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Piloting cross-boundary training to develop cancer care nursing

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The emphasis on lifelong learning is clearly evident in government policy from 1997, with most progressive organisations encouraging the implementation of lifelong leaning approaches as an integral part of staff development (Marchington and Wilkinson, 2002).


VOL: 100, ISSUE: 02, PAGE NO: 34

Christine Lawther, PGDip, BA, RNT, RGN, is head of education, St Ann’s Hospice, Manchester

Sue Taylor, BSC, RGN, is in-patient services manager, St Ann’s Hospice, Manchester;Ann Bell, RGN, is clinical placement development manager, Christie Hospital NHS Trust, Manchester;Helen White, MSc, BSc, RGN, is matron, thoracic medicine, South Manchester University NHS Trust


The emphasis on lifelong learning is clearly evident in government policy from 1997, with most progressive organisations encouraging the implementation of lifelong leaning approaches as an integral part of staff development (Marchington and Wilkinson, 2002).



Lifelong approaches to learning require a shift from the traditional way of thinking of training as the development of crafts or skills, to a recognition of the importance of helping people to learn how to learn and encouraging innovative and flexible models of learning. It is about individual growth and opportunity (Department of Health, 2001).



In industry there is a definite link between lifelong learning, staff morale and productivity. As Harrison (2002) states: ‘People hold the key to more productive and efficient organisations.’



Ashton and Felstead (2001) and Stern and Sommerland (1999) suggest that learning organisations are characterised as holding a belief at senior level that training, employee development, motivation, accountability and the ability to self-manage are vital to company success. This builds on the aims of Investors in People, an award given to companies who can demonstrate a culture of continuous improvement by the adoption of a planned approach to learning.



Lifelong learning in health care
In health care there have been significant changes to the way in which learning takes place at all levels. The introduction of more flexible approaches that encourage exploration of a range of opportunities and outcomes form the basis for much of the undergraduate and postgraduate training. These include activities such as problem-based learning, the promotion of models for reflective practice and portfolio development, each of which require a transition from learning about practice to learning in practice.



In nursing, however, for staff who wish to progress up the career ladder there is still an emphasis on the acquisition of qualifications coupled with first or higher degrees. The policy document Working Together, Learning Together (DoH, 2001) suggests that learning and development are key to the government’s vision of patient-centred care.



Furthermore, they suggest that provision of flexible learning opportunities should be aimed at enabling staff to progress their careers and build on their skills and expertise. While the NHS spends over £2.5bn per year on education and training, informal work-based learning opportunities contribute significantly more.



It is timely to consider the relevance of and rewards for these activities, given that a lack of support for education and training, and limited opportunities for career progression are cited as high contributory factors to low morale (Callaghan, 2002).



Within the field of palliative care, issues surrounding the recruitment and retention of staff are evident (National Council for Hospice and Specialist Palliative Care Services, 2000). There are particular concerns around D and E-grade nurses, perhaps due to the high ratio of trained staff and the subsequent limited opportunities for promotion. This was particularly true for the hospice in which this project took place.



Subsequent discussion with two other trusts reflected a similar position, particularly among those staff working with patients with cancer.



In an attempt to address potential motivation and retention issues, promote collaborative working practices and share experiences across very different care settings, it was agreed that the potential to deliver a rotational placement package, covering an 18-month period, should be explored (Box 1). This approach is in keeping with recommendations in The NHS Cancer Plan (2000).



The sites
The three participant organisations within this project include a regional cancer centre, a pulmonary oncology unit within a university teaching hospital and a large independent hospice. Due to the fact that this was a pilot project, and given the comparatively small numbers of qualified staff within the hospice unit, it was agreed that one nurse from each centre would be involved.



The regional cancer centre



The regional cancer centre - the Christie Hospital - is situated in Withington, South Manchester and comprises:



- North Western Medical Physics;



- The Patterson Institute for Cancer Research;



- The hospital itself.



The hospital itself has 300 beds and deals with approximately 15,000 inpatients, 75,000 day cases and 70,000 outpatients per annum.



The three major therapies offered at the hospital are radiotherapy, chemotherapy and surgery, and these are often given in combination. The hospital is a designated teaching hospital for the University of Manchester. The rotation took place on a ward that provided both radiotherapy and chemotherapy.



The hospice



The hospice is the largest independent hospice in the UK serving a population of 2.2 million. Based on three sites it offers holistic rehabilitative and specialist palliative care services enabling individuals with a life-threatening illness and their families to maximise their quality of life.



The site in which the rotation took place comprises:



- Two inpatient wards with a total of 36 beds;



- A day-therapy service;



- Various outpatient clinics;



- A respite-at-home team.



In the inpatient unit there are in the region of 500 admissions per year, with the average length of admission being 17 days. Sixty-three per cent of those admitted died during their inpatient stay and 37 per cent of patients were discharged.



The pulmonary oncology unit



The pulmonary oncology unit (POU) is a purpose-built unit based in South Manchester University Hospitals NHS Trust. The POU has 16 beds and provides active treatment for patients with lung cancer. This is predominantly through chemotherapy, with patients attending as day cases or as inpatients.



It also provides palliative care and respite care. A dedicated day-case unit has recently been added, with funding from Macmillan Cancer Relief. This affords the opportunity for patients to be cared for in a setting that promotes privacy and dignity.



Setting up the project
The idea for the project arose following discussions between the director of clinical services at the hospice and senior managers from each of the participating sites. The discussion had focused on the broad principles of developing collaborative working opportunities, and as such, was part of a wider agenda.



Once a broad agreement had been reached, management of the project was devolved to clinical managers from each of the participating sites, along with the hospice head of education. Early discussion led to the agreement that an 18-month rotation should be made available. This would comprise:



- An initial three months on the nurses’ home site to prepare for the programme;



- Followed by two periods of six months each in a different clinical setting;



- Returning to the home site for a final three months for evaluation.



Participants would be supernumerary for the first two weeks of each placement, following which time they would be included in the staff numbers.



It was decided that the opportunity should be available to E-grade nurses in the first instance. By restricting it in this way it would ensure that each clinical area would be in a position to maintain an appropriate skill-mix for the duration of the project.



Formal study



Objectives and learning outcomes for each of the rotation areas were developed. As part of the programme included the opportunity to partake in a formal course of study, it was important that these objectives reflected those required by the identified courses. The courses on offer included:



- The oncology course;



- The continuing care of the dying patient and family;



- The advanced palliative care course.



The participants were able to choose one of these in accordance with their own personal development needs.



With regard to the undertaking of academic study, it was agreed that participants should be actively encouraged to enrol on an appropriate course, but that the final decision would be theirs.



The participants were, however, required to keep a reflective journal throughout their experience as well as provide evidence of how they had met the learning objectives for the programme.



Working practices



Issues regarding contracts, uniform policy, pay arrangements, the reporting of sickness, holidays and responsibility for disciplinary matters all needed to be agreed before advertising the programme. This was particularly important as each area has different working practices and policies.



Employment responsibility



A number of points were agreed with regard to the responsibility of employers and employees participating in the pilot:



- The employment responsibility for each participant remained with the initial employer;



- To manage the holiday entitlement, each participant would spread his or her holidays with no more than three weeks to be taken on any one placement;



- Rather than having a full induction at each placement, all three participants would participate in a single week-long induction programme offered at one hospital. This ensured that the participants had all received mandatory training in fire, health and safety and resuscitation;



- Staff participating in the programme would be expected to commit to the full 18 months, unless there were mitigating circumstances.



The intention in agreeing these points was to prevent any of the areas becoming understaffed as a result of the project.






Having set down the working details, the rotation opportunity was advertised to staff in each of the clinical areas concerned. The staff in these areas had been made aware of the programme as it was being developed and so it was a disappointment to the facilitators that there were no applicants.



Undeterred, the facilitators took it upon themselves to ask their staff what it was that was preventing them from making applications. The overriding concern appeared to be the length of the placements. Staff felt that 18 months was too long to commit to and also that 12 months away from their home trust could potentially alienate them from their colleagues.



In light of the feedback, the facilitators met again to address these concerns. It was agreed that the overall programme should be shortened to 12 months. This would comprise four months on placement, followed by two months back in their home trust, a further four months on their second placement, and finally two months in their home trust again. The period in their home trust would afford time for the participants to complete their home trust objectives.






In order to offer ongoing support, each of the clinical areas would be asked to identify a mentor. It was also agreed that a study day would be held every two months to enable each of the participants to reflect on and share their experience ‘warts and all’. Built into these days was formal reflective practice, in which the participants were asked to identify an incident to discuss with their colleagues and facilitators.



The programme was reconfigured and re-advertised, this time with success. As part of their application, staff were asked to submit a supporting statement as to why they wished to undertake the programme. All of the staff recognised the need to continuously develop their practice and all wished for a deeper understanding of the patient’s cancer journey.



One applicant voiced this by saying: ‘This opportunity would allow me to gain a better understanding of the full cancer journey, and thus be better equipped to understand the issues and empathise with patients in my care.’ In addition all expressed their initial apprehension at moving out of their ‘comfort zones’.



Getting Started
Having identified three members of staff to take part in the programme, a mentor was identified in each clinical area to support and encourage each nurse on rotation. In addition it was recognised that ongoing support would be required from the relevant managers if the students were to achieve their learning outcomes.



Accordingly a programme of bimonthly study days was drawn up. The days would be held in each of the participating trusts in turn. The intention was to keep the format of the day informal. The presence of managers would ensure that potential administrative and managerial problems could be dealt with speedily and efficiently.



The main focus of the day would be to listen to how the staff were adapting to their new work environments. With the aid of his or her journal, each nurse would be asked to reflect on an aspect of care that he or she had experienced. The afternoon would be given over to private study and reflection in order to ensure that the participants had the time to research the evidence base of their newly developed skills.



The first study day was held after the induction programme and was used to establish the format of future study days, and to talk through any initial anxieties and concerns. The concept of shared reflective practice was introduced and the staff were given a pro forma to guide their reflection. The process was kept as simple as possible, using four key headings:



- The identification and description of an incident (not a case study);



- The participant’s feelings about the event;



- An analysis of the relevant factors;



- The identification of learning from the incident and any future learning needs highlighted by it.



The programme was monitored informally on an ongoing basis, with formal evaluation taking place at the end.



All of those involved used the study days well, and willingly shared their experiences, both in terms of presenting their reflection and in contributing to the subsequent discussion. Time away from the clinical environment afforded them the opportunity to compare and contrast experiences and it was apparent that the presence of managers, who were genuinely interested to hear of these experiences, was appreciated.



At the end of the rotational programme, each candidate was asked to write an evaluation of his or her experience. Consideration was given to the development of a pro forma. However, it was felt that a better understanding would be gained by allowing each participant to recall his or her experience on his or her own terms.



Subsequent submission of three very different, but equally informative evaluations justified this approach. The support given by their ‘new colleagues’ in allowing them to find their feet, ask endless questions and make the most of this opportunity was much valued.



In particular the advice and support from mentors proved invaluable. Staff also acknowledged the support of their managers, particularly in having two weeks of supernumerary status. In the event this was not possible. However, the participants were understanding of the reasons for this and appreciated that ‘the best laid plans’ can go astray.



Reflective practice



The formal reflective practice, which all admitted was a new experience, proved to be beneficial. In the evaluation one staff member summarised the benefits by saying: ‘I found this very worthwhile in that it gave rise to lively discussion, useful suggestions and most of all a sense of mutual support.’



Another stated: ‘Writing down reflections weekly, although initially arduous, did become cathartic. Coming to the end of the rotation I realised the amount of information I have accumulated constitutes a comprehensive record of years of nursing experience. This has encouraged me to learn from positive and negative experiences, but will also serve as something that may enhance elements of my portfolio.’



The format of the study days was welcomed, as one participant stated, ‘not only as a forum for reflective practice, but also for raising issues and discussing how we were getting on with our placements. I feel that we shared a sense of commitment to the rotation, and these meetings helped us to sustain this commitment and sense of ‘ownership’ of this new venture’.






Surprisingly few difficulties arose. Those that did tended to focus on different working practices or organisational issues. One participant commented on the challenges of working to different policies and protocols in what was a relatively short period of time.



There was also a strong feeling that as E grades there was an expectation that they should take responsibility for the clinical areas when on duty. They perceived that this may have caused difficulty for other members of the team, although other team members never expressed this, either formally or informally.



Shortened programme



The decision to both shorten the programme and provide an opportunity to return to their home trust part way through the experience was welcomed by all involved. This was summarised by one participant who wrote: ‘I felt that the two months back at the home trust was essential to touch base and reacquaint myself with my own role.



It also gave me an opportunity to consolidate my learning before moving on to the next placement.’ From the managers perspective there were also benefits to this approach, as the participants shared their experience with their colleagues.



Final evaluation
The final evaluation took place during a meeting held one month after the programme had finished. The purpose of this meeting was to ensure that the participants had successfully reintegrated into their own working environments, and to establish whether, in the cold light of day, they felt that the experience had been a worthwhile one (Box 2).



From an organisational perspective, the three participants embraced the opportunity wholeheartedly. As a result their personal motivation, confidence and enthusiasm have all increased, and this is evident in their current practice.



In addition, they act as a resource for other staff members by willingly sharing their new skills and knowledge.



Although the number of staff directly involved in the pilot was small, all three organisations reported very clear benefits. The continuation of this venture is assured and a new programme, which is following the same format, has now started.



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



Investors in People
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