the reality of clinical learning in critical care settings: a practitioner:student gap?

The reality of clinical learning in critical care settings:

a practitioner:student gap?

RUTH ENDACOTTRUTH ENDACOTT MA, PhD, RN, Dip N

Professor of Clinical Nursing, La Trobe University, Bendigo, Victoria, Australia, and Visiting

Professor of Clinical Nursing, Institute of Health Studies and University of Plymouth,

Plymouth, UK

JULIE SCHOLESJULIE SCHOLES MSc, RN, DPhil

Professor of Nursing, Centre for Nursing and Midwifery Research, University of Brighton, Falmer,

Brighton, UK

MARNIE FREEMANMARNIE FREEMAN BA, PhD, RN, HV

Senior Research Fellow, Centre for Nursing and Midwifery Research, University of Brighton,

Falmer, Brighton, UK

SIMON COOPERSIMON COOPER BA, MEd, PhD, RN

Head of Education, Westcountry Ambulance, Ambulance College, Derriford, Plymouth, UK

Accepted for publication 12 November 2002

Summary

• This article reports on the clinical phase of a study commissioned by the English

National Board for Nursing, Midwifery and Health Visiting to evaluate the

effectiveness of educational preparation for critical care nursing [Scholes &

Endacott (2002) Evaluation of the Effectiveness of Educational Preparation for Critical

Care Nursing. ENB, London]. The authors draw on observation and interview data

from clinical settings (general and paediatric intensive care units; operating theatre

departments; accident and emergency departments and coronary care units),

focusing specifically on the way in which curricular intentions were made a reality

in clinical practice. The reality of learning in practice is examined, with evidence

from the data to illustrate the real world of clinical practice.

• Different models of support and supervision are identified, alongside strategies

used to create different learning opportunities. The majority of students remained

in their own workplace when undertaking the English National Board for

Nursing, Midwifery and Health Visiting clinical course. This raised a number of

issues for the students and their colleagues which we have labelled the

practitioner:student gap. The authors discuss the impact this has on supernu-

merary status, perceptions of learning and opportunities to undertake placements.

Keywords: clinical learning, critical care, education, students.

Correspondence to: Ruth Endacott, Professor of Clinical Nursing,La Trobe University, PO Box 199, Bendigo, Victoria, Australia (tel.:+61 3 5444 7814; e-mail: [email protected]).

Journal of Clinical Nursing 2003; 12: 778–785

778 � 2003 Blackwell Publishing Ltd

Introduction

This study followed a literature review and documentary

analysis of critical care courses (Scholes et al., 1999),

which identified considerable diversity in the written

curricula. The focus of the current work was to undertake

an empirical study to ascertain if such diversity was

reflected in the �lived� curricula or was an artefact of

documentary analysis. The authors acknowledge that there

is some contention regarding the inclusion of Emergency

Department and Operating Theatre courses as �critical

care�; however, courses for these specialities have been

given this label and often share some content with

intensive care and coronary care courses. Hence, they

were included in this study. These courses were also of

interest to the researchers as, although the majority of

critical care work is about maintaining patients’ stability, it

is the high risk of instability that demands constant

vigilance and assurance that the nurse can respond

appropriately to these situations (Department of Health,

2000). Similarly the assessors of students undertaking

courses in these specialities need to assure themselves that

the assessee could cope efficiently and effectively with the

unexpected, untoward or unfolding clinical situation.

Methods

The study reported in this paper was undertaken in three

phases.

PHASEPHASE 1

Five Higher Education Institutions (HEIs) were identified

who ran the following critical care programmes: ENB 100,

124, 176/183, 199 and 415. A further HEI was sampled

for the ENB 415 course only. A range of academic staff

and students were interviewed (n ¼ 202) about their

expectations, and experiences with the programme.

PHASEPHASE 2

Clinical environments linked to each of these institutions

were visited. Data were gathered by interview and

observation to:

1 seek the views of a range of clinical stakeholders

(n ¼ 109) about the course and the range of compe-

tencies students acquire whilst on the programme, and

2 observe and/or explore how practice assessment was

deployed. Data were collated from 80 episodes of

observation conducted in 49 units linked to the case

study HEIs.

PHASEPHASE 3

Competencies were generated from analysis of these data,

along with a distillation of practice assessment tools and

learning outcomes from the sampled institutions. The

competencies were evaluated through a consultation

exercise with stakeholders from education, practice and

management (n ¼ 297 respondents). The competency

statements for each course and responses to the consul-

tation are available from the Centre of Nursing and

Midwifery Research, University of Brighton.

This article focuses on phase 2 of the study; other

aspects of the study findings are reported elsewhere

(Scholes & Endacott, 2002). The case study HEIs and

related data excerpts, are identified throughout this paper

as case studies A–F.

The clinical settings

Key factors in the clinical setting, and its subrole as a

learning environment are given in Fig. 1. A range of

organizational constraints influenced the geography, staff-

ing and profile of the clinical environment, and the learning

environment was influenced by the nature of the course

(design and assessment tool) and its perceived value. The

impact of those factors on the student role and the reality of

clinical learning is explored, following a profile of the

different clinical settings in which data were collected.

The range of clinical settings visited is presented at

Table 1. These data highlight the diversity in practice

settings from which the students were stepping to attend the

English National Board for Nursing, Midwifery and Health

Visiting (ENB) clinical course. Fieldwork data demonstra-

ted that the clinical settings used for the study reflected the

national picture, for example, variation in patient case-mix

and levels of organ support, shortage of beds resulting in

emergency department care stretching beyond initial

assessment and transfer (Audit Commission, 1999). This

led some clinicians and academics to question the extent to

which a �national� critical care course could meet local needs:

I think A & E work has changed so much over the last

four to five years. I am not sure the courses are

keeping up to date with the changes that are taking

place in the department itself. Things like thrombo-

lysis. There should be a whole module on that… then

there should be something relating to standards that

are coming out of the national framework. Things that

managers have to implement but feel they are battling

alone because staff want to be there with the patient

rather than collecting statistics. (C2/199 Man)

However, key to this complex matter is whether

education should confront students with the contradictions

Education for clinical nursing The reality of clinical learning in critical care settings 779

� 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 778–785

in their work or whether it should be focused on supporting

the reality of their clinical worlds even when this is less than

ideal. Therefore to what extent should the status quo be

challenged? One course leader described the problem:

I cover 5 Departments and work in them as well, they

are mostly like bomb alley! Very difficult places to

work where people are struggling to achieve learning

in a lot of different things! They then come on the

programme and we are talking about critical thinking,

decision making – we ask them to analyse and to

consider and do HE things – and we talk about care

issues, e.g. c/o older person in A & E, and cover

loads of different aspects – which is really good. But,

I am sorry, when I go out there and look around I

find nurses out there unable to cope with the most

basic things and the most basic rules for patient care

are not being met. (B/199 CL)

The type of patients the units and departments received

was not only influenced by the local demography but also

the type of specialities the Hospital and or Consultants

had established. For example, some paediatric intensive

care units offered advanced ventilation and extracorporeal

oxygenation therapies whilst others had to refer children

requiring these interventions to specialist centres. The

patient case mix had an impact on the learning oppor-

tunities available for students, as seen in the following

excerpts from the module evaluation data under the item

�things that hindered your learning�:lack of intubated patients for part of the module.

(F 415/Std2)

Table 1 Clinical settings visited for phase 2

Speciality

No. of units/

departments Size (range)

General intensive care units 12 4–30 beds

Emergency departments 13 26 000–950 000

new patients p.a.

Operating theatre

departments

7 4–15 theatres

Coronary care units 11 4–15 beds

Paediatric intensive

care units

6 4–16 beds

Roles in practice – value of the course Assessment tool

Course days – course work

Supervisor/assessor student

‘learning environment’ subcultural values toward teaching and learning

critical friends open challenge and review

Organizational/resource constraints

Clinical environment

Unit profileRange of opportunities

within MDT Patient profile

specialitiesPatient dependency

Staffing ratios Shift patterns Permanent vs. agency staff Other students Clinical educator roles

Geography Open plan Discrete locations Visual/auditory access

Figure 1 Factors influencing the

learning environment in the clinical

setting for ENB students.

780 R. Endacott et al.


Swan Ganz monitoring session not helpful as rarely

used. (F/415/Std3)

Whilst students undertaking the course in this partic-

ular setting could go to other units for placement if they

wished, the main focus was on gaining competence to

manage better the type of children admitted locally. This

ethos was seen in some clinical settings across the range of

critical care specialities.

The impact of the clinical settings on student

support

Reports from students and academics indicated that

current staff recruitment and retention had adversely

influenced the amount of support available to students on

long clinical courses. Many recent developments have

been aimed at inducting and developing staff new to the

speciality. However, many units were also experiencing

the loss of practitioners with many years experience, who

would have helped facilitate novices and shared their

experiential wisdom with the team.

The pressure on critical care beds and services has been

widely reported. Developments to enhance efficiency and

effectiveness of provision have resulted in greater patient

throughput (Audit Commission, 1999). Resources have

been stretched and in many instances, �experienced� staff

undertaking the ENB long clinical courses were consid-

ered part of the staff complement rather than students in

their own right. This significantly impacted upon study

leave for students and the amount of support and

supervision they experienced. In many instances there

was a difference between the espoused values of managers

in terms of their support for students and the reality of the

students experience. Burkitt et al. (2001) reported that

this findings was not isolated to critical care, but was a

phenomenon evident in preregistration courses and other

postregistration provision.

In the past, units and departments could predict peaks

and troughs in activity throughout the day (or, at least, the

week). The changing profile of the workload meant that

�quieter periods� were no longer predictable and were

becoming less frequent. Therefore, times when the student

and assessor could spend some time together to go through

practice assessment documentation during the working day

were sporadic. In one example, over a period of 5 weeks,

the student and mentor had managed to work two shifts

together (D1/199 St1). Conversely, another student in the

same NHS Trust had a close working relationship with

their mentor based on a supervisory role established in the

students’ preregistration training. There was evidence of a

good rapport between the two and the mentor was using a

variety of strategies to assist the student to integrate theory

and practice (D1/199 Field Notes). However, the example

of not working with a supervisor was a common situation

and students from a number of sites reported that they

reviewed and completed their practice assessment docu-

mentation with their assessor outside the department and

outside normal working hours:

I have found it very difficult to find the time. You

may be on the same shift but to get time out to

discuss it is almost impossible. It is just too busy at

the moment. Since I have started the course I have

been on the same shift twice but we haven’t had time.

We both have had to go in on our days off to go

through the (practice assessment) document.

(E/199/St Focus Group)

Hence the reality of clinical settings meant that the

�student� role could be subsumed by the practitioner role or

even ignored in practice: being a student simply referred to

the time attending study days (the practitioner:student gap).

Supernumerary status

Supernumerary status was always intended to be about

emphasizing learning needs over meeting service needs.

However, managers consistently articulated in the present

day NHS that service needs took precedence within the

current staffing crisis. This perception was significantly

amplified when the �student� was considered a well-

established member of the unit’s staff who was service

rostered throughout the course or for part of it. The need

to draw upon their clinical skills and contribution to service

was necessary because (i) there was no �backfill money� to

fund replacements and (ii) even if there were, the unit

might not be able to recruit another member of staff to

replace them. This perception significantly influenced

support and supervision, the assessment of practice and

time that was set aside for educational activities:

I appoint Ds and Es as the work members of the team

I cannot employ them unless I offer them some form

of further training. …I want to encourage them to do

the courses, but I cannot afford to have them totally

supernumerary. (B1 CNM 183)

Here we see a set of competing demands: the course was

critical to recruitment and retention, but at the same time,

if the course demanded too much time away from service

it created an undue burden on the existing staffing

resource. A solution to this problem (and as a means of

ensuring parity across different units), supernumerary

time had to be rationed or negotiated. Rationing was often

inextricably linked to the number of students that could be

sent off to do the course at one time.



Leaving the unit short staffed left some students feeling

guilty about trying to protect their supernumerary time,

and managers feeling guilty about not being able to fully

facilitate their learning:

it’s put on you to get what time you can, and you

know that your department is short staffed, how

much of your time do you ask for when you know

that you’re not necessarily going to get replaced.

(D/183/Student1)

Managers also, on the whole, acknowledged the prob-

lems faced by students undertaking placements in their

own setting:

…it is very difficult for them to step outside of their

normal work role into a supernumerary student role. It

is also difficult for their colleagues to accept that

because they are on a course they are not actually part

of the work force. I think that sort of thing is a lot easier

if you doing a placement in another environment. The

workload being such as it is, every pair of hands is used

and nobody is supernumerary. (C/199/Man 1)

Given these constraints a variety of strategies was set in

place by the education provider, and in some cases the

units, to maximize the education experience whilst

meeting service provision in an attempt to reduce the

practitioner:student gap:

• student and mentor/assessor working on the same shift

on at least 1 day per week

• planning for new learning through placements in the

same setting (in particular, working in a different

theatre suite) and

• swapping students between hospitals on a �quid pro

quo� basis.

Each of these strategies had their drawbacks (Scholes &

Endacott, 2002) and were largely viewed as a compromise

driven by lack of staffing resource.

1. SHARED SHIFTSSHARED SHIFTS

Generally, in the intensive and coronary care units,

technological monitoring and visual display screens at the

bedside were simultaneously transmitted to a visual

display screen at the nurses’ station, meaning that a

patient’s physiological parameters were under the surveil-

lance of a range of clinicians. Therefore, when a student

was allocated to a patient’s bedside, even if they were not

directly working with a supervisor or assessor, they were

receiving indirect supervision. However, in the Emer-

gency Department, a student might be rostered to work

alongside their mentor/assessor, but they might not

necessarily get to work in the same �zone� of the

department on that shift. Even if they did, they might

spend a substantial part of the day in another discrete

division of that zone and have minimal contact throughout

that working day (B/Std FG, E/Std FG). The speed and

increasing demand of patient turnover and requirement to

meet targets for first and second level assessment of the

patient meant that time with the �student� might be further

diminished (B4/A & E).

2. NOVEL LEARNING IN THE SAME TRUSTNOVEL LEARNING IN THE SAME TRUST

In sites C and D, theatre managers were required to give

the ENB 183 students supernumerary time for anaes-

thetics and recovery experience. However, most of these

students did stay in their own theatre department because

of a lack of replacement monies to enable placement in

another NHS trust. Students did get to experience novel

learning through placements in the base department,

although this was not without its problems:

The manager was not going to let me go out of the

department; she needs to keep me here. For example,

I come on duty at one o’clock and I might be working

with my mentor until five but as soon as five o’clock

comes, then I am required to be a member of the team

and not a learner. I was one of only a few nurses that

could do joint replacements. So I might be in the middle

of doing a urology anaesthetic list, and then be dragged

away because so and so has gone off sick, and there is no

one to scrub for a knee replacement (C/183/Al)

3. THETHE �QUID PRO QUOQUID PRO QUO� ARRANGEMENTARRANGEMENT

Managers were clear that �visiting� students were not as able

to meet the demands of the setting as their own staff familiar

with the environment. Equally students sometimes per-

ceived that they were not able to practice at the level they

were used to in a new environment because of constraints set

in place by service managers in the host environment:

I felt that was quite a strange place. They didn’t really

understand why I was there. I was qualified and I was

an A & E nurse (but) it took a couple of weeks to get

anybody to trust me and to be able to do anything.

They wouldn’t let me do triage. (C/199/Al, 2)

The students highlighted the tensions that were felt on

placement, working in settings where practice was different:

K was a bit constricting; nurses there work according

to their grade. For example, D grades aren’t allowed

to check drugs with another D grade. They aren’t

allowed to change ventilation settings. (D/100/St/2)

I have felt a little bit of a spare part on placements

elsewhere. Yes, it is a great learning environment and

you get to experience other ways and methods of



achieving something, but you feel useless because of

policy restrictions. There is a lot you can’t do. You feel

you should be more active in the role while you are

there but often you can’t because of policies!

(A/100/St/FG)

However, another student also highlighted that it was

about working in a different staffing structure:

I think just what struck me most was really the

organisation of the way things are and how they ran

things. At (name of Trust), the nurse in charge didn’t

necessarily float, they could quite easily have a patient

if they were full. …they often ran on an �E� Grade in

charge, with the Senior House Officer as their �on-call�doctor. They only had two ITU consultants and if they

were both off you had the anaesthetic consultant. I am

used to having a least an �F� if not a �G� in charge there is

normally a specialist registrar on call so that was a bit of

a shock to the system, but that is just the way they work

and their grading doesn’t allow for them to do it any

other way. (D/100/St1)

All these tensions caused dysjuncture, whereby the

student could no longer function at a level equivalent to the

ability they could demonstrate in their �home unit�. This was

an issue when they were completing competency assessment

because the usual smooth and dextrous patterns of working

in a familiar environment (that equated to being in control of

the situation by an assessor) could be lost because of working

in a new context (A/100/Education Sister/1). Therefore,

some students felt that their clinical competence was

impeded by environmental factors rather than their actual

ability to perform at the bedside.

Some lecturers, assessors and managers who had experi-

enced that status on their own ENB programme identified

full supernumerary status as the �gold standard�. However, at

institution D, this approach had been tried but was not well-

evaluated as the students attending the course at that time

had a lot of clinical experience and felt �molly coddled�(D/100/LP). The current approach of providing some

supernumerary time in another setting was seen as providing

a �middle ground�. However, there was evidence that

students could undertake the whole of the clinical course

without a placement or visit to another unit (B4/100/Sister).

This situation created a potential problem when trying to

establish core competencies and national threshold stand-

ards. What might be considered core in one setting, because

of patient dependency might be determined as irrelevant in

another. This illuminates an important issue labelled the

practice:competence gap (Scholes & Endacott, 2002). This

refers to a situation whereby a student based in one setting

and unable, for whatever reason, to undertake clinical

experience in another, cannot acquire a competency. This

might suggest that competence is not �core�. However,

stakeholders could not agree on which competencies should

be considered core because if that competence was viewed as

�everyday� in that setting, from an ethnocentric perception,

it was considered core or essential.

Perceptions of learning

Notions of how supernumerary practice and supervision

were constructed by the students illuminated some

distinct perceptions about the meaning of these learning

opportunities:

If you are very busy, you are looking after a critical care

patient but you are not working with anybody more

senior to yourself. You are learning through experience

and you might use the doctors as a resource (to ask):

�what is going on here, why is this happening?� If you

are rushed off your feet you don’t get the chance to be

actually be taught or to work with somebody. You are

part of the numbers. The nurses have got their own

patients or they are running the unit, and that is just the

way it goes and it depends on the doctor, if they are

rushed off their feet they don’t have half an hour to

spend with you. (D/100/St/3)

A few of the doctors here… have been very good and

say: �right now (name of student), what are you

seeing here? What is your feeling about this patient?

Why do you think�? They are really good, but I think

that is because my face is well known and they are

encouraging. (D/100/St/2)

Here we can see a distinct difference in the notion of

being challenged �on the hoof� to an expectation of setting

time aside to �go over� underlying theory. This was

student-specific rather than course or unit-specific. One

manager described how students could sometimes be quite

rigid in their interpretation of supernumerary practice

within service provision:

…and they will actually say �I am supposed to be

supernumerary you know, and I have been looking

after this patient all day� and I say �Well yes, I can

understand that, what else had you planned to do

today� �Well, nothing� �You haven�t planned a visit,

you haven’t planned to go to the library’ �Well no,

but…� �Well you can�t be sitting around doing

nothing, this is a learning experience for you, do you

feel supported looking after this child’ �Yes� �Has

there been any problems?� I think if they are left

unsupported that is very different, and left just to get

on with it in a situation which they can’t deal with,

but they are not, and even the more junior nurses

have got to be put in clinical situations where they are



going to learn and expand their knowledge and skills

and they can’t do that by standing at the side of the

bed with their hands folded. (F/415/Man/1)

A lot of people need support in understanding how to

use clinical time. You have to actively encourage them

to have a look at the patient: how did they get here?

What is their history? Look at the notes – the pattern of

stay in the hospital! There will be something interesting

to learn! But, there is a temptation for the student to

say: �just a couple of chest pains! I�m going to the

library!’ But you can get them past that! (A/124/CL)

From interviews with a range of stakeholders, the

reasons for undertaking placements were:

• opportunities to visit specialized units to expand the

scope of practice

• exposure to more general environments when the

student was based in a highly specialized unit

• exposure to special patient groups when the work base

could not provide the full scope of experience to meet

the learning outcomes

• exposure to practice in a referral unit

• exposure to practice in Units from whom referred

patients had been sent

• exposure to novel environments and

• rendering the familiar as strange to encourage reflec-

tion, critique and practice development.

Other methods deployed in the courses to �make the

familiar strange� included the use of laboratory time and

supervised simulations. Critical to this approach was to

ensure that the students were given �amnesty� or a safe

environment in which they could declare or demonstrate a

lack of competence no matter how many years experience

they had prior to the course:

I really try and drive home to the students that they

can ask anything and get to know and learn any skill

that is relevant. It is their time, if you like an amnesty

time where they can admit: �I have got through to this

stage but I don�t really know how to insert whatever’.

I (create) an open atmosphere and they do use the

outlet. (A/LP 199)

This was performed to cover clinical skills such as

advanced life support, advanced trauma life support, as well

as suturing, plastering and other practically oriented

procedures. Once again critical to such an outcome was

having lecturer practitioners (LPs) who had current clinical

expertise and could relate to real or recent patient scenarios.

Discussion and conclusions

Students came from a variety of clinical settings who

managed patients with variable levels of dependency. This

meant that the range and amount of experience the students

had encountered was widely disparate. When and why

students were selected to do the long clinical courses varied

between NHS trusts. This led to a heterogeneous student

population on the courses. Pitching the appropriate level and

depth of knowledge was a constant challenge. Lecturers were

having to accommodate a wide diversity in interpretation

about the purpose of the course and seeking to deliver

material that served a diverse audience. Purchasers, manag-

ers, students, assessors and lecturers may not have necessar-

ily shared the same aims and objectives for the course as those

stated in the curriculum document (Scholes et al., 1999).

Staff recruitment and retention problems often meant

that �course students� and their supervisors/assessors had to

subsume their learning goals and needs to that of providing

the service (Phillips et al., 2000; Burkitt et al., 2001; Scholes

& Endacott, 2002). Even where the curricula stated a period

of supernumerary time for placements and visits to other

localities, this might not have been realized. In some places

this was managed by the students negotiating direct swaps

with one another to ensure they experienced work in other

localities. However, managers and students did not feel their

contribution could match that delivered in their own

familiar work base.

Managers in certain NHS trusts provided study leave

and supernumerary time but were under pressure to

relinquish this time to ensure parity and equity for all the

students in the cohort.

In some cases, students were given supernumerary time

to work with their assessor in their own work base. Others

gave supernumerary time to release students to undertake

placements in other units to expand the students’

repertoire of skills. In another case, �supernumerary time�was constructed as day release to attend college for the

taught component of the course.

Levels of supervision were variable and the level of

support provided by most supervisors was less than that

stated in the curriculum document. Some units identified at

least 1 day a week when the student would work on the same

shift as their supervisor/assessor. Students identified that

although they were allocated on the same shift this did not

necessarily mean they would work with their supervisor

especially where the geography of the unit was such that

they may be allocated to quite different and distinct areas,

e.g. A & E. However, there were examples within this

setting of excellent models of facilitation and assessment,

often achieved through personal investment by the assessor

and assessee. This supports Phillips et al. (2000) who

contest that �the system is founded on individual effort�(p. 150), and compromise between �getting the job done�and investing time in learning and assessment.



There was mixed opinion about the value of placements

and broadening the students’ experience through place-

ments in localities other than the work base. Some

considered it irrelevant and others that it could be

potentially dangerous to have brief exposure to new skills,

which could then fade because of lack of rehearsal over

longer periods of time. But other managers felt that initial

exposure to widened range of skills and capabilities could

only enhance the students’ performance in the work base

and were a necessary component of the course. However,

variability in length of placements, or an absolute com-

mitment to continuing experience within the work base,

does raise significant questions about the feasibility of

standard competencies for practice (Redshaw et al., 1999;

Scholes & Endacott, 2002).

The importance of structured reflection from a skilled

facilitator was critical (Schon, 1991; Johns, 1995; Scholes,

1995; Jasper, 1999). However, reflection can expose vulner-

abilities and coping strategies which can enhance anxiety

levels (Rich & Parker, 1995). The extent to which assessors/

mentors were prepared to manage the complex and time-

consuming process (Palmer, 1994) to achieve perspective

transformation (Mezirow et al., 1990) was limited. Further-

more, the �student� might defend themselves from such

insights especially if they are work based (Scholes, 1995;

Scholes & Endacott, 2002). Furthermore critical, thoughtful

reflection can be at odds with certain aspects of competency-

based assessment especially when undertaken in the �real time

context� (Phillips et al., 2000) – in this case, in critical care

delivery.

The study data enabled identification of a range of factors

that enhanced the integration of theory and practice in the

reality of the clinical situation (Fig. 2). However, these

factors will work only where all parties acknowledge the

potential for a practitioner:student gap. The clinical courses

appeared to be more effective where students were facilitated

to see the potential of learning from �everyday� encounters

through a critical lens, i.e. the familiar was made strange

either by working in a novel context or through facilitation

and challenge to enable them to see an alternative way of

working. This approach, focusing on student learning rather

than assessor teaching, will not be successful without

considerable investment, and in particular, the re-examina-

tion of value systems and priorities about learning in the

practice setting by all the stakeholders involved (ENB/DH,

2001). After these values have been clarified, supernumerary

status for the student to encounter learning in novel

environments might be reconsidered. However, if it is

decided to keep the �student� in their work base, a way to

maximize learning opportunities might be to reflect on the

benefit of making the assessor supernumerary rather than the

student. In this way the assessor can facilitate or enhance the

potential of learning from everyday encounters in the clinical

setting and maximize the students’ learning experience under

direct supervision within the �real time� �real world� pressures

of clinical practice.

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1. Comparative secondments: The opportunity to visit and work in environments other than their work base to make comparisons about working practices and distil better modes of working which could be reported back to the ‘home’ Unit.

2. Learning culture: Clinical environments that fostered a positive learning environment and explicit teaching strategies within the working day (this was evident in teaching hospitals and DGHs).

3. Facilitation and mentorship: Where students were facilitated and supported to work along side their practice assessors and mentors.

4. Student identity: Where the course member was clearly identified as a ‘student’ within the work base and was given the opportunity to expand their practice through working with clients or patients with a range of challenging conditions.

5. Supported reflection: Where students were given the opportunity to revisit work base skills (either in a laboratory or in the practice setting) and declare weaknesses in their own performance under conditions of‘amnesty’.

Figure 2 Factors which enabled the integration of practice to theory.



the reality of clinical learning in critical care settings: a practitioner:student gap?

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