in comparison to the clinical environment, this may be due to the higher staff to student ratio in university classes. However, although students often perceived themselves as an added responsibility in the clinical environment, this should not be the case in the university environment as they are an intrinsic component. Moreover, in relation to the Governments mandate and Health Education England s reform to nursing education, this study finds that caring about and caring for have been conflated. It is caring about that has been emphasised, despite the majority of poor caring incidents being rooted in fundamental caring for care tasks. The findings from this study strongly suggest that student nursing caring values are highly appropriate for the nature of the job they are training for. Our online survey shows they are apparent at recruitment, and do not change in any significant way at any point during their education and training programme. However, what does appear to change during the course of study are students expectations. Our data has highlighted a number of ways in which expectations have not been met, including academic work loads, very little spare time or holidays, the nature of placements, practice mentors attitudes, and the lack of available time their educators have to spend with them. Expectations have also been challenged politically, in terms of their professional degree status, low staff morale, staff shortages and the attitudes of wider society. However, students work hard to hold on to their values and to ensure their own readiness to care. They endeavour not to reproduce any negative experiences of learning, and actively assert that

9 they will mentor future students in positive ways. We conclude it is their caring about values that actually sustains and motivates the majority of students to continue with their education in conditions that can, at times, be extremely challenging.