4 Preparation for learning in practice
• To introduce the principles of learning in practice
• To identify teachers who will be involved in supervision, teaching and assessing in practice and at university
• To identify what to consider pre-placement
• To consider how to meet some of the NMC Standards and Competencies during the placement experience
Introduction
Levett-Jones and Bourgeois (2009) outline much of what we discuss in this section and others, and they offer excellent advice and guidance for students prior to, during and after placements. If you are reading this book, you will probably be undertaking either a programme of study where the course is clearly divided into a 1-year common foundation programme (CFP) and a 2-year branch programme (NMC 2004) or one where there is no CFP and branch evident but still requires a programme of study which enables you to achieve outcomes (NMC 2010a) which are field of practice specific (what was branch outcomes).
Regardless of which NMC outcomes you are having to achieve, the principles remain the same. You must also ensure that you adhere to both the student. Guidance on Professional Conduct (NMC 2009) and your future Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (NMC 2008). It is very important that you read these and discuss them with your personal tutor before undertaking placement learning and also your mentor when you meet for the first time.
Each university will have its own curriculum expectations with regards to achievement of learning outcomes and assignment requirements, but every student, through whatever practice assessment documents and processes developed, has to achieve the NMC Standards and Competencies in theory and practice in order to become a registered nurse. These combined requirements lead to an academic award (in future, a degree will be the minimum academic award to enter the nursing profession) and a professional award and subsequent registration as a nurse (RN).
To help you achieve these in a clinical placement context, you will be supported by a named mentor and a number of other qualified nurses (now known as registrants) as well as other healthcare workers and professionals. We have already considered the general roles of some of these in Chapter 1, but it is important for you to consider the specific roles and responsibilities of those who will facilitate your learning and be responsible for assessing your knowledge and skills in a placement.
Key roles linked to student learning in practice
The mentor
Every student who is to gain a clinical placement learning experience has to have a named mentor (mandatory requirement of the NMC (2008)) who will be their main facilitator of learning, their supervisor and the assessor of their practice. All mentors should be experienced nurses who have completed a course of mentorship preparation or have an equivalent qualification in their own field which is recognised as being appropriate to supervise and assess student nurses in practice. (This latter individual will only be able to undertake this role in specific placements and not at the major progression points in the new NMC (2010a) guidance for curriculum delivery.) It is the mentor who is responsible for assessing your learning and competence in practice. As well as your practice assessment document, the mentor will also complete your ongoing record of achievement (ORA) (NMC 2007). (See Box 4.1 for an example of the mentor role and expectations of you as a student in relation to the ORA. Please note that this is only a very brief version for illustration purposes and that all universities will have different and very detailed practice assessment documentation.)
Box 4.1 Example of possible guidance notes for students and mentors during a placement
The assessment process
Week 1
Student MUST negotiate with their mentor a time for their initial interview to discuss learning needs and goals and agree an action plan for achievement.
Student MUST share with their mentor their ongoing record of achievement from any previous placements and any action plans resulting from their last assessment of learning in practice.
Student will ensure that mentors are aware of any non-practice assessments they need to complete which may require their support for achieving, such as a client-focused assessment or evidence-based practice on a placement-specific topic.
Student may also have additional practice-based assessments to achieve in the placement, such as medicine management, handwashing skills or (ward/patient care) management.
Mid-point placement experience
Student and mentor will ensure that they meet to discuss progress at some point halfway through their placement experience and also to determine if any actions from previous placement (ORA information) are being achieved. Evidence of progress will be gathered from a range of sources, including student skills record/practice assessment documents, other qualified nursing staff (registrants) and other health workers in direct contact on a regular basis with the student.
Student MUST receive constructive feedback from their mentor at this point and also on an ongoing basis. Their mentor must ensure that the student is being taught new skills and gaining new knowledge through ongoing evaluation of learning and any deficit from their original agreed action plan can be re-negotiated if required. This mid-point meeting is an essential one for the student who may require additional support from their mentor to achieve successful completion of their practice assessment in this placement.
Final placement period
Student and mentor MUST meet during the final week of placement and a suitable time agreed. (The importance of this final placement assessment is critical for those students in their final placement as their practice will be required to be assessed by the sign off mentor.) All evidence must be available about their progress on the placement and all documents available for discussion and signatures. Self-evaluation may be required as part of their practice assessment documents.
It is at this stage that the student has to offer clear evidence that they have achieved their goals, met the required NMC competencies for the placement and a record made of their overall performance during their placement.
Ongoing record of practice assessment could indicate decisions by the mentor such as:
Not achieved: although some outcomes achieved, the student's overall performance has not met the required standard or achieved required NMC competencies for this placement. Student and mentor discuss the outcomes and agree subsequent actions according to university policies.
Your main mentor will be supported in their role by a number of other appropriate personnel and, in some placements, more senior student nurses will take an active role in the teaching and support of students as part of their role in transition learning outcomes.
If you are a senior student undertaking a surgical placement in your final year of study, it is an ideal opportunity not only to learn to care for patients and their families in this environment but also to help less experienced students learn how to care for a patient undergoing surgery.
Agree a learning goal with your mentor to do this and don't forget, make it SMART: Specific, Measurable, Achievable, Realistic and Timely (Fowler 1998). For example, to teach a first year student nurse how to prepare a patient for surgery:
• Specific: focuses on a very specific topic.
• Measurable: it can be tested by questions and answers and by how the student prepares a patient for surgery.
• Achievable: this is a surgical ward with patients going to operating theatre every day of the week.
• Realistic: maybe you have had a lecture and participated in a seminar at university about teaching others, and this is also your second surgical placement in 3 years so you have more than a basic knowledge of what is required.
• Timely: it can be achieved in the student's placement experience regardless of length and you will be able to see the impact of your teaching.
Setting goals like this with your mentor not only demonstrates your willingness to learn but also helps you to expand your own knowledge and skills and consolidate previous learning.
In preparation for meeting your mentor, check out any online information you can access about your surgical placement, as well as the hospital or other environment where it will be. Check out the kind of surgery that takes place there and write out a draft plan of what you want to experience and learn during the time you are there. This could be a short placement within a larger placement learning pathway (or a ‘hub and spoke’ placement) or a single placement where there may be opportunities to experience a snapshot of a total patient experience.
Sign off mentor
The role of the sign off mentor is to ‘sign off’ a student's proficiency in the NMC Standards and Competencies at the end of their NMC-approved programme (Levett-Jones & Bourgeois 2009). This role is undertaken in the final placement only, but the decision will be based on the decisions of other mentors who have recorded and approved the student's progress in their ongoing record of achievement in previous placements. These mentors are critical to the assessment of a student's fitness to practice as a safe and effective qualified nurse, and they are responsible and accountable for providing the evidence on which the sign off mentor makes their final assessment. To be a sign off mentor, the qualified nurse must have undertaken a further course beyond that of mentorship.
As a student in your final placement, it is essential that you meet with the sign off mentor for the equivalent of 1 hour per week, in addition to the 40% of time working with your mentor normally. This is to ensure ongoing and constructive feedback is given as to your progress in the placement, and also builds on your previous ongoing record of achievement. (Please refer to the full NMC guidance on issues of confidentiality and access to your ongoing record of achievement at: http://www.nmc-uk.org/Documents/Circulars/2007circulars/NMC%20circular%2033_2007.pdf.)
Practice education facilitator
This is a relatively new role in practice education. Practice education facilitators (PEFs) are mainly employed to support mentors in their role and to act as a link between them and colleagues in universities. A study by Carlisle et al (2009:715), evaluating the role in Scotland, found that:
Findings indicate that the PEF role has been accepted widely across Scotland and is seen as valuable to the development of quality clinical learning environments. PEFs provide support and guidance for mentors when dealing with ‘failing’ students, and encourage the identification of innovative learning opportunities. PEFs play an active part in student evaluation of their placements, but further work is needed in order that the feedback to clinical areas and mentors is timely.
Some PEFs will work with mentors to develop supplementary learning opportunities for students in practice, such as study days, workshops and shared learning opportunities with other healthcare professionals.
PEFs also work with mentors and link teachers/tutors from universities, to develop and ensure that student placements are quality learning environments. They will also be involved in evaluation of your learning experience in the placement and the educational audit, whereby a specific tool is used by the placement area to evaluate the quality of the overall learning environment, to which you will also have contributed.
Link teacher
It is important to make a note of your link teacher's name in your student diary because there may be a time when you need to contact the university directly, for example to speak with your personal tutor who may not be available, and the placement link teacher may be able to help you instead.
The link teacher role was introduced to ensure that there remained strong links between education and service areas when nursing education was transferred into the higher education sector in the UK. Initially, this role was key to the successful development of the learning environment in clinical practice, working with ward managers and mentors to develop placement learning opportunities and experiences for students as well as ensuring their quality. Of late, this role has become less visible but the link teacher still has a key role to play in ensuring that the areas which they link with support student learning (Arkell & Bayliss; Pratt 2007). You can check the identity of your placement link tutor through the placement learning information on your university website and also when you arrive in your allocated placement. In many areas, the link teacher works closely with the PEFs in ensuring good learning experiences for students, and some still retain hands-on clinical care and case loads. Some are also employed as lecturer–practitioners by NHS organisations, where they work half-time in the university and half-time in a clinical specialty (Buchan et al 2008).
Key preparation before starting your placement
Roberts (2010) outlines key things that you can do to prepare before starting a clinical placement. These include making sure you attend your planned clinical skills and simulated learning sessions and, if an opportunity is planned into the timetable, undertake some additional practice in the clinical skills classroom, either on your own or with a colleague, ensuring that your skills tutors are aware that you are doing so.
Practising skills prior to undertaking a placement can enhance your confidence when asked to undertake tasks. Taking a blood pressure, for example, is an essential skill to learn if undertaking a surgical placement, given the importance of blood pressure as an indicator of potential problems post-surgery such as shock due to excessive loss of blood.
Some universities have excellent resources for students to use on their student learning sites, accessible via personal passwords. You can also find useful resources and books which make a valued addition to pre-placement preparation (for example, see: http://www.oup.com/uk/orc/bin/9780199534456/01student/checklists/ (accessed December 2011)).
Log on to your university learning resource centre (such as BlackBoard) and find the online learning material with regards to clinical skills or preparation for practice placements. (See the University of Nottingham for an example of practice learning pages: http://www.nottingham.ac.uk/nursing/practice-learning/index.aspx (accessed December 2011).)
Use the following as a checklist prior to starting your placement.
| Item | Yes | No |
|---|---|---|
| Checked dates of placement | ||
| Found out where it is | ||
| Found out best way to get there | ||
| What time to arrive | ||
| What to take with me | ||
| What to wear (see uniform options) | ||
| Name of mentor and ward/unit/health centre manager/sister | ||
| Logged on to the course learning resource centre (Intranet/password needed) and checked for any messages from programme/module leader/personal tutor | ||
| Found out information available on any practice learning links on the school website | ||
| Found out link teacher's name for the placement | ||
| Undertaken some initial reading about the kinds of patient problems I may come across and the possible care of the patients | ||
| Obtained a personal file for using at home to make notes on various health problems, signs and symptoms, medications, surgical interventions, etc. | ||
| If time, practice some skills relevant to placement in clinical skills lab with teacher agreement | ||
| Refresh knowledge in any notes undertaken in lectures/seminars at university | ||
| Obtain at least one book from library or other resource which is relevant to the clinical placement, e.g. Pudner (2010) | ||
| Ensure plenty of time to get to placement on the first day |
Make sure you visit your placement whenever possible prior to commencing your actual clinical experience and obtain the name of your mentor and the first week's off duty (the hours of learning practice noted on the nursing duty rota, usually posted on the staff notice board) which may also be negotiated with your mentor when you get there.
Key university roles and professional conduct issues and practices in ensuring successful learning outcomes and opportunities in clinical placements
The personal tutor
The role of the personal tutor is central to the successful transition and journey through your specific field of practice (branch) pathway and programme of study.
It is expected that all students are allocated a personal tutor, normally from their own field of practice such as mental health, learning disability, adult or children and young people's nursing. A study by Por and Barriball (2008:100) showed that lecturers who undertook this role provided a range of activities from the ‘provision of pastoral care and acting as a referral agent to other services such as student support networks, to monitoring student progress and giving academic support when required’. The main types of support that most students required were linked to these issues.
Discuss with your personal tutor what they consider their role to be and how you can ensure that both of you can work together with regards to achieving your outcomes during clinical placement.
Many universities have specific criteria for the role and also guidance for what students expect from personal tutors and vice versa. Find out if your university has a document of this kind and discuss it with your personal tutor when meeting for the first time.
Your personal tutor will play a key role in helping you to achieve your personal and professional development goals or similar processes, which involves discussion of overall progress on your programme (including placement learning) as well as keeping records of achievements in a portfolio (Timmins 2008).
Expectations of being a student in practice placement
During your clinical placement, you will be a supernumerary member of the team. It is important to understand what this does and does not mean. Being supernumerary means that even though your name might appear on the staff duty rota, you are not counted in the staff numbers as being a member of the workforce on that shift.
Supernumerary does not mean that you do not become involved in learning to work alongside your mentor and other members of staff and telling staff in the placement that you cannot do something because you are there only to observe. It also does not mean that you can come and go as you please (you may think this is extreme and wouldn't happen – trust us, it has been known!), unless of course you have come to an arrangement with your mentor in the placement regarding specific learning hours. Some placements, for example outpatient departments, only open 8 am to 5 pm Monday to Friday; if that is the case then you also work, or a better word is ‘practice’, within those hours as required by the university. Some of you might also be on placement for 3 days a week and then at university for the other 2 days. (See Roberts (2010) for an explanation of some of the issues with regards to supernumerary status (see Box 4.2).)
Box 4.2 Excerpt from Roberts (2010) on supernumerary status and its importance
‘Your role as a learner in practice is strengthened by “supernumerary status”. As a student nurse you do not “go to work” in the way that the professionals and other paid staff do. You go to a placement to “learn” for a short time and then move to another placement to learn more. In your placement you are of course working as well (e.g. assisting patients, learning nursing procedures, attending case conferences, etc.) but as a student nurse you are there principally to learn through the work you are doing’ (Roberts 2010:138).
Expected professional conduct and behaviour: fitness to practice
In 2009, the NMC published its first edition Guidance on Professional Conduct for Nursing and Midwifery Students and a second edition with minor amendments was published in September 2010. This new guidance is a very important document for all students regardless of the individual programme of study requirements or practice placement, and as such its implications for students must be stressed. You can read it in full at: http://www.nmc-uk.org/Students/Guidance-for-students/ (accessed December 2011).
In addition, another critically important document for students is the guidance on good health and good character (NMC 2010b) which can be read in full at: http://www.nmc-uk.org/Students/Good-Health-and-Good-Character-for-students-nurses-and-midwives/ (accessed December 2011).
So what do these mean for you as a student going into a clinical placement? In brief, good health (and poor health) and good character are defined as follows (NMC 2010b):
Good character
1. Good character is important and is central to the code in that nurses and midwives must be honest and trustworthy. Good character is based on an individual's conduct, behaviour and attitude. It also takes account of any convictions, cautions and pending charges that are likely to be incompatible with professional registration. A person's character must be sufficiently good for them to be capable of safe and effective practice without supervision.
Good health
2. Good health is necessary to undertake practice as a nurse or midwife. Good health means that a person must be capable of safe and effective practice without supervision. It does not mean the absence of any disability or health condition. Many disabled people and those with health conditions are able to practise with or without adjustments to support their practice.
Poor health
3. If a nurse or midwife is in poor health it means that they are affected by a physical or mental health condition that impairs their ability to practice without supervision.
4. Applicants who declare health conditions or disabilities should be assessed where appropriate with support from a disability services team or adviser. Any assessment should focus on what reasonable adjustments can be made to support the applicant to achieve entry to or maintenance on our register.
Read the meaning of these for students in the NMC Guidance on Professional Conduct (see Box 4.3) and consider their importance for undertaking a surgical placement. Also check out the NMC website for up-to-date information on professional practice and student-related issues: http://www.nmc-uk.org/ (accessed December 2011).
Box 4.3 Extract from the NMC (2009) Guidance on Professional Conduct for Nursing and Midwifery Students
What do good health, good character and fitness to practise mean?
The NMC provides guidance on good health, good character and fitness to practice.
Good health is necessary to undertake practice as a nurse or a midwife. Good health means that a person must be capable of safe and effective practice without supervision. It does not mean the absence of any disability or health condition. Many disabled people and those with long-term health conditions are able to practise with or without adjustments to support their practice.
Good character is important as nurses and midwives must be honest and trustworthy. Good character is based on a person's conduct, behaviour and attitude. It also takes account of any convictions and cautions that are not considered to be compatible with professional registration and that might bring the profession into disrepute. A person's character must be sufficiently good for them to be capable of safe and effective practice without supervision.
Fitness to practice means having the skills, knowledge, good health and good character to do your job safely and effectively. Your fitness to practice as a student will be assessed throughout your pre-registration programme and, if there are ever concerns, these will be investigated and addressed by the university.
You should familiarise yourself with the student regulations and fitness to practice procedures in your university. Ask your tutor or mentor for more information
Possible learning outcomes to be achieved in a surgical placement
To enable you to consider some possible learning goals to achieve in a surgical placement, we have identified one competency statement from each of the four NMC (2010) domains to illustrate how you can negotiate relevant experience and associated knowledge and skills to help you attain successful outcomes in these areas. Each one has an activity that you can use to help you prior to your surgical placement.
General learning outcomes (NMC Gereric Standards examples)
Domain: Professional Values
9. All nurses must appreciate the value of evidence in practice, be able to understand and appraise research, apply relevant theory and research findings to their work and identify areas for further investigation.
This is a competence which underpins the achievement of many other competencies and is an essential part of undertaking a qualified nurse's role (Holland & Rees 2010). How you approach this competence will depend very much on where you are in your programme of study prior to undertaking a surgical placement. If a first year student, you may just be beginning your journey of discovery with regards to what is evidence for practice, how you find it and how to understand and evaluate it in order to be able to determine whether it is evidence that you can use in your practice or to support your assignment work (Holland 2010). However, this is a competence that you must achieve at some point in your programme of study to become a qualified nurse, and which your sign off mentor will expect to see evidence for at the end of your programme of study.
The following activity helps you to develop knowledge in preparation for your placement experience and also enhances your developing skills of searching for evidence, critiquing its relevance for practice and sharing it with other colleagues.
Find three articles on one aspect of surgical care, which can include the whole perioperative period. (These can be related to one specific focus across all fields of practice or related to one specific field of practice.)
Summarise the evidence and present it to your fellow students at an appropriate opportunity in your placement and following discussion with your mentor.
Determine whether the findings of these research papers could help change practice in your placement and the care of patients.
To help you with this activity, here are some examples of papers you could use to support pre-placement learning and develop your critique skills on the subject of anxiety and surgery.
• Grieve R J (2002) Day surgery preoperative anxiety reduction and coping strategies. British Journal of Nursing 11(10):670–678.
• Stirling L (2006) Reduction and management of perioperative anxiety. British Journal of Nursing 15(7):359–361.
• Pritchard M J (2009) Managing anxiety in the elective surgical patient. British Journal of Nursing 18(7):416–419.
Also, see Holland & Rees (2010) at: http://www.oup.com/uk/orc/bin/9780199563104/01student/chapters/ (accessed December 2011) for examples of article evaluation tools (Ch. 7) and other material regarding evidence-based practice resources.
You can also access the Foundation of Nursing Studies website where you will find a range of information about the impact on practice and practice development that some of their funded projects have made: http://www.fons.org/default.aspx (accessed December 2011).
Domain: Communication and Interpersonal Skills
2. All nurses must use a range of communication skills and technologies to support person-centred care and enhance quality and safety. They must ensure people receive all the information they need in a language and manner that allows them to make informed choices and share decision making. They must recognise when language interpretation or other communication support is needed and know how to obtain it.
During your placement experience, you will meet and care for patients and their families from a wide range of different cultures whose first language is not English, and where communication with carers may not always be easy for the patient or the carers. You will also meet other patients who have different kinds of communication needs, such as deafness or speech impediment. In other situations, you may also find patients who are unconscious for a prolonged period of time, for example during surgery or on intensive care units following surgery. How will you learn to identify communication needs when the patient is unable to articulate their fears and anxiety?
Looking at Case history 4.1, consider what your actions would be in the situation, and then set yourself a learning goal to meet this competency to discuss with your mentor.
On your first day on placement, you are asked by your mentor to stay with an elderly Polish man who will be going to theatre soon. You can see he still has his hearing aid in (Gilmour 2010, p.20) but when you introduce yourself to him and tell him you will be staying with him until it is time for him to go to the operating theatre for the operation on his leg (he is expected to be considered for an amputation), it is clear that he does not fully understand you and begins to ask why he is going to theatre for surgery on his leg and what is going to happen to him. When asked, he knows where he is, which hospital he is in, his name and what has happened to him so far to prepare him physically for going to theatre.
Relating this scenario to the competency, it is clear that managing this kind of situation effectively within your own sphere of experience and knowledge will enable you to achieve many of the different elements required:
• It is clear that the patient does not seem confused from the questions you have asked him based on your knowledge of how to find out if the patient is confused about his situation.
• It is also clear that he is able to hear you as he still has his hearing aid in and this can safely stay in until he is in the anaesthetic room to aid communication until he is anaesthetised (Gilmour 2010).
• He can obviously understand what you are saying in English as he has responded to your basic questions to try and determine if he has become confused for some reason.
The main problem appears to be around why he is going to theatre for surgery on his leg and what is going to happen to him. Given that he will be going to theatre soon, this is a situation which needs to be resolved urgently in order that he is reassured and so that he understands clearly what options were involved when he gave informed consent. It is important to ensure people receive all the information they need in a language and manner that allows them to make informed choices and share decision making.
It is essential to tell your mentor immediately. Reassure the patient that you will get someone to come and talk to him again about his surgery and that you will come back to sit with him. If it is agreeable to him, reassure him that you will go with him to the theatre environment.
The mentor, as a qualified nurse who is bound by the NMC Code, should immediately call the surgical team and ask one of them to come and explain again to the patient about his surgery and what is going to take place.
You can see from this possible scenario that being a nurse requires not only effective communication and good interpersonal skills but also a knowledge of ethical issues involved in decision making and informed consent, and consideration of all the possible options regarding the questions of patients.
A goal from this learning exercise could be that you will: consider all aspects of communication when patients are admitted to hospital, with a focus on issues underpinning informed consent and different cultural and language needs.
Domain: Nursing Practice and Decision Making
10. All nurses must evaluate their care to improve clinical decision making, quality and outcomes, using a range of methods, amending the plan of care, where necessary, and communicating changes to others.
Clinical decision making is a vital skill for student nurses to learn, as is finding ways to do it in a systematic way (Box 4.4) (Aston et al 2010).
Box 4.4 Domain: Nursing and Decision Making
Generic Competence
1. All nurses must use up-to-date knowledge and evidence to assess, plan, deliver and evaluate care, communicate findings, influence change and promote health and best practice. They must make person-centred, evidence-based judgements and decisions, in partnership with others involved in the care process, to ensure high-quality care. They must be able to recognise when the complexity of clinical decisions requires specialist knowledge and expertise, and consult or refer accordingly.
(NMC 2010:26)
To be able to make decisions that are safe and appropriate for the patient, yourself and others, you need to recognise different kinds of decisions you as a student may come across in a surgical placement. We now consider some of these and determine what knowledge and skills you need to be able to act on these decision-making situations. These are areas you may need to revise prior to starting your clinical placement.
Note: we are talking generally here and this applies to any field of practice student who is undertaking a surgical placement.
Exposure to other fields of practice (or branches) is an absolutely essential part of your learning, and understanding the patient experience for example, from the point of view of someone with a mental health problem or who has learning difficulties undergoing surgery is relevant to all student nurses. In the main, this book focuses on adult surgery, as children have a very specific additional set of needs, although all the principles we discuss here are just as relevant to students experiencing a children's surgical placement.
Decision making in a surgical placement
On a daily basis, you will be working with either your mentor or other members of the team and learning from them how to care for patients having surgery for various reasons. Part of this care will involve using the nursing process stages or assessing, planning, implementing and evaluating care and, in many placements, using a nursing model as a framework for this. In some placements, you may encounter what is known as an integrated care pathway approach where all healthcare professionals caring for the patient have an opportunity to record their decisions regarding their input into patient care. It is important to note at this point that all qualified nurses are accountable for any decisions they make with regards to patient care. As a student, you are also responsible for your actions and must work towards being professionally accountable.
Read the guidance on professional conduct for students (NMC 2009) again to ensure you fully understand these issues and discuss the meaning and implications for you as a student with your personal tutor.
Consider the following situations during the assessment stage of the nursing process when you might be required to make a decision and then consider what kinds of decision-making models these are based on (Box 4.5).
Box 4.5 Decision-making theories (based on Thompson & Dowding 2002)
Information-processing model
This framework, like others, has key steps to making decisions in practice. The first step is gathering preliminary clinical information about the patient, which can be considered as picking up cues (cue acquisition). This can be linked to the first stage of the nursing process, where you assess a patient's needs using a nursing model framework, e.g. the Roper, Logan and Tierney model (Holland et al 2008). Some of this information might be picked up before you even meet a patient and may come from a range of other places and people (see Ch. 5 on pre-admission assessment).
The second step is to develop some idea of what is wrong or what a patient's needs are from this information (e.g. health problems, signs and symptoms) and also to make a possible nursing diagnosis or hypothesis about what the problems might be.
The third step is to interpret all these cues and measure them against what you think is the problem; this is known as ‘the reasoning process (interpretation)’ (Thompson & Dowding, 2002:10).
The final step involves ‘weighing up all the pros and cons of each possible explanation for your patient's signs and symptoms and other information gathered’ (2002:10) and choosing an option that is based on the most evidence you have.
This kind of decision-making process may at first seem very structured for someone new to nursing, but as you gain more experience of similar situations and health problems, you will begin to link some cues to information in your memory bank of previous experiences, both in nursing and in your personal life.
The intuition model
Some of you will already have heard experienced qualified nurses say ‘I just know there is something wrong’ or ‘I have a gut feeling about this situation’. They cannot, however, offer an explanation at the time of how they know, or the knowledge that goes with this knowing. Thompson and Dowding (2002:10) state that ‘despite variations in the definition, there are commonalties in that intuition is perceived to be a process of reasoning that just happens; that cannot be examined and that is not rational’. You may already have come across the idea of intuitive decision making in the work of Patricia Benner (1984), and some of you may have phrases from her work such as novice, advanced beginner and (developing) expert included in your assessment documents.
The cognitive continuum model
Making decisions in nursing practice is often a combination of the models above. A model that demonstrates how this can happen, is one where there is range of decision-making situations based on different types of evidence, in other words a continuum or range of decisions from intuition, where there is no immediate evidence seen other than the ‘experience’ of the nurse, to one where there is clearly a series of evidence cues enabling clear decisions to be made, possibly using some kind of ‘decision-making tree’ or pathway. In some surgical placements, you will come across processes called protocols which are, in basic terms, steps laid down which are to be followed when making a decision for a range of situations. These protocols are normally evidence based, and examples include clinical procedure steps for infection control practice or a directive for a major disaster. A study by Rycroft-Malone et al (2009) showed that qualified nurses used other kinds of information to help them make decisions even where protocol-based care was in place, and showed a range of decisions rather than following a standardised approach. When you are in your placement, there may be an opportunity to contribute to making decisions which will impact on patient care, but also learning to make decisions as part of your developing leadership and management role is essential for a qualified nurse.
What kind of decision making is taking place in the following brief scenarios and how can you learn to prepare for such events or similar ones in your field of practice or generally?
1. A qualified nurse with 10 years' experience of working on a surgical ward has brought a patient back from theatre and has been taking his observations half hourly. These have been within normal parameters for a patient just returned from theatre. She has come to his bed to give him sips of water which he is now allowed, and sees that he is pale, rather restless and a bit breathless. She immediately tells the student nurse that the patient is bleeding somewhere. (There is nothing at this stage to indicate this directly as his signs and symptoms could be due to other things as well.)
Up to this point, all she has done is look at the patient, drawn on her experience of caring for similar patients and decided that in her ‘expert’ view he is bleeding somewhere rather than anything else.
2. On that ward, there is a protocol to follow if a patient exhibits certain behaviours or signs such as those above, for all patients who have had major surgery, in the first 4 hours postoperatively.
The qualified nurse immediately puts this into action: take all observations, temperature, pulse and respirations plus blood pressure and, if showing significant signs of change from the previous pattern, inform the doctor immediately (for example if the blood pressure has dropped from 120/70 mmHg to 70/50 mmHg and there is a raised pulse of 130 beats per minute). Then the protocol requires that all wounds, drains, dressings are checked. At the same time, the patient should be asked if he is in pain.
Kind of decision making: information processing.
In undertaking all these activities, the nurse is gathering various cues and information regarding the physiological status of the patient as well as the physical and psychological status.
3. In observing his wound and dressing, the qualified nurse can see only a small amount of blood on the surface that would be expected on the dressing of someone who has had major surgery 3 hours previously. The patient, however, still has the same cues and she still believes he is showing signs of a serious bleed. At this stage, she uses her clinical judgement and decides to ask the student to help her turn the patient onto his side. Underneath the patient and soaking the sheet is evidence of a large loss of blood.
A normal response when asked to follow a protocol is to check everything on the list or pathway of decision making, as this is one which covers all patients as a benchmark for determining what is happening. It is information gathering. However, what the qualified nurse has done is use the cognitive continuum model where both types of decision making can work together in order to make the most effective and, in this case, urgent reassessment of the patient's situation. This allows the surgeon to make a clinical decision on whether to take the patient back to the operating theatre immediately in order to resolve the postoperative bleeding.
Domain: Leadership, Management and Team Working
5. All nurses must facilitate nursing students and others to develop their competence, using a range of professional and personal development skills.
If you are a first year student, you might look at this competence and think ‘I am never going to be able to do that until I'm in my third year’. You are correct in a way, as that is one of the competencies you will have to achieve by completion of your programme to be signed off in practice placement as being ‘fit for practice’ as a qualified nurse.
However, even as a first year student, there are skills that you can learn to work towards this, and learning something new and showing another student at the same stage as you how to do it is a good way of learning. This could be in the clinical skills laboratory first, then during the placement.
An excellent example, and one that students will definitely need to learn to undertake on a surgical placement, is that of taking a patient's blood pressure – both electronically and manually. Using both is an essential component of the Essential Skills Cluster: Organisational Aspects of Care (9), where it makes clear that before students can progress to the second part of their programme, they need to be able to accurately undertake and record a baseline assessment of blood pressure using manual and electronic devices (NMC 2010:113).
Use the following resource to remind you how to take a blood pressure reading and consider how you would then show and explain this to another student underpinned by an evidence base: http://www.bhsoc.org/how_to_measure_blood_pressure.stm (accessed December 2011). This facilitates the development of their competence in one thing while developing your competence in another. It is also helpful to prepare yourself by reading through notes you already have from lectures or from skills teaching sessions, so that you feel you know something before going to placement. (See also Ch. 14 in Brooker & Waugh 2007.)
Summary
We have seen that as well as preparing for what to expect from a surgical placement, it is also essential that you prepare yourself as a developing professional and student who has to be successful in achieving your assessment of practice and competencies for the NMC and eventually the register as a qualified nurse. This chapter has given you some examples of how to facilitate some of your learning in these areas and additional information is also found throughout the book to supplement and add to the guidance in this section.
Arkell S., Bayliss Pratt L. How nursing students can make the most out of their placements. Online. Available at: http://www.nursingtimes.net/nursing-practice-clinical-research/how-nursing-students-can-make-the-most-of-placements/199226.article (accessed September 2011)
Aston L., Wakefield J., McGowan R. The student nurse guide to decision making in practice. Maidenhead: Open University Press; 2010.
Benner P. From novice to expert. California: Addison–Wesley; 1984.
Brooker C., Waugh A. Foundations of nursing practice: fundamentals of holistic care. Edinburgh: Mosby; 2007.
Buchan J., O'May F., Little L. Review of models of employment for nursing roles which bridge practice and education. Edinburgh: A report for NHS Education for Scotland, Queen Margaret University; 2008.
Carlisle C., Calman L., Ibbotson T. Practice-based learning: the role of practice education facilitators in supporting mentors. Nurse Education Today. 2009;29(7):715–721.
Fowler J. The handbook of clinical supervision: your questions answered. Salisbury: Quay Books; 1998.
Holland K. Utilising research and evidence based practice in assignment work. In: Holland K., Rees C. Nursing: evidence-based practice skills. Oxford: Oxford University Press, 2010.
Holland K., Rees C. Nursing: evidence-based practice skills. Oxford: Oxford University Press; 2010.
Holland K., Jenkins J., Solomon J., Whittam S. Applying the Roper, Logan and Tierney model in practice. Edinburgh: Churchill Livingstone; 2008.
Levett-Jones T., Bourgeois S. The clinical placement. Edinburgh: Baillière Tindall; 2007.
Nursing and Midwifery Council. Standards for proficiency for pre-registration nursing education. London: NMC; 2004.
Nursing and Midwifery Council. Ensuring continuity of practice assessment through the ongoing achievement record. London: NMC; 2007.
Nursing and Midwifery Council. The code: standards of conduct, performance and ethics for nurses and midwives. London: NMC; 2008.
Nursing and Midwifery Council. Guidance on professional conduct for nursing and midwifery students. London: NMC; 2009.
Nursing and Midwifery Council. Standards for pre-registration nursing education. London: NMC; 2010.
Nursing and Midwifery Council. Good health and good character: guidance for approved educational institutions. London: NMC; 2010.
Por J., Barriball L. The personal tutor's role in pre-registration nursing education. British Journal of Nursing. 2008;13(2):99–103.
Pudner R., ed. Nursing the surgical patient, 3rd ed., Edinburgh: Baillière Tindall, 2010.
Roberts D. How you will learn in practice. In: Hart S., ed. Nursing: study and placement learning skills. Oxford: Oxford University Press, 2010.
Rycroft-Malone J., Fontenla M., Seers K., Bick D. Protocol-based care: the standardisation of decision making? J. Clin. Nurs. 2009;18:1490–1500.
Thompson C., Dowding D. Decision making and judgement in nursing – an introduction. In: Thompson C., Dowding D. Clinical decision making and judgement in nursing. Edinburgh: Churchill Livingstone, 2002.
Timmins F. Making sense of portfolios – a guide for nursing students. Maidenhead: Open University Press; 2008.
Donaldson J., Ness V. Maintaining a safe environment. In: Docherty C., McCallum J. Foundation clinical nursing skills. Oxford: Oxford University Press, 2009.
Gilmour D. Perioperative care. Pudner R., ed. Nursing the surgical patient, 3rd ed., Edinburgh: Baillière Tindall, 2010.
Waugh A., Grant A. Ross and Wilson anatomy and physiology: colouring and workbook, 3rd ed. Edinburgh: Churchill Livingstone; 2010.
There are a number of publications for student nurses at the RCN website which are helpful to read prior to undertaking any clinical placement experience. Access this link for these publications: http://www.rcn.org.uk/development/publications/publicationsA-Z?78808_result_page=H#H (accessed December 2011).
1. Helping Students Get the Best from their Practice Placements (RCN 2002). Please keep in mind when reading this that the NMC has amended their standards for pre-registration nursing education (NMC 2010a).
2. An Ageing Population: Education and Practice Preparation for Nursing Students Learning to Work with Older People (RCN 2008). A resource pack for nursing students. A very useful publication based on a research project which will help students understand the specific needs of older people in any healthcare setting.
3. Benchmarks for Children's Orthopaedic Nursing Care (RCN 2007). An excellent publication relating to children's nursing care in an orthopaedic context which also has sections relating to surgical nursing and pre- and postoperative care.
4. Dignity in Health Care for People with Learning Disabilities (RCN 2010). Another excellent publication offering examples of best practice in caring for people with learning disabilities in various healthcare settings, including being in hospital.
5. Dyslexia, Dyspraxia and Dyscalculia: a Toolkit for Nursing Staff (RCN 2010) . This is an RCN publication that has been developed for students as well as qualified nurses and others and, in particular, a supportive one which is reassuring for any student with any of these three learning difficulties to negotiate assistance before and during placement.