delegation and supervision of health care assistants’ work
TRANSCRIPT
Delegation and supervision of health careassistants’ work in the daily management
of uncertain and the unexpected in clinicalpractice: invisible learning among newly
qualified nursesAllan, H, Magnusson, C, Evans, K, Ball, E, Westwood, S, Curtis, K, Horton, K and
Johnson, M
http://dx.doi.org/10.1111/nin.12155
Title Delegation and supervision of health care assistants’ work in the daily management of uncertain and the unexpected in clinical practice: invisible learning among newly qualified nurses
Authors Allan, H, Magnusson, C, Evans, K, Ball, E, Westwood, S, Curtis, K, Horton, K and Johnson, M
Publication title Nursing Inquiry
Publisher Blackwell Publishing
Type Article
USIR URL This version is available at: http://usir.salford.ac.uk/id/eprint/39450/
Published Date 2016
USIR is a digital collection of the research output of the University of Salford. Where copyright permits, full text material held in the repository is made freely available online and can be read, downloaded and copied for non-commercial private study or research purposes. Please check the manuscript for any further copyright restrictions.
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INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES 1
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Authors’pre-publicationmanuscriptofacceptedpaper:
Allan,HelenT.andMagnusson,CarinandEvans,KarenandBall,ElaineandWestwood,SueandCurtis,KathyandHorton,KhimandJohnson,Martin(2016)Delegationandsupervisionofhealthcareassistants’workinthedailymanagementofuncertainandtheunexpectedinclinicalpractice:invisiblelearningamongnewlyqualifiednurses.NursingInquiry.ISSN1320-7881(Accepted/Inpress)InvisibleLearning15072016accepted.pdf
Abstract
The invisibility of nursing work has been discussed in the internationalliterature but not in relation to learning clinical skills. Evans and Guile’s(2012)theoryofrecontextualisation isusedtoexploretheways inwhichinvisible or unplanned and unrecognised learning takes place as newlyqualifiednurses learntodelegatetoandsupervisetheworkof thehealthcare assistant. In the British context, delegation and supervision arethoughtofasskillswhicharelearnt ‘onthejob’.Wesuggestthat learning‘on-the-job’ is the invisible construction of knowledge in clinical practiceandthatdelegation isaparticularlytellingareaofnursingpracticewhichillustratesinvisiblelearning.UsinganethnographiccasestudyapproachinthreehospitalsitesinEnglandfrom2011-2014,weundertookparticipantobservation, interviewswith newly qualified nurses,wardmanagers andhealthcareassistants.Wediscusstheinvisiblewaysnewlyqualifiednurseslearn in the practice environment and present the invisible steps tolearningwhichencompass theembodied, affectiveand social, asmuchasthe cognitive components to learning.We argue that there is a need forgreater understanding of the ‘invisible learning’ which occurs as newlyqualifiednurseslearntodelegateandsupervise.Key words: newly qualified nurses, delegation, invisible learning,preceptorship
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES
Delegationandsupervisionofhealthcareassistants’workinthedailymanagementofuncertainandtheunexpectedinclinicalpractice:invisible
learningamongnewlyqualifiednurses
Theinvisibilityofnursingandcaringhasbeenconsideredintheliterature(Allan,
2002;Strauss,Fagerhaugh,Suczek&Wiener,1982;Wilkinson&Miers,1999)before.
Suchworkhastendedtofocusontheinvisibilityofnursingatthestructurallevelasa
feminisedoccupation(Gamarnikov,1978;Oakley,1993),orattheepistemologicallevel
whereitisargued,theknowingattheheartofnurses’workisoverlookedinfavourof
biomedicalknowledge(Allan&Barber,2005;Bjorklund,2004;Miers,2002).We
discussanaspectofinvisiblenursingwork,namelytheinvisiblelearningnewly
qualifiednurses(NQNs)engageinwhenlearningtodelegatebedsidenursingcareto
healthcareassistants(HCAs)andsupervisetheirperformance.Thedelegationofcaring
workbynursestoHCAshasevolvedovertimeandbedsidecareislargelyundertaken
byHCAs(atleastintheUK)(Francis,2013);yethownurseslearntodelegateand
supervisethisaspectofbedsidecareremainsaninvisiblepartofboththenursing
curriculumandpractice.Webuildonideasaroundtheinvisibilityoffeminisedworkin
nursing(Oakley,1993)andthedevaluationofbedsidenursingcare(Allan&Barber,
2005)todrawattentiontoinvisiblelearningoftheseformsofworkbynursesasthey
delegatetoandsuperviseHCAs.Thisinvisibleworkissometimesreferredtoas
comprising‘soft’,interpersonal(Bolton2004)skillsbasedon‘personalattributes’
(Windsor,Douglas&Harvey,2012);invisibility,femininesoft,personaland
interpersonalskillsarefrequentlyconflated.Thelearningoftheseskillshasnotbeen
studiedinnursing,anddelegationandsupervisionappearnottobetaughtorassessed
inthecurriculumorinclinicalpracticetothesameextentasotherskills.
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Inthispaper,weaddressthisgapintheliteraturetoconsiderdelegationand
supervisionofHCAsbynewlyqualifiednurses(NQNs)anddiscusstheirinvisible
learningastheybegintodelegateandsuperviseHCAs’work.Wedrawonempirical
datafromethnographiccasestudies(Magnusson,Horton,Curtis,Westwood,Ball,
Johnson,Evans&Allan,2014).
Literaturereview
Invisiblelearninghasbeendiscussedinrelationtothehiddencurriculumwhich
entailsthe‘processes,pressuresandconstraintswhichfalloutside…theformal
curriculumandwhichareoftenunarticulatedorunexplored’(Bignold&Cribb,1999;
24).Ithasalsobeenusedtodescribeasetofinfluencesthatfunctionatthelevelof
organisationalstructureandcultureincluding,forexample,implicitrulesforhowto
survivetheinstitution,suchascustoms,rituals,andtakenforgrantedaspects(Lempp&
Seale,2004).AccordingtoBjørnavold(2000)unplannedlearninginworksituationsis
invisibleinthesensethat‘itisdifficulttodetectandappreciate’;andthatmuchof
‘know-how’isinvisiblylearntthroughpracticeandthroughpainfulexperience.Wehave
arguedinapreviouspaperthatknowledgerecontextualisationdelineatesthewaysin
whichpreviouslyinvisibleandinter-relatedknowledge,knowledgewhichisunplanned
andunrecognised(EvansGuile,Harris&Allan,2010).Inthispaperwearguethatthis
learning,ifreflectedupon,becomesexplicitandlinkedforNQNs,enablingthemto
developconfidenceintheirabilitytomanagethestaffwithwhomtheywork
(Magnussonetal.,2014).Ourworkhascontributedtoadiscourseontherelationship
betweentheoryandpracticebycritiquingtheideaofknowledgetransferand
suggestingtheuseofrecontextualisationofknowledge.Here,wedevelopthis
perspectivefurther,toexplorethewaysinwhichinvisiblelearningtakesplaceasNQNs
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES
encountertheuncertainandunexpectedastheylearntomanagepatientcareinclinical
areasthroughthedevelopmentoftheirdelegationandsupervisionskills.Indoingsowe
developanempiricallybaseddescriptionofinvisiblelearninginNQNs’practiceof
delegationandsupervision;onewhichcapturestheinvisible,unrecognisedand
unplannedstepstolearningandwhichencompassestheembodied,affectiveandsocial,
asmuchasthecognitive,componentstolearning.Wedescribefoursteps:1)learning
throughmistakes;2)learningfromdifficultexperiences;3)informallearningfrom
colleagues;and4)‘muddlingthrough’toillustrateinvisiblelearning.Wearguethat
invisiblelearningwasobservedamidstthepressuresandconstraintsofworkingina
teamwhichreliedheavilyonHCAs(Magnussonetal.,2014),andtherulesandrituals
(Allan,Magnusson,Ball,Evans,Horton,Curtis,&Johnson,2015)andexpectationsof
NQNs(Johnson,Magnusson,Allan,Evans,Ball,Horton,Curtis&Westwood,2014)which
formedanintegralpartoftheworkplaceculture.
ThisarticlereportsononeaspectofawiderUKresearchproject(Magnussonet
al.,2014)whichexploredhowNQNsrecontextualiseknowledgelearnedduringtraining
topracticeasaqualifiednurse.Akeythemewhichemergedfromthestudywas
‘invisiblelearning,’aninformallearningprocessdistinctfrommoreformallearning
mechanisms.Aparticularareawhereinvisiblelearningwasobservedwasnurse
delegationto,andsupervisionof,HCAsinperformingbedsidenursingcare.While
delegationandsupervisionofnursingcarearecrucialtothesafe,effectiveandefficient
deliveryofbedsidecare,andfailuresinsuchworkcanresultinriskstopatientsafety
andpatientoutcomes(Anthony&Vidal,2010;Standing&Anthony,2006),thisisthe
firstobservationalstudyoflearningtodelegateandsupervise.
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Despitetheincreasingrelevanceofdelegationandsupervisionfortheroleofthe
modernnurse(Gillen&Graffin,2010;Standing&Anthony,2008;Weydt,2010),these
skills do not form a central component of undergraduate nurse programmes or
preceptorshipprogrammesintheUK.Thesewereintroducedtosupportthetransition
fromstudent toregisterednurseusually in the first sixmonthsofqualifying (Hasson,
McKenna&Keeney, 2013). Preceptorship programmes are variable across individual
clinicalsettings(deWolfe,Perkin,Harrison,Laschinger,Petersen&Seaton,2010)with
aprogramme lasting frombetween twoweeks inonehospital tooneyear inanother
and NQNs entitled to one week of supernumerary practice to one month. The
preceptorshipphasecanbearealityshock(Hollywood,2011)withmanyNQNsfeeling
asiftheyhavebeen‘throwninatthedeepend’(Whitehead&Holmes,2011,19),leftto
‘sinkorswim’(Hughes&Fraser,2011,382)or‘fumblealong’(Gerrish,2000,473).Itis
therefore important to understand how NQNs make sense of (recontextualise)
knowledgelearntintheuniversityastheybegintheirnewroles,andalsotointerrogate
whether the knowledge taught serves NQNs’ self-perceived needs. This process of
learninginnewcontextsissometimesreferredtoasknowledgetransferorknowledge
translation(Kothari,Bickford,Edwards,Dobbins&Meyer,2011)thatis,thetransferof
knowledge taught inuniversity todifference clinical settings.However the conceptof
knowledgetransfer(KT)iscontentious(Evans&Guile,2012;Kotharietal.,2011)with
Kothari et al., (2011) suggesting that learners use an interaction-based approach to
knowledgetransferratherthanasimplesingleactoftransfer.Ithasbeensuggestedthat
‘invisiblelearning’canplayanimportantroleinnurses’informallearning(Eraut,2004)
andcanbecentraltowhether,andhow,NQNsareabletomakethesuccessfultransition
duringpreceptorship(BjørkTøien&Sørensen,2013).
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We draw on Evans and Guile’s work (2012)which stresses a new approach to
understandingprofessionalknowledge, “onewhichconcentratesondifferent formsof
knowledge including those manifested in ‘skills’ and ‘know-how’ and embedded in
communities aswell as propositional knowledge” (2012, 245). This is not knowledge
transferredbutknowledgerecontextualised.EvansandGuile(2012)haveshownhow
curriculumdesigners recast disciplinary knowledge (from its disciplinary origins) and
workplace knowledge (from its professional and/or vocational contexts) and combine
theminlearningprogrammes,tolaythefoundationsforknowledgeablepractice.Inthe
classroom,teachersmaychoosepedagogicstrategies,suchas ‘real life’casestudiesor
problem-based learning topre-figure thedemandsofpractice fornewentrants (or to
simulate new situations through ‘learning labs’ for experienced workers). But, most
importantly, knowledgeable practice develops through learning in and through the
workplaceitself,throughobservationofothers;throughmentorship,coachingandpeer
learning and by drawing on new ideas and experiences accessed through work and,
often, beyond work. Timetabled sessions and instruction in nursing preceptorship
programmescanintroducecodified,proceduralandworkprocessknowledgebutunlike
disciplinaryorsubjectknowledge,wherethereareclearcriteria leadingtothegoalof
greater abstraction and depth in understanding, there are few rules about how to
structureandsequencethecontenttowardsthegoalofknowledgeablepractice,asthe
latter depends on invisible learning. The invisible learning is often triggered by the
activity and the context. Knowledge recontextualisation takes place when the NQN
recognises anewsituationas requiringa responseandusesknowledge– theoretical,
proceduralandtacit-inactsofinterpretationinanattempttobringtheactivityandits
settingunderconsciouscontrol(vanOers,1998).Whentheinterpretationinvolvesthe
enactment of a well-known activity in a new setting, an adaptive form of
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recontextualisationtakesplaceasexistingknowledgeisusedtoreproducearesponse
inparallelsituation.Wheretheinterpretationleadsthelearnertochangetheactivityor
itscontextinanattempttomakearesponse,aproductiveformofrecontextualisation
takes place, as new knowledge is produced. Knowledge recontextualisations are
fundamental toworkers beginning to enact existingworkplace activities; orworking
withexperiencedotherstomodifychangetheminthefaceofunexpectedoccurrences
or the need to find new solutions. In the clinical context, forms of knowledge are
embedded in routines,protocolsandartefactsaswellas inorganisationalhierarchies
and power structures (Allan et al., 2015; Evans et al., 2010). As well as learning to
participate inworkplace activities and to useprotocols and artefacts, newly qualified
practitioners use work problems as a further ‘test–bed’ for theoretical and subject-
basedknowledge.Thisisfacilitatedwhenworkplacescreatestretchingbutsupportive
environmentsforworkingandlearningandlearnerstakeresponsibilityforobserving,
inquiringandacting.Learners,throughaseriesofsuchknowledgerecontextualisations,
come to self-embody knowledge cognitively and practically. This is a process that is
invisibleinthesenseintroducedearlier,asitisdifficulttodetectandappreciate.
Methods
Our research aimwas to understand howNQNs recontextualise knowledge to
allowthemtodelegateandsupervisenursingcareonthewardswhenworkingwithand
supervising healthcare assistants. Ethnographic case studies (Burawoy, 1998) were
conductedacrossthreehospitalsitesselectedformaximumvariability(seetable1).
<PleaseinsertTable1aroundhere>
Ethical approval was obtained from the National Health Service Research
Authority (NRES), each participating hospital research and development committee,
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES
andeach teammember’suniversity ethics committee.The research teammet toplan
sharedobservationandinterviewschedules;datawerecollectedbyallmembersofthe
research teamthroughparticipantobservations(approximately230hours)andsemi-
structured interviews,withNQNs,HCAs, andWardManagers/Matrons.Observations
werelocatedinhospitalwards,followingaNQNforashiftass\heworkedwiththeHCA
assigned to the same group of patients and in particular focusing on their delegation
andsupervisionpractices.Observationsincludedallnursingactivitiesundertakenona
shift fromarrangingdischarges,washingand toiletingpatients tomakingbeds,doing
thedrugroundsandwritingupnursingnotes.Shifts includednightshifts,handovers,
andtransferofpatientsbetweenclinicalareas;threeteammemberswhowerenurses
worked alongside NQNs as participant-observers while two non-nurse observers
maintaineda fullyobserverrole.Asmuchaspossible, interviewswithNQNs followed
observations of those sameNQNsworkingwith HCAs and interviewswere also held
with theHCAs they hadworkedwith and theirwardmanagers. (See Table 2 for full
detailsofdatacollection).Staffwereinvitedtoparticipatebyletterandwereconsented
toparticipatebeforeeachobservationandinterview.Patients,whilenotthefocusofthe
research,wereconsentedtoparticipateintheobservations.
<PleaseinsertTable2aroundhere>
Observationsnotesand interviewsweretranscribedverbatimbya transcriber.
Datawere analysed using thematic analysis (Guest, MacQueen & Namey, 2012) both
manuallyandwiththequalitativesoftwareNVivobyoneresearcherandthenrawdata
andthemessharedattwodataanalysisworkshopswithalltheresearchers.
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Findings
Our findings highlight the importance of both visible and invisible learning to
NQNs.Visiblelearningwasevidentintime-tabledpreceptorshipactivities,assessments
andmentorship.However,asweobservedNQNsacrossthreehospitalsforsubstantial
periods(230hours),weobservednumerousexamplesofinvisiblelearninginpractice,
aswell as examples of visible, formal learning.According to our analysis, this largely
invisible learning took four main forms: learning through mistakes; learning from
difficultexperiences;informallearningfromcolleagues;and‘muddlingthrough.’
Learningthroughmistakes
The NQNs encountered unexpected situations on a daily basis, and as part of
recontextualising knowledge learnt at university, they also learnt through making
mistakes.ThefindingsdemonstratethattheNQNsmademistakesrangingfromminor
tomoreserious,andthatthiswasconstantlyontheirmindsastheywerechargedwith
takingonmoreresponsibility:
I think you learn from your own mistakes and other people’s mistakes as well
because youknow, there’s a lot of ‘this couldgowrong, this couldgowrong’ but
whenlikeyou’reactuallyfacedwithityourselfyousortofrealiseitandit’sthelittle
thingsthathappenlikethatcauselikeabiggererrorandthenthat’sityouhaveto
takeastepbackthenandthink‘god,whatelsecouldgowrong?’(SiteANQN14)
WardmanagerswereawarethatmakingmistakeswasapartoflearningforNQNs.On
wards where nurses felt well-supported, there were strategies which provided them
withasafetynetduringthisperiodof‘trialanderror’asthiswardmanagersuggests:
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES
I’mnotgoingtoletyoumakeamistake,…..soit’sabouthavingsafechallenge,it’s
aboutifIseeyoudoingsomethingwrongI’mgoingtellyaandI’mnottellingyouto
getatyouI’mtellingyoubecauseoneIdon’twantyoutohurtthepatientsandtwo
Idon’twantyouasaperson tomakeamistakeand it’sabouthaving that safety
backup(SiteAwardmanager3)
Thisextracthighlightstheapproachofwardmanagerswhopracticeda‘safechallenge’
strategywhichempoweredNQNstotalkopenlyaboutwhenthingsnearlywentwrong;
in a sense thesewardmanagers carried the burdenwith them and supported them.
Allowing health professionals to reflect and learn from patient safety incidents is
supportedbycurrenthealthcarepolicy.However,so-called ‘blameandshame’patient
safety cultures are still common in healthcare organizations which obstruct the
possibilityoflearningfromerrors(Feng,Bobay&Weiss,2008).Onwardswherethere
wasa ‘safe challenge’ approach,NQNs feltmoreable to learn frommistakes ina safe
way:
Ifyoukeepthinking‘I’mgoingtomakeamistake’thenyouwillmakeamistakebut
Iknowthesupport’salwaysthereandthesupportworkersandtheHCAshereare
reallygoodso, Iknowthat if Iwas, if I’daproblemthat there’s themandthere’s
othernurses intheotherteamsaswellso IknowIcangotothem,so Iknowthe
supporthereisreallygoodonthisward.(SiteANQN12)
But in some cases, where a mistake had been made and an even more serious one
averted, the learning was painful as this nurse describes. She had relied upon a
healthcareassistanttocheckthatthepatientgoingtotheatrehadthecorrectnameon
thewristband,andconsequently,hadsignedoffthepaperwork.
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I’ve had lessons along theway that Iwon’t trust themagain to, to do something
correct,yeah,becauseI’velearntthehardwayreally…theanaesthetistcameback
andtheysaid‘thepatienthadawrongwristbandonherleg’,‘shehadthepatient’s
nameofanotherpatientonher leg’andthecareassistanthadput[it]onher leg
andIhadn’tdoublecheckedit(SiteBNQN2)
Amistakehadobviouslybeenmade and a seriousuntoward event reportwas raised
againstthisnurse.Sheexpresseddeepregretaboutthis incident,butfeltthatshehad
learntandwouldnevermakethesamemistakeagain.Theriskofunsafemistakescan
beprofound,forbothpatientandnurse,aswashighlightedbythiswardmanager:
I’veworked in other placeswherenewly qualifiednurses because they’veworked
thereastheirlastplacement,peopleseeitasanautomatictransitionthattheywill
justcomeinandfitontheoffdutyandbeaqualifiednurseallofasudden…that
willknocktheirconfidencecompletely if theypickupbadpracticesstraightaway,
they’ll start cuttingcorners, theywon’tdeliveronwhat’sbeenaskedof themand
they’llfail,youknowandwearesettingthemuptofailifwedothat,soabigbelief
ofmineistoembedwhatthey’velearntinthelastthreeyearsandtryandsortof
easethemintothat,youknow,andembedgoodpracticefromthebeginningreally.
(SiteAwardmanager1)
Wesuggest thatgoodsupport structuresat the levelof thewardwerecrucial for the
NQNs as they navigated through their new status as staff nurses with its attendant
greater responsibly and higher levels of authority. It was evident that the risk of
makingmistakesandpotentiallyharmingpatientsmadeNQNsscared,andforsomethe
emotionalburdenwassogreatthattheymovedintodenial:
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Likefear,likeyou’restraightawayscaredandthenlikeyoufeelbadifthepatients’
beenhurtandthenif,anythingworseIdon’tthink,Ican’tthinkaboutit,because
causingharm to a patient that’swhatwe’re not supposed to do,we’re to do the
oppositesoifyoudocauseharmevenifit’sjustbymistakeit’snot,its,Ijustdon’t
wanttothinkaboutitreally.(SiteANQN14)
Learning from mistakes can be a powerful learning tool where knowledge may be
effectivelyrecontextualisedfrompracticeexperiences.Howeverourfindingsindicated
that experiential learning can also be traumatic, particularly if there is little or no
reflective space and can, in turn, produce poor practice ‘cutting corners’. It can also
resultinpatientsafetybeingcompromised.
Learningfromdifficultexperiences
Our findings suggest that some of the NQNs were under-prepared for
particularly demanding situations, including major emergencies, and the deaths of
patients. Experiencing such situations, coming to terms with them, and developing
confidenceintheabilitytohandlethem,arecrucialtotheNQNs’successfultransitionto
qualifiednurse:
A lot of student nurses have never been exposed to cardiac arrest, so in that
situationthenursesstrugglebecauseitisadifficultsituationandit’snotonethat
youhavealotofthetime[with]…(SiteCwardmanager4)
Ihadmy firstcardiacarrestacoupleofmonths,wellat leastacoupleofmonths
agonow,butitsounds,thissoundsawfulbutbecauseI’vehadthatI’mnotscaredof
ithappeningagainnow.(SiteBNQN9)
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ThesetwoextractshighlightthesignificanceofNQNsencountering,andlearningtocope
with,cardiacarrests,andhowtheexperiencingofsuccessfullydealingwithonecanbea
significantconfidence-builder.HoweverforsomeNQNsamajorincidentwhichdoesnot
have a successful outcome, and/orwhere there has been inadequate support, can be
traumaticasanobservationfield-notesuggests:
NQNtellsmesheisnervouswhenlightsareoffinbayatnightbecauseshecan’tsee
thepatients.Shewouldliketohavethelightonbyeverybed.Butluckilythepatient
withatrachy[eostomy]whichneedsclearingisbyawindowandlightison,good.
Sheexplainstomethatthispatientcoulddieifshedoesnotlookafterherproperly
–bigresponsibility.Shealsotalksaboutsomethingthathappenedlastyearwherea
youngpersondied inher sleepduring thenightwhen itwasdark. Iasked if they
knewwhypatientdied.Nursesaysheneverheardaboutthecauseofdeath.(SiteA
obs1)
ItwasevidentthatthelackoflightinthenightmadethisNQNveryanxious,asshefelt
that she could not effectively observe the patients in her care. She used a torch to
illuminatethefacesofpatientsasshewalkedaroundthebedsinthedark.Inaddition,
sheassociateddarknesswiththedeathofanotheryoungpatientwhohadsadlydiedon
herward and thisworriedher. TheNQNexpressed fear that this couldhappen again
withoneofherpatients.Whatappearstohavebeenamajorfactorforthenursewasnot
justthepatient’sdeath,butalsonotknowingwhythepatienthaddied,andnothaving
hadtheopportunitytodebriefaboutitafterwards.
ThedatasuggestthatgoodsupportstructuresatwardlevelarecrucialforNQNs
duringtheirpreceptorshipperiod.Itwasevidentthatmajoreventshadthepotentialto
eitherbuildorundermineconfidence,dependentuponboththeoutcomeandalsohow
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theincidentwasdealtwith,andwhethertheNQNwassupportedinmakingsenseofthe
experience,orinotherwords,recontextualisingknowledge.
Informallearningfromcolleagues
Our analysis suggests that invisible learning with and from colleagues takes
three main forms: observation, informal discussion, and ‘osmosis’ (unconsciously
absorbingpractice styles and skills fromothers).Thisnursedescribeshowmuch she
learnedfromwatchingapatientbeingtoldshehadaterminalcondition:
Yeah,andIwatched,Iwasinoncewithaladywhowasmypatientandshe’djust
been told that she had terminal bowel cancer and the bowel specialist nurses in
thereandtheyhadaconsultantin,soIwentinaswell,butIwaswatchinghow,I
was using it, because I didn’t, I didn’t say anything because you know, I was
watching it, how they dealt with, and I picked up a lot of really good
communicationskillsfrom,fromthem.(SiteCNQNS1)
ThisNQNishighlightingtheimportanceofbeingabletowitness,anddrawknowledge
fromthehandlingofaparticularlydifficult,andsensitive,situation.
Participants alsodescribed learning frommoreexperiencedHCAsas thisHCAherself
observes:
They[NQNs]needsupport,theyneedalotmoresupportthanobviouslythestaff
thathavebeenherealongtime.ButweareagoodteamIthink,andwedogive
themallthesupporttheyneed…I’veknownrecentones[that]haveaskedme
things,whichIthink,‘Whyareyouaskingme?’ButobviouslybecauseI’vegot
experienceandI’vedonethejobforawhiletheyknowtheyIknowquitealotof
things….(SiteAHCA3)
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES 15
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NQNsinourstudywerethemselvesawarethattheycouldlearnfromHCASalso:
‘Ithink,whatI’venoticedisthesesupportworkersknowmorethingsthanwedo,
theyknowalot,it’slikeyouthinkalltheydoismakingbedsbutwhenyou’redoing
awarddressing,theywilldobestdressings,becausethey’vebeenhereforlongtime
…betterthanus,and…asanewlyqualifiedIfoundalotofhelpfromthesupport
workers.’(SiteCNQN8)
Boththeseextractshighlightthevalueofinformalsupportwithcolleagueswhether
qualifiednursesornot.However,whileitwasrecognisedthatNQNscouldpotentially
learnalotfromHCAs,someparticipantswereconcernedaboutthesafetyaspects,as
thisHCAobserved:
Iwaswithanotherstaffnursewho’dbeenhereforawhileaswellandthisnewly
qualifiednursewastakingoutapatient’sdrainandshewasn’tsurehowtodoit,
butIknewhowtodoitanywaybecauseI’veobserved,Idon’tdothatmyselfbutwe
weretellingherandIwastellingher‘thisishowyoudoit’,I’mnoteven,I’mnot
evenqualifiedtodothatbecauseIdon’tdothatbutwhenI’mtellingherthisishow
youdoit–Ishouldn’tbetellingherlikesheshouldknowalready…because
otherwiseyou’rekindof,you’rewalkinginthedarkotherwiseandyouknow,you’re
putting,you’reputtingpatientsatriskifyoudon’tknow.(SiteAHCA2)
Thisextractshowsthattheremayberisksattachedwithlessstructuredlearning,and,
inparticularlearningfromlessqualifiedcolleagues.ManyNQNsspokeofthebenefitsof
informaldiscussionswiththeirpeers:
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES
…andpeoplejusttalkaboutitandyou’llbelike‘yeah,yeah,I’vedonethesame’or
‘I’vedonesimilar’or‘howhaveyoudonethat’,youjustsortof,youknow,peersI
suppose,learningfrompeers….(SiteANQN9)
So,herewecanseetheimportanceofbeingabletoinformallydiscussscenarioswith
peers,andofexchangingideasandexperiences,andalsoofmutualidentification.
Invisiblelearningby‘osmosis’involvesabsorbinggoodpracticefromcolleagues
withoutbeingfullyawareofdoingso:
Ensuringthatthey’vegotqualifiedstaffworkingwiththemandwhatwetrytodo
iswetrytomixthestaffthattheyworkwith,soalthoughtheyhaveapreceptorwe
tryandgetthemtoworkwithdifferentstaffsotheycanseehowdifferentpeople
workandtheycanpickthebesttraitsoutofeachofmembersofstaff.(SiteAward
manager2)
Thistypeoflearningalsohasitsadvantagesanddisadvantages:nursescould
potentiallypickup‘bad’aswellas‘goodpractices’byunreflectiveworkingwithmore
experiencedcolleagues.Thishighlightstheimportanceofreflectivespacestoencourage
criticalthinkingamongnurses,especiallyNQNs.
Muddlingthrough
Despitethepresenceofformalpreceptorshipprogrammes,participants
nonethelessdescribedtheirexperienceofpreceptorshipas‘muddlingthrough’
uncertaintyindelegatingandsupervisingworkdelegatedtoHCAs;theydescribedusing
routinestomanagethismuddle,tomakethings‘fitintoplace’:
Itjustseemslikeamuddlewhenyoustartandthenaftersixmonthsitallseemsto
fitintoplace.(SiteBNQN2)
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES 17
17
This‘muddlingthrough’involvedaperiodofstruggleastheNQNstriedtogainmastery
overdelegatingandsupervisingHCAs;masterywhichoverwhatwasastressful
experience,a‘struggle’astheylearnttheworkroutineandcopedwithlowstaffing:
Ididstruggle[at]first,likemaybemonth,twomonthsnearly,untilIgotmyselfa
roundroutineandthen,thenit’sgonebetterandbetternow,nowit’s,ifwe’vegot
enoughstaffthenifthestaffinglevelsaregood,thenyeahyoucangetajobdone,
withouttoomuchstressandIcanactuallyfinishontime.(SiteANQNS2)
ManyNQNsthoughttheperiodof‘muddlingthrough’wasanecessarypartoftheir
adjustmenttobecominganeffectivedelegator,aconfident,nursewhocouldsupervise
HCAsintheirwork:
Theydid,theydidsortofgiveyoulecturesaboutyouknow,howto,todelegateand
whathaveyouandhowtousethosekindsofskillsbutIdon’tthinkanything
preparesyouforituntilyoucomeinthejobbecauseyoucan,youcankindof
theoriseabouthowyou’regoingtodoitbutits,youhavetoadapttoyour
surroundingsandwhoyou’reworkingwithandIthinkonlybydoingthejoband
gettingyourconfidenceupasaqualifiednursethat’showyoukindoflearntodoit
andhowtodoitreally.(SiteBNQN7)
Forsomenurses,‘muddlingthrough’astheylearnttodelegateandsupervisefora
groupofpatientswasnotasuccessfulexperience,‘you’regiventoomany
responsibilitiestoosoon.‘Muddlingthrough’couldcontributetoattritionratesamongst
theirpeers.
It'sreallysadyouknow,alotofmyfriendswhoqualifiedasnursesthesametime
asmehaveleftnursingaltogether.There'snotenoughsupportontheward,not
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES
enoughseniorstaff,newlyqualifiednursesareputuponandgiventoomany
responsibilitiestoosoon...It'swornmedown.Youdon'texpecttobeworndownin
yourfirstsixmonths,youknow.Youcomeinallenthusiastic,youwanttomakea
difference,youwanttobethebestnursethatyoucan,butthenthere'snosupport,
andsomuchpressure,andyou'renotallowedtoflourish.(SiteBNQNF)
Forothernurses,however,the‘muddlingthrough’eventuallyledtoasuccessful
transition.HeretheNQNreflectsonbecomingmoreconfidentassherealisesthatshe
hastheknowledgetodelegateandsupervise‘whereveritwasstored’andshedoesthis
throughpersonalreflectionandthroughdiscussionwithothers:
TheknowledgewasthereIjustdidn’tfeelthatitwasthereandIdidn’tfeelthatI
knewenoughbutthenwhenIstartedtalkingaboutitanddoingitandpulling
thingsyouknowfromwhereveritwasstoredIthought‘wow,Idoknowthis’,you
know,‘wow,wheredidthatcomefrom?’,Idoknowwhatitistobeanurse…you
lookatyourselfinthemirrorandthink‘Icandothis,Iamanurse’,youknowIam
agoodnurse’(SiteANQN13)
ThesedatawouldsuggestthatNQNsneedextensivesupport,bothformalandinformal,
duringtheirperiodof‘muddlingthrough’tolearntodelegateadsuperviseHCAs.
Withoutthissupport,qualityofcareandpatientsafetymaybecompromised.
Discussion
Inthefourtypesofinvisiblelearningidentified,wesuggestthatNQNsstriveto
manageuncertaintyandbringordertounexpectedandnewsituationsinwayswhich
use,stretchandchallengetheirknowledgeinallofitsforms.TheNQNslearnnotonly
toenactestablishedworkplacepracticesandproceduresbutalsotomodifytheir
responsesinthesearchforsolutionstounexpectedoccurrencesorinthelightof
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES 19
19
experiencesofmistakesthey,orothersaroundthem,havemade.Theylearnthrough
thisprocesstodeveloptheirjudgmentofwhatconstitutessafepractice,andenactit
througheffectivedelegationorappropriatesituationsforlearningfromco-workers.
Learningthroughdifficultexperiencesandmistakesaremostreadilyassociatedwith
productiveformsofknowledgerecontextualisation.Inlearningthroughmaking
mistakes,forexample,productiveformsofknowledgerecontextualisationaretaking
placewhennewknowledgeorinsightsareproducedinrespondingtounexpectedor
unpredictablesituations.Butinpracticebothadaptiveandproductivemodesco-exist.
Adaptiveaswellasproductiveformsofknowledgerecontextualisationcanresultfrom
mistakes,asNQNsadjusttheirapproachtousingexistingprotocolsorproceduresin
differentcontexts.Theseadaptationscanbeeitherbeneficialordetrimentaltopractice:
theexampleshaveshownhowdefensivepracticescansometimesbetracedtoadaptive
learningthathasresultedfrommakingmistakesordifficultexperiences.The
deepeningofadaptivetoproductivelearningthroughknowledgerecontextualisationis
crucialforactivitiessuchasdelegation,wheretherearefewpre-existingguidelinesand
wherethedevelopmentofattunedjudgementiscrucialtoeffectivepractice.
SupportingNQNstoworkingthroughdilemmasabouttrustingco-workersordifficult
experiencessuchasthedeathofpatients,potentiallybenefitsfromaknowledge-
awareapproachtopreceptorship,onethatenablestheNQNandpreceptorto
articulatewhatislearnedandtoconnectitwithpriorlearningtodevelopcurrent
practiceandmovefromadaptivetoproductiveknowledge.Thesesocio-cognitive
processescontributetothedevelopmentoftheattunedjudgmentsthatdefine
knowledgeablepracticeandsupporttheprocessbywhichNQNsthinkandfeeltheir
wayintoprofessionalidentities.Intheiraccountsof‘muddlingthrough’,newly
qualifiednursesareadaptingexistingknowledgeofmanydifferenttypestorespondin
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES
thecontingenciesofthepresentmomenttomultiplepressuresanddemands.Their
responsesarethemselvescontextualizedintheroutinesandprotocolsofrecord
keeping,patientconfidentialityandsafetychecks.Theyarealsomodifiedaccordingto
workplacerelationsandtheorganisationalhierarchiesthatinfluencehowNQNs
communicatewithHCAs,doctorsandtheirpreceptor.Knowingwhen,howandwith
whomtocommunicateinanemergencyorunpredictablesituationcanbecriticalto
theoutcome.TheNQNisthusbuildingproductiveknowledgeofhowtoworkwiththe
protocolsandmanagetheworkplacerelationsthatareembeddedinclinicalpractice,
towardsthegoalofknowledgeablepracticeandattunedjudgment.Thefindingsshow
howNQNscometoembodyknowledgecognitivelyandpracticallyandsuggestarange
ofpracticesthatcouldimprovesupportfortheseimportantformsoflearning.
Conclusion
Inthisarticle,wehavedescribedfourtypesof‘invisiblelearning’asNQNsmake
thetransitionfromstudenttofullyoperationalqualifiednurse.Thisinvisiblelearning
canbemadevisibleandamenabletointerventionandsupportwhenitisunderstoodas
morethantheexperiencesthatinevitablyoccurwhenNQNsencounterthepressures
anddemandsofthe‘realworld’ofpractice.Thefourtypesallentailtheinterplay,inthe
contingenciesofthemoment,ofsubjectknowledge,proceduralknowledgeandformsof
personalknowledgethatarecontinuouslyused,refinedandreworkedinthepractice
context.Productiveandadaptiveformsofknowledgerecontextualisationco-exist.
Adaptiveformsarenotalwaysbeneficialtopracticeandproductiveformsare
strengthenedbyaccessto,andsupportfrom,expertandintellectualresourcesthat
enabletheNQNto‘standback’fromchallengingsituationsandthinkabouttheminnew
ways.
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES 21
21
Inthecontextofdelegationandsupervision,theknowledgerecontextualisation
processesinherentin‘invisiblelearning’havearangeofpracticeimplications.Learning
throughmistakesindelegationandsupervisionraisesquestionsaboutthedistinction
betweenmistakesthatcanpotentiallybeharmfultopatientsandstaff,andmistakes
thatareperhapslessrisky.Itmightbepossibletohavecontrolsinplacewhichassess
thelevelofriskinvolvedindecision-makingsuchas‘flagging’areasofHCAbedsidecare
whichrequiregreaterorlessermonitoringbytheNQN.Theuseofsimulatedsituations
aspartofnursetrainingandpost-qualifyingtransitionmightoffertheopportunityto
make‘safemistakes’inthecontextofdelegationandsupervisionofHCAswhichcanbe
usefulforlearningpurposes.
LearningfromchallengingexperiencescanbeextremelyhelpfultoNQNsin
buildingtheirconfidenceinbeingabletohandlepotentiallyfrightening,challengingand
emotionallystressfulsituations.However,withoutadequatesupportandreflective
spacethisopportunityforpositivelearningcanhavetheoppositeeffect,increasing
NQNfearsandanxieties,anddecreasingtheirconfidencelevels.Itisimportanttohave
mechanismsinplacetoensureNQNsareofferedappropriatesupportanddebriefs
followingsuchmajorevents.ProvidingNQNswithadequatesupportswillalsoenable
themtoprovideadequatesupporttotheHCAstowhomtheydelegateandsupervise.
Learningfromcolleaguesinformally,viaobservation,discussionandosmosis,
canbeinvaluabletotheNQNduringtransition.However,again,thereisthepossibility
for‘bad’aswellas‘good’learning.ItisimportanttosupportNQNsindevelopingtheir
ownreflectiveandcriticalthinkingskills,inordertoensurethatwhattheylearnis
beneficial,ratherthandetrimental,totheirpractice.Itisalsoessentialtodistinguish
betweeninformalcollegialsupportbetweenexperiencedHCAsandNQNs,and
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES
situationswherethereisanover-relianceuponHCAstosupportNQNs,andalmosta
‘reversedelegation’betweenthem,inwayswhichmightbeinappropriateandwhich
couldhavepatientsafetyimplications.
Thesenseof‘muddlingthrough’maybeaninevitablepartoftheNQNexperience
astheytransitionfromstudenttofullyfunctioningqualifiednurse.However,itis
importanttothinkaboutthepossibleimpactonHCAsofthis‘muddlingthrough,’to
ensurethatthisdoesnotleadtoaconfusing,negativeandpossiblyburdensomework
experienceforHCAs.Moreover,althoughNQNsmightfeelasiftheyare‘muddling
through,’itisimportantthatthisshouldnotactuallybethecase.Thereshouldbeaclear
pathwayandpurposetotheNQNs’preceptorship,closelymonitoredandsupported,
andwithrobust,reliableandeffectivementoringpractices.Ourstudydidnotfindthat
thiswashappeningconsistently.Thereneedstobeagreatemphasison‘visible
learning,’particularlyeffectivesupportatwardlevel,aswellascloserscrutinyand
supportfor‘informallearning’ontheground.
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES 23
23
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Datacollectionmethod SiteA SiteB SiteC Total
Observationofnurses
(twice/nurse)
17nurses
34obs.
6nurses
12obs.
10nurses
20obs.
33nurses
66obs.
(approx.
230hours)
NurseInterviews 16 4 8 28
HCAInterviews 6 2 2 10
WardManager/
MatronInterviews
5 3 4 12
TOTAL(Interviewsand
Observations)
61 21 34 116
Table2.Summaryofdatacollected(November2011toMay2012)
INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES 29
29
SiteA SiteB SiteC
Wardspecialities
where
participants
worked
• EAU
• Elderly
• Medicine
• Trauma
• HDU
• Surgical
• Adult
• General
• EAU
• Medical
• ADU
• Surgical
• Adult
• General
• Surgical
• Respiratory
• Medicine
• Gastro
• Adult
• General
Approximate
numberofbeds
700 700 450
Preceptorship
programme
Yes Yes Yes
Table1Overviewofthethreehospitalsiteswhichparticipatedinthestudy