Confirmation of the main themes

As described in the previous chapter a systematic process of thematic analysis generated the identification of a number of themes that captured the most significant patterns in the data relevant to answering my research question. Determination of the importance and relevance of the themes was not simply related to the frequency of occurrence, but rather the priority of the themes following from a selective analysis of the data that told a particular detailed story. The isolated themes are independent, distinct and clearly defined but also fit together to form a clear focus and purpose towards the overall analysis and addressing of my research question (Braun & Clarke, 2013). The fact that the themes fit together in such a way is again indicative of how Lave and Wenger’s (1991) work provided a structure and theoretical perspective to the iterative process of data analysis.

114 The main themes are

1) Becoming a nurse

2) Engagement with ‘old timers’

3) The University – Practice Dissonance

In this chapter, therefore, I will provide a broad narrative which seeks to understand the complexity of the subjective experience of student nurses’ participation in the various aspects of their practice across a BSc adult nursing programme; to explore their shifting identities and gain insight into their understanding of what it means to be a nurse.

5.3 Background

I propose that discussion of the current health care context; generated in some ways by apparent ‘failures in care’ highlighted by documents such as The Francis Report (Francis, 2013) has challenged nurses, and others, to fundamentally explore what it means to be a nurse. Moreover professional, political and media discussions have frequently implied a particular, fundamental flaw or insufficiency in the education, training, values, insight or identity of the current nursing students. This suggests that to avoid further examples of such ‘failures to care’ nursing needs, in some way, to ensure that the future nursing workforce embody a set of values that represent an essential and consistent view of what nursing is and what it means to be a nurse. For some members of the nursing profession, for example, these values and behaviours are often currently articulated by the so called 6Cs of nursing – care, compassion, competence, communication, courage and commitment that are the bedrock of the vision and strategy for nursing, midwifery and care staff ‘Compassion in Practice’ (Department of Health, 2012).

Adult nursing students at Universities in the United Kingdom undertake a course which is divided into 50% theoretical study and 50% practical clinical experience. The theoretical component includes lectures and seminars - some with students from other fields of nursing - and time spent in smaller groups and the clinical skills laboratory exclusively with adult field students. Within the university where the research took place, a student’s practical clinical experience includes working within a specified local NHS Trust on a variety of placements. Adult nursing is focused on the care of people from the age of 18 years and above and can offer students experience of caring for people who need immediate help and support in hospitals or community settings or assisting people to recover and manage more long-term conditions. Promoting good health and assisting people to care for themselves or members of their family or community is also a key focus that student nurses gain insight into throughout their three- year course.

115

The first year students participating in the research have additional support whilst on their clinical experiences by a system of allocating associate lecturing staff to first year placement areas. First year students are visited by these members of staff whilst within their placement areas to help ensure progression and the delivery of an appropriate and supportive learning environment; and to encourage the provision of appropriate learning opportunities to enable the achievement of set learning outcomes.

5.3.1 Academic staff in practice

The university where the research took place, emphasise that many of the academic staff are not only registered nurse teachers but often still work within the clinical setting when not teaching. This is believed to help maintain clinical competence and thereby make staff better placed to support students on their learning journey. The issue of clinical competence and subsequent alleged credibility has been the source of much debate for many years within nurse education (Leonard, McCutcheon & Rogers, 2016; Price, Hastie, Duffy, Ness & Jacqueline, 2011; Ousey & Gallagher, 2010). This debate has included concern of the lack of precision, clarity and consistent use of the terms credibility and competence themselves. Interestingly during the focus groups and interviews several students highlighted the fact that some university staff still worked in the clinical setting and appeared to value it, not least as a potential defence against any accusation from mentors and other clinical staff that the university did not really recognise or understand the current health care context.

Yr1 FG2 ‘right everything they told you at uni forget it, .... this is what really happens’

The students believed that academics continuing to work in clinical practice in some way contributed to a greater understanding of their own student experience; and also further legitimised learning in university as of equal relevance to their progression as the learning that occurred in practice.

Int2 ‘You are told at uni that them on placement know best and the mentors are there to teach you and this and that and a lot of our lecturers are still working people...’

However as Ousey and Gallagher (2010) have argued the great, and increasing, diversity of nursing roles make it impossible for educators to maintain expertise and therefore offer credibility in all of those roles and aspects of nursing practice. Leonard, McCutcheon and Rogers (2016) also argue that being ‘in touch’ through clinical practice risks limiting education to simply replication of what is known and reducing the facilitation and development of new knowledge to challenge, transform and extend practice.

116 5.3.2 Practice Education Facilitators

A further role designed as a supportive link between the university and clinical placements is also offered to all nursing students by Practice Education Facilitators (PEF), whose responsibility is to provide additional support and advice to mentors and students within clinical areas and proactively promote a quality learning environment, improve communication and enhance the pre-registration students’ experience. Within the research, several students discussed their experience with their PEF, questioning the objectivity of the role; should students feel the need to question the support they were receiving from their mentors or have concerns about practice standards generally. In previous chapters I have discussed the value of Lave and Wenger’s work on communities of practice (Lave & Wenger, 1991) and the insights thus afforded when exploring and understanding the subjective experience of student nurses, their learning and their shifting identities. As Wenger highlights, identity is produced as a lived experience of participation in specific communities and the learning required and derived is through participation that is structured to allow access to practice for others, in this case nursing students, who are, at least initially, non-members of these communities of practice (Wenger, 1998).

The PEFs, along with mentors and others, have a significant role in facilitating the participation of student nurses and therefore are instrumental in the on-going reconstruction of their identity as they progress and move into what is inevitably, at least initially, unfamiliar territory. As Wenger (1998, p.167) explains participation is a very complex notion and can include a range of differing forms including full participation or an ‘insider’ or full non-participation or ‘outsider’. Wenger further articulates the notions of peripherality and marginality that I found of particular value when analysing the data within the study.

5.3.3 Peripherality

Lave and Wenger’s approach to knowing and learning and the theoretical framework of communities of practice was again insightful in conceptualising the data during the analysis. Whilst some degree of non-participation is inevitable for student nurses, the source or rationale behind such non-participation may be different and also crucial to the learning and identity formation of the student. Wenger claims that peripherality which entails non-participation

might still be positive, and indeed, necessary to enable less than full, yet enabling participation. The principle of supernumerary status of nursing students in practice may be viewed as a type of legitimate peripherality for example. As I have discussed in a review of the relevant literature, the value of supernumerary status for student nurses as a framework for learning,

117

progression, development and achievement of competence is at least controversial with some members of the nursing profession (Allan et al., 2011).Moreover the reality of supernumerary status in the experience of many student nurses is also disputed:

Yr2 FG3 ‘On the placements we were just basically used as a healthcare assistant for free - you could go through the whole course like that’

Yr1 FG1 ‘You do get used as a HCA, you just do’

Peripherality may also be influenced by the specialties that the adult nurses gain experience of during their progression as a student. These specialities, at this university, may include high dependency; intensive care; cardiothoracic and cardiology nursing; emergency nursing; care of the elderly; renal nursing; theatre nursing; community nursing and many more. Student nurses’ transition through their training can be viewed as a journey, and indeed according to Wenger (Wenger, 2010) all learning can be viewed as such a journey with the forming of identities coming to reflect the landscape of that journey.

5.3.4 Participants

The participants, as student nurses on a BSc adult nursing course were all ostensibly engaged in a process of collective learning in a shared domain of interest – two of the elements that help constitute a community of practice. They came from different backgrounds with many differing demographic profiles. Their ages ranged from 18 to 45; with a range of cultural backgrounds and previous healthcare experience. Some students had no previous clinical experience whereas others had more than three or four years experience as a healthcare assistant or in other support roles. There were only two male participants in the year one focus groups and all other focus group and interview participants were exclusively female.

According to Braun and Clarke (2013) there is rarely a clean separation between data collection and analysis within qualitative research, and immediately following the first focus group and each subsequent focus group I was immersing myself in the data. This involved repeated listening, transcription and subsequently reading and frequent re-reading of the material. All students who were prepared to contribute further via individual interviews had offered their contact details as part of the original consent process. Following initial analysis of the data, therefore, I then undertook three individual interviews from each year to further explore, confirm and gain greater depth of insight and understanding of the data. All but one of the participants in the interviews had contributed to the original focus groups. One participant contacted me via messaging on the Shifting Identities of Student Nurses Facebook page and

118

expressed her interest and desire to contribute despite her inability to attend the original focus groups.