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Research

Building a professional identity: views of pre-registration students

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Five students at City, University of London offer insight into how they are building their professional identity and what role the registered professionals who teach them play in this

Abstract

The way student nurses and midwives perceive their professional identity has changed considerably since the move from hospital-based to university-based education. Students develop a professional identity in a variety of ways, including through their interactions with registered professionals working as academics, but we know little about what they think of their lecturers’ backgrounds. As part of a larger study on revalidation and academic nurses and midwives, semi-structured interviews were conducted with five pre-registration students at City, University of London. This article discusses the students’ views on the clinical credibility of their lecturers and their own professional identities, as well as their understanding of revalidation.

Citation: Attenborough J, Abbott S (2018) Building a professional identity: views of pre-registration students. Nursing Times [online]; 114: 8, 52-55.

Authors: Julie Attenborough is associate dean, director of undergraduate studies; Stephen Abbott is honorary senior research fellow; both at the School of Health Sciences, City, University of London.

  • This article has been double-blind peer reviewed 
  • Scroll down to read the article or download a print-friendly PDF here  (if the PDF fails to fully download please try again using a different browser)

Introduction

During pre-registration nursing and midwifery education, students develop an understanding of their profession, its scope and boundaries through interaction with their lecturers and exposure to clinical practice. However, little is known about students’ views of their lecturers’ professional backgrounds and how this relates to their own identity.

The introduction of revalidation by the Nursing and Midwifery Council (NMC) in 2016 brought renewed focus on the clinical credibility of academic staff educating student nurses and midwives in universities (Attenborough, 2017). After the first year of revalidation, the NMC reported that 2% of registered nurses and midwives revalidating (n = 4,148) were working in education (NMC, 2017). This article reports on the findings of a small-scale qualitative study investigating students’ professional identity, their views on the clinical credibility of academic staff and their understanding of the revalidation process.

Literature review

There has been a considerable change in the identity of student nurses and midwives in recent decades. The move from hospital-based to university-based education has caused a tension of loyalties; students are required to engage in practice for prolonged periods and then switch their emphasis to being critically thinking students at university. This dual identity is described in the literature (Brennan and Timmins, 2012).

In 1997, Hindley asked: “Does the midwifery lecturer promote learning by demonstrating research-based knowledge rather than emulating clinical competence?”. The article – written in the early days of the nursing and midwifery journey into higher education – called for a shared vision for the future, with a model that outlined:

  • Clinical excellence and academic excellence for those registrants working in higher education;
  • Associated investment in staff to support that;
  • More research to establish how students perceive their lecturers’ clinical credibility.

There is some evidence that students are not confident in terms of their professional identity upon registration (Grealish and Trevitt, 2005) and that they think it should be given more emphasis during their pre-registration education (Cook et al, 2003). In a study about academic staff role modelling for student nurses, Baldwin et al (2017) highlighted the importance of academic staff presenting a reconciled image of their professional identity to help students develop their own. They also described the process of storytelling by academic staff about their clinical practice.

Similarly, in a study examining how student nurses construct their identity in clinical practice, Walker et al (2014) described five key elements (Box 1) and highlight role modelling as being particularly important for students to understand the meaning of being a nurse. Students’ perceptions of nursing were negatively influenced by poor role models.

Box 1. Construction of students’ nursing identity

The following elements have been identified as helping to positively influence student nurses’ construction of their identity in clinical practice:

  • Positive role models
  • Belonging
  • Peer support
  • Critical thinking abilities
  • Confidence

Source: Walker et al (2014)

Foster et al (2015) reported on the importance of the link lecturer and the value of this role to student nurses. They found that the understanding of clinical practice by academic staff acting as link lecturers is a crucial feature of support for students.

Reporting on a study examining student nurses’ expectations of their lecturers, Lovric et al (2017) found that students had high expectations of their lecturers’ competences and that these expectations increased over the duration of the course. Students had slightly lower expectations of their lecturers’ clinical competence than of their ability to teach, but reported that their lecturers’ abilities and behaviours in general were highly influential.

Study method

As part of a wider study on revalidation and academic nursing and midwifery, an independent researcher conducted semi-structured interviews with five students at City, University of London. Box 2 describes how participants were recruited and which courses they were studying. In the interviews, the participants discussed:

  • The clinical credibility of the academic nurses and midwives teaching them;
  • How helpful it was to hear about their lecturers’ experiences of clinical practice;
  • How they felt about their professional identity;
  • Their knowledge of, and concerns about, revalidation.

Box 2. Participants’ recruitment and course

In total, 1,200 students were contacted via their programme director and asked whether they would agree to participate in the study. A sample of five students was selected to represent, as far as practicable, the courses delivered at City, University of London. Students were on the following courses:

  • Student 1: PGDip Adult Nursing
  • Student 2: BSc Children’s Nursing BSc (Hons) Child Nursing
  • Student 3: BSc Mental Health Nursing BSc (Hons) Mental Health Nursing
  • Student 4: MSc Adult and Mental Health Nursing
  • Student 5: BSc Midwifery (Hons)

As funding was only available for a small and time-limited study, we chose a qualitative approach; this allows researchers to identify and explore key issues, but not to generalise findings. Ethical approval was granted by the Ethics Committee of the School of Health Sciences at City, University of London. Interview transcripts were analysed systematically for themes, with a deliberate search for divergent cases.

Findings

Credibility

Participants expressed the view that it was not important if lecturers were not absolutely up-to-date on every detail of practice, as they were usually teaching theory. The participants knew or assumed that most of their lecturers were qualified nurses or midwives, and reported that many had given a brief account of their clinical careers.

It was apparent that academic staff did inform students of their clinical currency:

“A lot of them make a point of saying that they do bank shifts […] or still consult within the hospital trust, they’re still part of the trust.” (Student 1)

A participant on a course leading to dual registration valued the range of experiences brought to the classroom by academic staff:

“Most of the staff on the general side […] seem to have done hardcore, intense, end-of-medicine stuff. And we’ve got a few that are associated with my course that have got dual registration, so we know quite a bit about their things.” (Student 4)

Participants differentiated between subjects taught:

“The ones who are teaching nursing classes, I think we wouldn’t take as seriously if they hadn’t worked as a nurse at some point.” (Student 4)

One participant expressed confidence in the robustness of the preparation of academic staff:

“In all the clinical skills classes […] they seem to be really on top of it, but I think it’s their professional pride […] they’ll have done their research, they’ll have double-checked that it’s right.” (Student 4)

Interestingly, one wondered when a lecturer would stop identifying as a clinician and start identifying as a lecturer:

“I don’t know if you maybe decide to go into academia and after 15 years, you go, ‘OK, that’s fine, I’m now a lecturer, I’m not a midwife anymore’.” (Student 5)

Storytelling

Several participants suggested that lecturers’ anecdotes from their nursing experience helped them to feel their way into their nursing role:

“Telling us stories, before we’ve gone on our first placement, about how working on a ward is actually like, I think is really important – because it gears you up a bit more and then it also gives you a bit of hope for the future, like, ‘Oh you’ve had a good career out of this, maybe I could too?’.” (Student 4)

In some ways, this helped participants make sense of the gap between university and practice:

It just gives it a bit more context. They can demonstrate […] how the theory doesn’t necessarily perfectly fit [with] practice or just the sort of things that you’re likely to face when you do get into practising.” (Student 1)

One participant described drawing on lecturers’ experiences when in practice:

It’s the little warnings they give about things [that] perhaps don’t go so smoothly; that’s what is really helpful, because they’ve already primed you a little bit.” (Student 1)

Participants valued the way in which academic staff who were registered professionals prepared them for practice:

The university […] really does prepare you for placement […] not only in the clinical sense but even the staff – the ones who are nurses now or have been – they tell you what to expect [from being] a nurse from day one … [They] tell us what to expect, both the positives and the negatives.” (Student 2)

Identity

Unsurprisingly, participants reported feeling like a student, rather than a nurse or midwife, when at the university – although one mentioned feeling like a nurse during simulation sessions in which students wore nurses’ uniforms. Equally unsurprisingly, when on placement in clinical settings, they felt more like a nurse or midwife, albeit to varying degrees.

One participant in the final year of a pre-registration course definitely felt like a nurse with nursing responsibilities, but others felt, at times, more like healthcare assistants. This might be because of the tasks that qualified staff were prepared to delegate to students, or tackle with them:

Some of them trust you to actually do stuff, and other ones are like, ‘no, you’ll sit in the office and you’ll read policies all day’. In which case, you feel more like a chastised toddler than an actual nurse.” (Student 4)

It could also have been because of how the notion of supernumerary status was interpreted:

A lot of the time, on placement, you have to be so hands off you don’t really feel like you’re doing nursing, you’re just watching it. The placement I’m on now […] a lot of the treatments are infusions, so I’m just stood there watching a lot of the day […]. So you just, you don’t physically do much unless you’re just changing beds or cleaning patients and all that.” (Student 1)

One participant commented on how students become cut off from their networks:

It does feel like you’ve got two lives. You’ve got your student life. You’ve got your nursing life […]. You hardly see your friends from university for three-month blocks, and then you’ll be with them quite a bit more. But you won’t be in the hospital for those few months [when you’re back in university], so you’re away from the trust and how the trust operates.” (Student 1)

Knowledge

Participants felt that the two settings complemented each other; only one reported an important gap between theory and practice:

We’ve been very much taught that the way to deliver a baby is hands off and that we don’t touch [the] perineum because it’s less likely to tear. Whereas, in practice, everybody is ‘hands on’ and the new research is showing that we should be hands on […]. I think they probably should have touched on [the] hands-on [aspect]. They talk a lot about finding your own way to practise, so if you’re not presented with both ways, then how can you find your own way?” (Student 5)

There was general agreement that the university prepared students for, and supported them in, clinical practice:

People were surprised how competent we are, even during the second day I was able to administer depot injections for the patients and the medication for all the patients. They were very surprised.” (Student 3)

The university was also seen as a safe place to discuss clinical practice:

You don’t want to look completely stupid in front of them, so it’s quite good to clarify what is and isn’t good practice when you get back to the university.” (Student 5)

Revalidation

All participants knew about revalidation, were able to explain the process and supported the principle. One reported challenges for registrants in practice:

I’ve come across some people in practice that were hating it, absolutely hating it […]. They hadn’t written anything down properly for a long time, so even short essays or short reflections [were] quite hard. And they were finding it really awkward to get all of their time stuff together […]. They were finding it a massive administrative burden.” (Student 4)

One participant questioned whether revalidation should be the individual nurse’s responsibility:

I think if you’re working for an establishment, they should automatically validate you […]. If you’re working for the NHS, surely they should be ensuring that’s happening anyway, and that anybody working for them has met those requirements. And then if they haven’t, then they should be contacting that person to say to them, you haven’t met the requirements.” (Student 5)

Participants were generally aware that registered professionals employed by the university would also need to revalidate, but some did not know how they would do that if they did not work in clinical practice.

Discussion

Key study findings are summarised in Box 3. Participants appreciated that their lecturers had experience of being nurses or midwives, and did not expect them to be totally up to date clinically. This tentatively supports the argument that pre-registration students should, on the whole, be taught by registrants with clinical experience.

Box 3. Key study findings

  • Being taught by registered professionals was important to students, but their lecturers being absolutely up to date clinically was less so
  • Students appreciated hearing their lecturers’ narratives about their experience of clinical practice, which prepared them for placements and gave them hope for their own careers
  • Students felt well prepared for their placements by simulation training and viewed the university as a safe place to discuss issues arising in practice
  • Students experienced a split identity between being a student and being a nurse or midwife
  • Only one student out of five described a definitive gap between theory and practice
  • Students understood Nursing and Midwifery Council revalidation and agreed with the principle, but were concerned about the time it might take to complete the process in practice

Participants also appreciated hearing about their lecturers’ time in practice – the storytelling of their professional and clinical lives (Baldwin et al, 2017). This appeared to help them prepare for practice, which is a difficult task (Grealish and Trevitt, 2005). Storytelling served to instil confidence and hope in participants, and prepare them for difficult situations in clinical practice. They noted that these narratives helped them appreciate what might happen when things did not go well in practice, as noted by Baldwin et al (2017).

While there was limited evidence of a negative effect of a lack of clinical currency on participants’ learning experience, their identity appeared to be split between university and clinical practice. In some ways, they described the same experiences as academic staff in the literature, who report being split between their clinical and academic identities (Logan et al, 2016; Andrew and Robb, 2011). Participants suggested that what formed their identity was their own skills plus the commitment gained from their relationships with other health professionals.

Participants appreciated the preparation for practice that simulated practice provided, and there was little evidence of the clinical practice-induced stress described by Gibbons et al (2008). One participant did report a difference between what was being encouraged in practice and what was been taught in the classroom, but there was no evidence of the view expressed in the study by Clements et al (2016) that clinical skills are more significant than academic skills – a view that puts into question the appropriateness of nurse training taking place in higher education.

There was limited evidence of a gap between theory and practice, and university was recognised as a place where students could discuss aspects of practice about which they were unsure. Participants stressed the importance of having a safe place to raise concerns and ask questions about what they had experienced in practice. This was identified by Walker et al (2014) as an important aspect of how students develop a professional identity. Although this does raise the question of why students feel they cannot query practice while on placement, it reinforces the role of academic staff in helping students to develop their professional identity.

Participants had a good knowledge of NMC revalidation, were able to explain its process and generally supported it. They were concerned, however, about how difficult it may be for registered nurses and midwives to find time for revalidation, and how difficult they might find the written element of revalidation.

Conclusion

This qualitative study had a small sample and can therefore only be regarded as exploratory. Further research with a bigger sample of students from a range of institutions would be useful to test the generalisability of the findings. 

Key points

  • The way student nurses and midwives develop a professional identity has changed
  • Students may experience a split identity between being professionals and being students
  • Students value being taught by lecturers who are registered nurses and midwives
  • Lecturers’ storytelling about their clinical experience can help students prepare for practice
  • Even if they agree with revalidation in principle, students may have concerns about how they will be able to achieve it
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