Introduction to the focus of the study – context and relevance to practice.

Currently, the Department of Health (DH) are reviewing standards for higher levels of practice, following the roll out of a consultation document requesting views from clinicians regarding the future of post-registration nursing careers (DH, 2007). Subsequently, following collation of feedback, a response report has been produced, indicating that the Department of Health would be working with the NMC to standardise levels of advanced practice (DH, 2008d). This post-registration exercise was undertaken alongside a consultation for the review of pre-registration nursing careers by NMC (NMC, 2007).

Nurses and educationalists eagerly awaited the detail, in terms of standards and guidelines, arising from these consultations. The Department of Health stated that they recognised the need for clear career pathways for nurses considering roles in specialist and advanced practice and nursing in the community (DH, 2008d). However, specific guidance in relation to levels of advanced practice is yet to emerge from the NMC or Department of Health.

In relation to this project, and in the absence of subsequent guidance regarding the plethora of specialist and advanced nursing roles, the Nursing and Midwifery Council’s definition of higher level practice has been adopted as the most appropriate reference (Appendix 1, NMC, 2002). This definition, when mapped against current standards of proficiency for specialist practice (NMC, 2001, 2004b), directly reflects the requirements for higher level practice (NMC, 2002). A statement within the Standards for Specialist Education and Practice (NMC, 2001) is also useful here, which states that ‘Specialist practice is the exercising of higher levels of judgement, discretion and decision making in clinical care’ (NMC, 2001, p4).

Practice at this level is therefore advanced beyond that of the first level registered nurse who has completed a pre-registration nursing programme at diploma or degree level. The final report for the Department of Health by Lord Darzi (The Darzi Report, DH, 2008c) recognises these levels, and offers strategic direction for policy and practice, to inform the development of career structures.

Given the outdated nature of some of the standards for specialist practice (NMC, 2001, 2004b), educationalists rely on nurse mentors, in particular PTs, to appraise ability in line with current practice, contemporary policy and underpinning theoretical principles. Mentors do, however, often experience difficulties in assessing students, and can find that the assessment strategies for practice do not reflect the

degree of effort employed by the student to meet practice competencies (Canham, 2001). Further consideration of mentor support is therefore necessary to ensure continuation of quality mechanisms for practice assessment.

Nursing programmes at specialist level, as with pre-registration nursing programmes, require a fifty-fifty, theory to practice assessment, which recognises the value and importance of practical clinical competence (NMC, 2001, 2004b). As identified in the introductory chapter, there has been rapid development over the last decade in pre and post registration nurse education, and expansion and development of nursing roles (DH, 2006). These developments have resulted in a competency led career progression, linked to a national Knowledge and Skills Framework (DH, 2004).

In order to meet and embrace the challenges of the current and future career structures, as recognised by the Department of Health (DH, 2006), nurse educationalists and practice mentors alike require support mechanisms which ensure that the fifty per cent practice component of assessment at higher levels is robust and evidence based.

Practice assessment in specialist practice takes the form of a practice portfolio, which contains evidence of ability at a higher level, to reflect the current NMC Standards of Proficiency (NMC, 2001, 2004b). A review of the literature related to portfolio development carried out by Endacott et al (2004) however, revealed that although there was general consensus regarding the theoretical approach to use of portfolios, there appeared to be a wide variation in portfolio content and structure. The importance of this study lies in the incorporation of evidence from a national telephone survey of Higher Education Institutions (HEIs), followed by four in depth case studies of portfolios. As the initial survey constituted a large sample (although precise

numbers of contacts are not stated), it was more likely to be representative of the population being studied (Polit and Hungler, 1994) and enabled analysis of extensive data. The study concluded by highlighting the importance of developing clear guidance for mentors and PTs, which identify the level of practice required to meet competencies set.

The challenge of articulating knowledge in practice has been debated for many years in a variety of the social sciences (Kolb, 1984, Schön, 1987, Eraut, 1994, Carr, 2005) and has been discussed at length in the initial literature review. Carr’s 2005 study was stimulated by the recognition that within practice, nursing students did not always fully grasp the detail, meaning and complexity of the experiences they were exposed to in community placements. Although this study offers a method of capturing meaning, Carr (2005) fails to identify how this method could be incorporated into everyday practice, however she does assert that by articulating the lived experience immediately after the event, new meaning can be gained to contribute to overall nursing knowledge.

Carr’s (2005) approach does not take into account the socialisation process that is considered necessary for the learner in order to develop knowledge and understanding in the context of the practice placement. This prerequisite is recognised by Cope et al (2000), and described as situated learning. The authors interviewed thirty nursing students, and drew on the seminal work of Lave and Wenger (1991) to support their stance. Lave, a social anthropologist and Wenger, a teacher, in their 1991 work discussed the concept of communities of practice; asserting that it is important to have joined a culture of practitioners in facilitating the development of proficiency. Lave and Wenger (1991) therefore consider the importance of the social aspects of learning; the degree of ability to participate in the community of practice, as follows:

Learners inevitably participate in communities of practitioners… the mastery of knowledge and skill requires newcomers to move toward full participation in the socio-cultural practices of a community. "Legitimate peripheral participation" provides a way to speak about the relations between newcomers and old- timers, and about activities, identities, artefacts, and communities of knowledge and practice. A person’s intentions to learn are engaged and the meaning of learning is configured through the process of becoming a full participant in a socio-cultural practice. This social process, includes, indeed it subsumes, the learning of knowledgeable skills.

Lave and Wenger, 1991 p29

This perspective on learning supports the requirement for specialist programmes to run over a minimum period of one academic year (NMC, 2001, 2004b); which enables the learner to settle into the placement area and understand the context of practice. This approach has thus far been adopted by the University of Derby, therefore students are enrolled on a full time basis at the University. During this period, it is hoped that this extended exposure through the fifty-fifty theory to practice approach of the course enables full participation by the learner in that community of practice; an aspect of the project focus which will be discussed further in the next chapter. Once this has begun to occur, practice assessors are required to appraise student development and proficiency.

My own project is undertaken to assist the community practitioner in their assessment of student ability when practising at higher levels within the community of practice.