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The role of the link teacher in the context of nurse education

The issue of whether nursing theory can influence clinical practice has been widely debated in the UK (Humphreys et al, 2000; Newton and Smith, 1998; UKCC, 1986). The role of the link teacher in nurse education was introduced to help facilitate a link between theory and practice in the clinical setting (Crotty, 1993). An effective clinical environment is viewed as highly beneficial in the promotion of this vital association (Saarikoski and Leino-Kilpi, 2002).

Abstract

VOL: 101, ISSUE: 50, PAGE NO: 33

Mark Mitchell, PhD, MSc, BA, RGN, NDN Cert, RCNT, RNT, is senior lecturer, School of Nursing, University of Salford, Manchester

The issue of whether nursing theory can influence clinical practice has been widely debated in the UK (Humphreys et al, 2000; Newton and Smith, 1998; UKCC, 1986). The role of the link teacher in nurse education was introduced to help facilitate a link between theory and practice in the clinical setting (Crotty, 1993). An effective clinical environment is viewed as highly beneficial in the promotion of this vital association (Saarikoski and Leino-Kilpi, 2002).

Despite the need to link theory and practice, the role of the link teacher has been limited over the last decade and considered a low priority compared with other aspects of academia such as classroom responsibilities and administration (Clifford, 1996). Frequently, the link role has been referred to as ‘just visiting’, ‘liaison’ or ‘support’ (Duffy and Watson, 2001; Clifford, 1996). Others have taken a broader view of the link teacher as supporting students and clinical staff and undertaking innovations, assessments and audits (Smith and Gray, 2001).

However, it has been suggested that administration dominates to the detriment of innovation and clinical teaching and that only a minimal amount of teachers’ time is spent in clinical activity (Lee, 1996).

Over the past decade the introduction of Project 2000 has taken a great deal of nurse educationalists’ time (Davies et al, 1996). It has also been suggested that more time should be spent on the management of higher education such as the role of the personal teacher in reflection (Hughes, 2004).

A strategy to rejuvenate the role of the link teacher in promoting nursing knowledge within the clinical environment may therefore be required. The demands of Project 2000, Fitness for Practice and Making a Difference (UKCC, 1999; 1986; Department of Health, 1999) do not promote knowledge of ill-health, disease processes, surgery or medical treatment (Murphy, 2000). This, together with the rise in student numbers, results in many students experiencing clinical placements for which they have had little theoretical preparation.

Nursing curricula prior to Project 2000 had greater definition. For example, students would learn about surgical nursing immediately before a surgical placement. The commitment required of clinical staff undertaking supervision and mentorship in the current system must therefore have increased considerably (Fisher, 2005; Saarikoski et al, 2002).

Limitations of the traditional link role
The challenging issues relating to the role of the link teacher include maintaining clinical credibility, reflection on practice and classroom activities and administrative commitments (Duffy and Watson 2001; Ioannides, 1999; Lee, 1996). It has also been suggested that teaching commitments and the number of years out of clinical practice hinder their clinical involvement, while Carlisle et al (1997) found that link teachers aged over 40 were least likely to spend time in the clinical setting as they may have lost their relevant clinical skills (Box 1, p34).

Registered clinical nurse teachers and lecturer practitioners were introduced to improve the situation (Cave, 1994). However, the role of the clinical nurse teacher failed to solve theory-practice issues and the effectiveness of the lecturer practitioner role is regularly questioned (Camsooksai, 2002; Cave, 1994), particularly over their effectiveness in reducing the theory-practice gap, role conflict, occupational stress and burnout, and the need for support and appraisal (Williamson, 2004). Under such sustained demands many find it impossible to fulfil their dual roles in education and practice (Leigh et al, 2002; Hollingworth, 1997; Rhead and Strange, 1996). Clinical placement coordinators have also been appointed to cope with growing student numbers. These roles, although well-intentioned, have largely become immersed in organisation and administration.

Regular communication between education and practice was vital in the early years of Project 2000 (Crotty, 1993), so the link teachers’ administrative role took priority. Project 2000 is now well-established but the link teachers’ organisational and administrative role has largely remained. Reasons for this include:

  • The heavy administrative requirements of Project 2000 resulted in many link teachers limiting their clinical involvement (Davies et al, 1996);
  • Administrative tasks dominate the working lives of nurse academics (Lee, 1996);
  • There is a lack of clinical link wards matching experience/expertise (Lambert and Glacken, 2004);
  • The large number of areas link teachers are expected to link with (Clifford, 1996).

The link teachers’ role in audit, assessment and management has widely continued, as it is less challenging, administratively convenient and a more politically expedient method of linking with a large number of placements. Although clinical tuition of students in placements was the original aim of the role this is rarely a central focus and staff nurses are most likely to teach clinical skills (Lambert and Glacken, 2004) as other clinical staff do not have time (Carlisle et al, 1997). The role has also been hampered by indiscriminate allocation of many to areas of which they have no experience, resulting in them lacking clinical credibility (Lambert and Glacken, 2004). In a survey of nurse educationalists (Carlisle et al, 1997), most felt it was desirable to ensure their clinical expertise corresponded with link areas, while linking with a smaller number of areas would facilitate greater clinical involvement (Clifford, 1996). The current method of linking with practice should therefore be challenged as it negates the possible contribution of link teachers to the creation and dissemination of ‘new’ nursing knowledge.

Link teachers in higher education
When nurse education was integrated into higher education many nurse educationalists felt the link teacher role should have a greater academic focus to help avoid the old stereotypes associated with nursing school programmes (Clifford, 1996).

Although the link teacher role is commendable, there is little evidence that it improves the clinical academic profile or adds to the knowledge students gain from the clinical experience. It is experiencing the context of nursing and being in close proximity to and being coached by health professionals that help students link theory to practice (Field, 2004).

For many nurse educationalists, the link teacher role is essentially concerned with maintaining clinical assessment and does little to support clinical staff or students in updating their knowledge of research (Newton and Smith, 1998). We should be more concerned with promoting clinical knowledge than audit and mentorship procedures in line with the original proposal that nurse educationalists must be clinically credible in the areas in which they teach (Cave, 1994; DoH, 1989). This could be adapted slightly and specific clinical research credibility be seen as desirable in link teachers (Fisher, 2005).

A way forward may therefore be the introduction of ‘new’ university schools of nursing into higher education, where managerial systems are likely to relieve nurse teachers of some administrative tasks and enable them to reconsider the nature of their role in clinical practice (Clifford, 1996). Therefore, more time and support should be available for link teachers to pursue the more academic aspects of clinical linking. A greater opportunity to undertake research as an integral part of the role should be embraced and more research must be undertaken (Camiah, 1998).

Nurse educationalists who have been in post for more than five years have been seen as having reduced clinical skills (Carlisle et al, 1997). However, they may be the very people who are intensely involved in clinical research.

A suitable method of linking for them may therefore be to establish a clinical link in direct alignment with their area of research interest. This would truly enable them to contribute in practice and help to give clinical staff contemporary research evidence for debate and possible implementation (Winch et al, 2005).

Such an increased academic focus would also benefit clinical colleagues. Sustained contact with a nurse educationalist with considerable theoretical knowledge specific to the clinical area, providing contemporary research, clinical discussions, journal clubs and access to national forums, may offer a more comprehensive link teacher service (Box 2). In this way they could contribute to clinical practice by helping to create and disseminate nursing knowledge specific to the link setting (Fisher, 2005; Winch et al, 2005). The opportunity to establish clinical links corresponding to areas of research interest and to disseminate information within the clinical placement, undertake clinical research and involve clinical staff in generating new nursing knowledge could be of considerable benefit to both practice and education.

Ambitions for an innovative role where clinical links correspond to research activity should not be secondary to clinical assessment regulation and audit. This approach corresponds far more accurately to the aims of the original link teacher role. As active researchers, we should support clinical staff in their endeavours to remain clinically updated by disseminating information on relevant clinical innovation. Such a focus may have a far greater impact on the quality of clinical education than clinical assessment programme regulation and audit. Since all schools of nursing are based in higher education institutions we should be more concerned with a clinical link role that promotes nursing knowledge than an administrative role carved out to aid the initial implementation of Project 2000.

The Quality Assurance Agency (QAA, 2001) stipulates that all clinical areas utilised by nursing students must have a named link teacher and be a supportive environment. This proposed method of linking should have little impact on the number of educationalists able to link with clinical placements - indeed the placements would become more educationally supportive. All clinical placements could have a named link teacher although roles may differ - for example a traditional link role with an eclectic clinical responsibility and a research-active role with a more measured responsibility.

However, while the QAA has an important role it is a government organisation overseeing the political agenda. The government wants a large number of nursing students to be educated to help achieve NHS reforms. However, these reforms do not have the promotion of nursing knowledge as a priority.

It could be argued that we are currently educating additional nurses for many to be undertaking medical roles and may thus be unwittingly involved in the erosion of nursing knowledge. The profession has been enticed into providing a convenient link role with little purpose other than to aid the education of large numbers of nursing students.

Such political bidding is by no means a new development - the role of the nurse educationalist has been widely influenced by external forces (Crotty and Butterworth, 1992). We cannot allow political practices with no professional substance to go unchallenged. Proactive schools of nursing may wish to consider designing, undertaking and evaluating a similar link teacher scheme (Box 3). Such data may help to provide evidence for an informed debate on the utility of such a method of clinical placement linking that reaches beyond political expediency.

Theory-practice challenges or political expediency
Evidence suggests a number of link teachers do undertake a greater academic role (Winch et al, 2005; Murphy, 2000) but where theoretical expertise and the clinical link do not correspond, this focus may be restricted (Lambert and Glacken, 2004). Nurse educationalists have been seen in the past as contributing little to clinical education, but have been perceived as organisers of placements (Papp et al, 2003) and facilitators undertaking supportive visits (Clifford 1996; Lee, 1996). Promoting policy to the detriment of nursing knowledge appears to be a traditional NHS school of nursing role carved out during Project 2000 implementation, from which schools of nursing must now attempt to break free.

Higher education establishments may therefore wish to take a firmer view of the link teacher role as true educationalists supporting students in clinical placements. Such a role may in future be a prominent source of research income in line with other health professions.

Additionally, the audit of trust clinical placements by university staff may be devolved. Growing ethical unease about the storage of personal information from NHS staff in higher educational institutions gained during educational audit may be become a pressing issue.

If this devolution occurs what will be the role of the link teacher? Once clinical audits become the domain of trusts all that will remain of our clinical role will be the maintenance of the clinical assessment programme for students. We must therefore be more proactive and decide, as a professional body, what is needed for the promotion of nurse education within the clinical setting. We cannot simply wait for the next policy to be passed down. Ownership of nursing must be by the profession - directing how nursing should progress rather than allowing the government to take the lead (Kitson, 2001).

The direction of nursing, its role and the clinical interventions deemed necessary cannot be determined by outside agencies. Again, the promotion of nursing knowledge and the employment of contemporary clinical research is crucial to our current and future role (Deans et al, 2003). The challenge for nurse education is to generate a knowledge base that nurses can apply to their practice, raise awareness that this spectrum exists and inform nurses of policy-making decisions and the need for strategic thinking (McIlifatrick, 2004). We must begin to practise what we constantly preach to our students and undertake evidence-based educational practice ourselves (Box 4). We must give greater respect to the professional evidence on the role of the link teacher and negotiate a balanced settlement between political aspirations and professional accountability.

Theoretical and clinical knowledge must be aligned both in the classroom and the clinical setting on a broader scale, as was originally intended (DoH, 1989). Furthermore, the creation of such an innovative link teacher role could exist alongside the traditional link role. Nurse educationalists wishing to maintain their historical links and familiar clinical assessment regulation/audit role could continue although future discussions on clinical links should focus on clinical credibility and clinical research. Achieving a negotiated balance between evidenced-based practice and political expediency may then help the link teacher role to move forward.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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