Literature suggests that recruitment and retention is an international problem in nurse education.
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VOL: 103, ISSUE: 40, PAGE NO: 30-31
Wendy Mayne, MSc, BA, DipHE, CertEd, RGN
Lecturer in professional and community education, University Campus, Hamilton, Scotland
Abstract Mayne, W. (2007) Transition from clinical support worker to nurse. www.nursingtimes.net
BACKGROUND Literature suggests that recruitment and retention is an international problem in nurse education. In Scotland over the last decade, new pathways that acknowledge professional and vocational as well as academic qualifications have widened the entry gate and provided opportunities for unqualified staff to consider nurse training.
AIM: To review the emergence of clinical support staff and to explore the experience of a cohort of non-traditional students as they embark on one such pathway.
METHOD: Using a qualitative approach the study explores students’ experience and measures their performance, recognising motivation and success. It also acknowledges barriers to learning within theory and practice.
RESULTS:The results revealed that students often found the transition from clinical support worker to student to registered general nurse to be both daunting and exciting, and role confusion characterised these transitional stages.
DISCUSSION: The paper discusses the transitional experiences of the respondents, highlighting the effect of socialisation and the importance of student support.
CONCLUSION: Recommendations include:
This group of staff should be recognised within the context of new gateways into pre-registration nursing, in the drive to improve recruitment and retention.
The change taking place in nurse education, and its impact on the transition experience of nursing students, should be recognised.
Over the last few decades, healthcare delivery in the UK has undergone fundamental change (Department of Health, 2006a). Demographic trends, greater diversity within society, advanced technology, inequalities within society and public expectation have all impacted on the NHS. In Scotland key policies such as Building a Health Service Fit for the Future (NHS Scotland, 2005) and Delivering for Health (Scottish Executive, 2005) have influenced the size and composition of NHS staffing, acknowledging the need for a flexible, competent workforce. These echo the recommendations of reports in England such as The NHS Plan (DH, 2000) and Our Health, Our Care, Our Say (DH, 2006b).
Programmes of education such as Project 2000, incorporating the definition of nursing students as supernumerary, and the discontinuation of traditional training and re-training programmes for first and second level nurses have affected recruitment and retention (Stokes and Warden, 2004; Gould, 2004). In the last decade a decline in the numbers entering nursing, together with difficulties in retaining staff, has affected service delivery (Coombs et al, 2003). The predicted decline in young people available for nurse recruitment has materialised due to overwhelming demographic change within society.
The impetus to widen access to pre-registration programmes with flexible entry and exit points has been driven by the changing demographic profile of the nursing student. Non-traditional students have become vital to the profession and have contributed to changes in the profile of nursing students (Houltram, 1996; Kevern et al, 1999). There has also been a growing awareness within hospital trusts of the value of healthcare assistants and clinical support workers (CSWs), and their potential to be used more effectively (Thornley, 2000; Stokes and Warden, 2004).
In an attempt to respond to these issues, the Scottish Executive created an alternative pathway into nurse education for CSWs (unregistered staff who act as assistants to the professional care team engaged in direct patient or client contact – other titles include nursing auxiliaries and care assistants). A programme was designed to help CSWs to prepare for entry into pre-registration nurse education, in which each received £7,500 towards salary costs while completing a one-year HNC course in healthcare. This new route of entry into nurse education was validated by the governing bodies of nurse education in Scotland, and supported by a partnership between the trust, further education and higher education institutions.
The literature suggests that a national increase in the employment of CSWs has occurred for several reasons. The delivery of pre-registration nursing programmes has changed dramatically since the introduction of Project 2000. Nurse education entered higher education and nursing students, previously responsible for a high proportion of direct patient care, now follow a three-year university-based programme. As a result of this restructuring and the introduction of supernumerary status of nursing students, the UKCC introduced a new category of support worker known as a healthcare assistant to work under supervision of trained staff, and to engage in ‘non-nursing tasks’ (Stokes and Warden, 2004).
Difficulties concerning the recruitment and retention of nursing staff are well documented (Glossop, 2002). The number of prospective students is dwindling; studies demonstrate that young people are no longer attracted to nursing due to its negative public image, poor working conditions and low pay. They also have a wider range of professions open to them and trends demonstrate that the number of actual and potential applicants to nursing is diminishing. In 1990, 25% of women with appropriate qualifications entered nursing (Firby, 1990), while a seminal study in 1997 revealed that only 11% of women chose a career in healthcare, of which most chose medicine over nursing (Hemsley-Brown and Foskett, 1997). More recently, statistics demonstrate that almost half of students in pre-registration education are aged over 26 (Nursing and Midwifery Admissions System, 2003).
Research suggests that retention of nurses is also problematic. UK studies demonstrate that the ‘reality shock’ described by Kramer (1974) still exists. MacLeod-Clark et al (1996) and Jowett et al (1994) suggested that newly qualified nurses lack practical ability and are unprepared for their role, which may pre-empt decisions to leave the profession. There is also evidence that a significant number of trained staff would leave the nursing profession if they could (Unison, 2000). Buchan and Secombe (2005) argued that the UK nursing labour market is facing a testing and unclear future.
Role expansion of nurse practitioners has also affected the increase in demand for unqualified staff (Withers, 2001). The European Working Time Directive now limits junior doctors’ working hours in an attempt to reduce sleep deprivation errors, and as a result, nurse practitioners have taken on a range of new tasks. Support workers are meeting patients’ care needs in an attempt to redress this balance and fill the gap in care delivery in a cost-effective manner. In a study by Thornley (1997), managers ranked cost-effectiveness as the first criterion for introducing healthcare assistants. The Performance and Planning Framework 2003–2006 (DH, 2004) included a target of 27,000 more healthcare assistants to be working within the NHS by 2005.
Combined research methods were used to provide rich data and a deep understanding of the lived experience of the student cohort. Questionnaires and a focus interview were used by the researcher, a lecturer with a responsibility for admissions within the school, to provide qualitative data. This was supported with quantitative data obtained from analysis of placement reports and theory assessments. This study acknowledges the phenomenological point of view that people interact with their environment, they are connected to each other and to their environment. A case study approach was used to support this research philosophy, combining qualitative and quantitative tools to provide insight and meaning to the student experience.
A pilot study was carried out using a previous student cohort to evaluate the research tool and identify potential problems in the design of the questionnaire, data collection and analysis. Questionnaires (Fig 1) were sent to eight students by internal post and seven completed questionnaires were returned. The same seven students took part in the focus group interview, which was facilitated in a non-threatening way, encouraging the participants to talk freely and honestly. A list of prompts devised from the questionnaire responses was used to suggest areas for discussion. These included the year spent in further education, the dual role of student and CSW, personal view of self (student vs CSW) etc. A scribe recorded the conversation, and the discussion was recorded on an audio tape.
Quantitative analysis of assessment in theory and practice for these students was carried out to add quantitative data to the study. The sample was necessarily small due to resource constraints.
Thematic content analysis was used to produce a detailed and systematic note of themes and issues that arose from both the questionnaires and the focus group interviews in a clear categorised way. Theory results for each participant were recorded, and two placement reports for each participant were summarised.
The biographical data suggests a mature student cohort, predominantly female, working in care.
The data revealed that students found the transition from CSW to student to registered nurse both daunting and exciting. Three were undertaking the course because they had an enduring career goal to become a registered nurse, while three said they enjoyed their jobs as CSWs but felt they were marking time; the secondment offered them the possibility to progress in their career.
However, the group also expressed fear of failure. They were concerned about whether they could ‘cope with the academic workload’ and adjust to college life generally. The effects of study on family life were a worry, and time was a significant issue for a student who would have to spend extra hours in the workplace to achieve required learning outcomes. Two other respondents indicated apprehension about giving up a secure job which was safe and familiar, coupled with the fact that they were embarking on a venture without knowing whether they would be successful.
The transitional experience as students within the further education college was described as enjoyable and valuable:
‘A good grounding for the next stage of the course … and great friends who always provide support.’
This was enhanced by the academic support and advice they received from lecturing staff in both further and higher education.
The students’ transitional experience was characterised by phases of socialisation into a variety of roles.
‘As a CSW I knew my role. As a student nurse I have to be responsible for my learning in order to improve my learning, knowledge and experience.’
This swing in self-perception was used to explain problems experienced by one student while in the clinical placement:
‘It is difficult at first to pull away from that role and push yourself as a student…’
Both the questionnaires and the focus interview revealed that respondents felt a lack of ‘student status’ in the workplace, which meant they did not receive the learning opportunities they required or hoped for. This contributed to a blurring of roles which impacted on their learning experience to varying degrees. All the students stated that this confusion about their role diminished once they were recognised as ‘nursing students’. As students from the higher education institution, three commented that they received reflection time, in accordance with the requirements of their course.
The questionnaire responses also suggested disparity in the students’ perception of themselves as nursing students as opposed to CSWs. They felt they had more time to ask questions, and more confident to ask questions, and three identified that this questioning was indeed part of reflection.
‘As a student you learn from doing and reflecting on good and bad.’
In the focus interview another commented that there was more time to reflect on why things were done, and a third student identified that this was the way in which students take responsibility for their own learning.
There was confusion concerning the boundaries and expectation of this role, however. The CSWs were not able to transfer some skills from one role to another. The participants expressed difficulty adjusting to their role as nursing students, particularly breaking the habits they had developed as CSWs. One commented that they found it difficult to ‘leave the floor, there was always something else to be done,’ in terms of attending to patient need at an auxiliary level. The years of experienceas CSWs meant this conflict of expectation was difficult to resolve.
Conversely, this familiarity of role was also given as an explanation for why five students found the clinical placement easy – they were familiar with the environment and routine.
Support was also discussed in both research tools in relation to the clinical learning environment.
‘My mentor involved me in as many experiences as was possible … the staff and my mentor were extremely helpful.’
The role of the mentor has developed and is used to facilitate students’ socialisation and provide personal support during the transitional experience.
‘I worked in the community for 11 years. I was unsure of the wards at first, but the staff and my mentor made the change of setting easy to work in and I soon learned the way the wards were run.’
The respondents felt they were encouraged to reflect on experiences they may have encountered for the first time, such as terminal illness, abuse or extensive trauma, and were supported by their mentors:
‘There was more time to learn new skills and experiences … I was offered more explanations about diagnosis and treatment.’
The focus group unanimously described the academic demands of the course as difficult, although all acknowledged that they were easier to organise now they were full-time students. The seven students passed all six assessed modules, giving a pass rate of 100%. The overall pass rate of the complete student cohort for this semester was 93-99%. All seven students received favourable placement reports in both clinical areas on completion of semester 3 of the higher education programme, when the study was carried out. The reports were completed by a variety of link lecturers and mentors in the placements, but there was a clear consensus about the students’ qualities and skills.
The reports of all seven students contained references to their ability to work as team members, highlighting that they could also work under their own initiative. Six were noted for their keenness to learn, and eagerness and enthusiasm were also commented on. Maturity was mentioned in relation to three students, a quality often linked in the reports to professionalism. Five students’ communication skills received comment, and six reports discussed the students’ sound demonstration of insight and the ability to link theory to practice.
Transition in general is exciting, overwhelming and confusing. The move from one role to another, one status to another, one function to another involves a series of complex behaviours marked by a variety of emotions. In nursing the transition from student to registered nurse is often ill-defined (Holland, 1999), and this experience is blurred by characteristics of nursing such as dual roles, students’ supernumerary status, and the hierarchical sequence of gaining skills and knowledge (White and Ewan, 1991). Change in the design and delivery of nurse education has also affected nursing students’ transition experience, creating a friction between the demands for academia and academic attainment and the day-to-day reality of nursing (Kelly, 1996; Rolfe, 1996).
Studies have found that in order to cope with transition, students need a framework that supports their journey towards acceptance into and by the profession (Delaney, 2003). This process, known as socialisation, was defined by Dingwall (1977) as: ‘A process by which newcomers to a group worked to make sense of their surroundings and came to acquire the kinds of knowledge which would enable them to produce conduct which allowed established members of that group to recognise them as competent.’
Many writers have described socialisation as sequential, involving clearly identified stages (Glaser and Strauss, 1971; Turner, 1982; Bradby and Soothill, 1993). These are usually characterised by experiences of separation, transition or social limbo, and incorporation. Windsor (1987) used Van Gennep’s (1960) model, labelling the three stages as becoming a nursing student, being a nursing student, and becoming a qualified nurse. Others have attempted to stress the deterministic view of socialisation within nursing (Melia, 1987), believing that students are active in the process not passive.
The confusion and lack of clarity regarding the role of unqualified staff is well-documented in several studies and underpins this research. The findings appeared to support these studies, demonstrating confusion and lack of clarity regarding the role of CSWs in their place of work where they also functioned as students, and this confusion impacts on the socialisation process. The role of CSW is seen to be the provision of patient care under the supervision of qualified staff (McKenna and Hassan, 2002). Other writers acknowledged the overlap between the roles of CSWs and qualified staff, recognising the CSWs’ contribution to patient care, evidenced by patient and staff satisfaction (Gould, 2004; Chang, 1998; Ramprogus and O’Brien, 2002).
The research findings demonstrate that this role confusion is implicit in the range of tasks and nursing activities carried out by the respondents in the roles of CSW and nursing student. All stated that this confusion diminished once they were recognised as ‘nursing students’. This coincided with a passage to another stage of the socialisation process marked by acceptance of and into the profession.
This dissonance, or discord, concerning socialisation was explored by Wood (2006), who investigated the experiences of healthcare assistants seconded into nurse training. Their transitional experience was impeded by this confusion concerning the roles and responsibilities of the support workers. This was demonstrated by mentors and colleagues’ high expectations of the students due to their previous care experience, and the juxtaposition of competence as a worker and learning as a student.
Despite this difference in perceiving the nature of socialisation, all writers concurred that it exists and is potentially stressful for those concerned (Holland, 1999; Delaney, 2003).
Mentorship has been identified as a key process in supporting nursing students through the process of socialisation (Kenny et al, 2004) and is crucial in minimising the stress they experience in the clinical environment. The role of the mentor is to facilitate students’ socialisation and provide personal support during this period, to ease the transition from learner to practitioner (Kramer, 1974).
The dynamic nature of nursing, extended roles and the emphasis on efficiency and effectiveness has increased the intensity of nursing and accentuated the potential for ‘reality shock’ in the clinical environment. The ENB and Department of Health (2001) suggested that mentors have a responsibility to facilitate student learning, supervise, support and guide students in practice, implement approved assessment procedures and assess competence.
The biographical details of this group of students support the findings of Thornley (1997). The cohort was predominantly female, aged 31–40, and some working full-time. The characteristics of these support workers match the two prerequisites for academic success identified by Kevern et al (1999), namely mature women with care experience.
The research indicated that these seven students had a wide variety of care experience, a strong motivation and readiness to learn, and were beginning to develop a problem-solving approach to their learning, which are well-known characteristics of adult learners (Knowles, 1990). These qualities were also noted in clinical placement reports by a variety of mentors and link lecturers. Student-centred learning was encouraged during their placement experience, and the students were encouraged to focus on the process of learning rather than the product of learning. Learning contracts with identified objectives were used to link theory and practice, and to demonstrate transfer of knowledge to practice.
This study aimed first to identify the CSWs’ transitional experience as nursing students in nurse education, and second as nursing students in the clinical setting. The third aim was to evaluate their performance on the adult branch programme in theory and clinical practice. The rich data provided by the case study approach suggests the following conclusions:
The current plethora of change within design and delivery of nurse education has affected the transition experience of nursing students;
A framework of support and mentorship is necessary to facilitate socialisation and transition;
The confusion and lack of clarity regarding the role of ‘unqualified staff’ in the NHS affects transition;
CSWs are motivated and enthusiastic and perform well in theory and practice;
The transition experience of CSWs is different to that of traditional students due to their unique experience and nature.
The literature review clearly indicates a difficulty in meeting CSWs’ training and educational needs. This is discussed within the study against a backdrop of a national agenda of lifelong learning and recruitment and retention strategies. The research reflects this initiative as an example of managers valuing staff and rewarding motivation, and providing an opportunity for their personal development. A future study could focus on this motivation and commitment, evaluating these qualities in the newly qualified staff returning to practice.
The literature acknowledges the characteristics of successful learners on nurse education programmes. This study indicates similar characteristics as features of the case study, and evaluation of theory and placement results indicates a successful performance by the respondents. This success can be seen as support for the growing number of gateways into pre-registration nursing, widening access and addressing the social inclusion agenda. Further study could investigate whether this is true of other cases on similar courses.
Role conflict and its impact on socialisation has been a dominant theme in the literature and throughout the study. The literature discusses the confusion surrounding the CSW role, concluding that the benefit of employing support staff should be weighed against the difficulties of delegation, supervision and training. The research also demonstrates role confusion between student and CSW. This should be addressed by small practical changes such as standardising uniform, ensuring CSWs have parity of learning opportunity, and appropriate facilitation and mentoring within the clinical areas. Recognition of the role of CSWs is fundamental to an attempt to address recruitment and retention, and should be supported by a structured, standardised approach to the provision of equal opportunities for unqualified staff.
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