Response
Debate on articles in Contemporary Nurse
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 093 - 095
Article Text
I wish to respond to the invitation by Elizabeth Patterson and Denise Cruikshank in their paper Promoting purposeful partnerships Vol 5(1) to engage in a discussion on the use of reflective strategies with students on clinical practice and the nursing staff in the receiving agencies.
The authors describe a model for clinical teaching which has the potential to enhance the learning of students and ultimately to lead to improvements in nursing practice in the cooperating agencies. However, the authors found that while the reflective sessions in which agency staff were involved were perceived positively by some groups, others gained little or nothing, with some agency staff having a negative response to the experience. The article described well the personal and political risks involved in reflection on practice.
Such a project faces considerable difficulties, not the least of which would be the changing composition of the group each day, due to the changing shifts of agency staff. Reflection may flourish in a climate of safety and continuity, where there is some agreement about purpose and a flat power structure (or power differences are acknowledged and become part of the discussion). These things do not happen quickly and group development will be impeded if the membership changes constantly.
Would it be possible, perhaps through staff development on reflective practice at the agency, to identify a cohort of staff who are willing to engage in reflective practice with students placed in their units. This would satisfy the need for genuine voluntary participants and would create a group membership which although changing day by day, was consistent over the period of the students' clinical placements. Some groups of agency staff may wish to continue meeting between clinical placements, perhaps facilitated by university staff on faculty practice.
My experience in working with students reflecting on their practice, mirrors that of Patterson and Cruikshank, that it can be a threatening process. Students will disclose issues from practice of which they are unaware of the implications, until after discussion and analysis in the group. They may then be left feeling exposed and humiliated. Several safeguards are important. It is crucial to negotiate confidentiality in the group. The reflective groups described in the article have several purposes, amongst which is evaluation of students, evaluation of the placement and evaluation of the group itself. A report focusing on nursing problems/issues requiring further learning/exploration, rather than on evaluation-whose content was agreed upon by all in the group, may help preserve confidentiality and promote safety, even if sacrificing some information.
Another strategy I have used to help preserve safety in the group is to focus on examples of positive nursing of which the participant is proud, in the early stages of group development and while the processes of reflection are being learnt. Analysis of positive examples can be as powerful for learning and the improvement of practice as can negative examples. They may even be more useful because they generate less defensive reactions. Participants can then be asked to consider what constrains them from being able to practice in the way they desire.
Patterson and Cruikshank have made a valuable contribution to the debate on the best means to improve the learning of students on clinical placement. The value of their approach is in highlighting the mutual benefits to be gained when students and practitioners reflect together.
Judith Condon, Dip Nurs Ed BA (Hons) Master Ed St
Lecturer, School of Nursing
The Flinders University of South Australia
I read with interest Professor Lumby's editorial View on Australian Clinical Chairs Vol 5(1). My first response was to revisit my own experiences with co-sponsorship of a clinical professoriate with Area Health Services and the university sector and the preparation of submissions for joint sponsorship of the clinical professoriate. Those involved in the development weren't quite sure what the establishment of a professorial unit would entail but we had a clear vision that it should be firmly grounded in practice.
In search of a clearer vision my colleagues and I had visited numerous nursing research centres in the United Kingdom and having noted the attributes of some of the incumbents concluded that Australian nurses had the required attributes to launch the unit and thus we decided to proceed. It was after all, we thought, essentially about managing a process of change.
The implementation experiences were much as Professor Lumby described, as were similar subsequent collaborative ventures between universities and Area Health Services and more recently with the Baptist Community Services. There were distinctive emergent themes, a feeling of challenge or a need for creativity, and a lack of self-consciousness but clear evidence of behaviours that suggest that we as nurses have come of age in the research arena.
It didn't occur to me that any nursing professorial unit should be modelled on or sanctioned by colleagues from medicine, it seemed instead to be driven by a need to say 'nursing matters' and 'we have something to offer' and 'there are questions posed by nurses that need answering'. I think, as nurses, we are credible and the establishment of a clinical professoriate simply formalises that credibility. Credible experienced personnel in nursing have alway found a way forward or established a mechanism for expression of their views. My recent experiences suggest we are becoming even more creative in our approaches to managing change. It seems, however, that sometimes only a few have clearly assumed responsibility for their decisions and the implications of those decisions, and it is difficult not to assume responsibility on their behalf. It's been too easy to defer to others. I think we are now less self-conscious about professing our discipline and that's what the clinical professoriate ought to be focused on, encouraging the development of our abilities to lead but remain true to ourselves.
To me the need for articulation between the clinic and the academy has never been greater. Yes, it's about managing resources better or differently, because the latter can be utilised to provide evidence of nursing outcomes. It's about a channelling of energies into things that highlight the impact of nursing interventions. Co-sponsorship of nursing research positions implies a shared responsibility to capitalise on the context and the energies of the health service personnel there in. It often implies a need for a redefinition of the impact of politics, context and interpersonal relationships. Long held assumptions can be challenged and untapped resources realigned. Nurses can now be caused to assume research activities within their daily roles. Frequently they have made a contribution to other people's research and often have not demanded acknowledgment for a truly interdisciplinary effort.
I think we need to take great care about the extent to which we encourage our professoriate to become immersed 'in the affairs of health care at all levels'. It is too easy to be consumed by the 'small stuff and distracted from the main game of completing research. I read about the balancing act inherent in this apparently multi-faceted role with some concern. I concur with Professor Lumby's assertion about the impact of personal stretching across roles, responsibilities and sites, but herein lies a dilemma-why is it that nurses in particular allow this to happen? Is there an answer in the demand for research support that's emerging? Besides the professoriate, there appears to be an increasing number of other research support staff in existence-nurses in research assistant roles, nurses assuming roles as research fellows and a supporting secretariat. Where are the funds for such infrastructure, I hear you ask? Accessing new resources is frequently not a possibility, but additional research support can be found by redirecting existing personnel into research-oriented support services. In this way we can reduce the demands on the professoriate and capitalise on the skills of others in a way that is re-energising and stimulating to them.
I think that the emerging professoriate in nursing is the mechanism for expression of leadership. The latter is about remaining faithful to your own personality and style and making decisions about what matters now. This requires remarkable skills in delegation to others in whom you have to trust. It's more about letting go and not pursuing things that ultimately won't make a great deal of difference. It's about self-determination. It's critical that we develop these behaviours. Leadership is different from management which is a very present-oriented activity and very necessary-people who are adept at directing the processes of management. Leadership is more focused on preparation for the future. The ultimate question posed by Professor Lumby relates to the extent of achievement or level of creativity/productivity that needs to be demonstrated (given the apparent lack of prescription in the role). She seems to be asking of those who have given her unlimited scope 'freedom to do what and to what end?' Perhaps the answer lies in what others have achieved as a result of the clinical professor's facilitation of others.
Professor Margaret McMillan, RN BA M Curr St(Hons) Dip N Ed PhD
Dean, Faculty of Nursing, The University of Newcastle
I would like to extend a voice of support to Wendy Morey's Exemplar A difficult death and gerontic challenge Vol 5(1). In 1994, I collected data from two nursing homes in New South Wales to identify the resident's perspective on nursing home-living (Fiveash 1994). During the period of fieldwork I could not help but notice the complexity and seriousness of resident's health status as well as the ratio of resident's to registered nurses. In both nursing homes, one registered nurse was responsible for approximately 20 residents on day shift, 40 residents on evening shift, and 80 residents on night shift. Nursing services included nursing care for the sick, dying and disabled. These services at times included the total care of the person, particularly if that person was seriously ill, dying, confused or for some other reason unable to care for themself.
Without exception every registered nurse who approached me made comment on the deskbound nature of their work, the amount of documentation necessary, not so much for the provision of nursing care, but to attract the appropriate funding to provide nursing service. (Resident classification indexes are completed regularly on every resident as well as lengthy and comprehensive nursing care plans.) Reduced lengths of stay and complex casemix increased paper work. Registered nurses said that they spent so much time documenting nursing care that there was little time left to implement care.
With the deskbound nature of their work and the increased complexity of resident's casemix, registered nurses found themselves professionally isolated and heavily reliant on assistants- in-nursing who often have no nursing qualifications and, sometimes no previous nursing experience. Even with the best of intentions, they do not have the nursing knowledge necessary to provide the level of care required.
It is unreasonable that nursing home residents should be transferred to another health service to receive treatment when the skilled care already exists or could readily be made available in the nursing home. The issue here is that nursing homes (or the residents living in the home) require adequate and appropriate resources. Skilled nursing practice cannot be developed overnight by assistants-in-nursing who have minimal or limited formal nursing education. Nursing knowledge is not everyday knowledge that people develop simply on the basis of experience, it is a complex special knowledge developed through years of education, training and clinical experience. Registered nurses working in nursing homes already meet the challenge of managing nursing services for large numbers of sick people. They require appropriate information systems to reduce the amount of documentation that removes them from direct patient care and situates them for lengthy periods in front of a desk. Adequate numbers of skilled registered nurses are required to provide optimum health outcomes congruent with best practice as deserved by the elderly sick population resident in nursing homes.
Barbara Fiveash, RN DNE BHlth Sc MN
Lecturer, Faculty of Nursing, The University of Newcastle
References
Fiveash B (1994) 'The articulate resident's experience of nursing home living'. Unpublished Masters Thesis.
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