Student Nurse | Brighton Journal of Research in Health Sciences

Feb
9

A focus on Placement Learning Opportunities for Student Nurses – literature review

Category: issue 1, volume 2 Tags: placement learning, Student Nurse Leave a Comment

Introduction

All student nurses are allocated clinical placements throughout their three year course, in which to develop their practical skills. Whilst in practice, they are supported by a designated mentor, who is the student’s identified lead for educational support. In this context, mentor support is provided by practitioners, who have undertaken an approved mentor preparation programme, approved by the regulatory body, the Nursing and Midwifery Council (NMC) (Nursing and Midwifery Council, 2008). The Code of Professional Conduct (Nursing and Midwifery Council, 2015) outlines a responsibility for all registered nurses and midwives, known as registrants, to facilitate the education of learners in clinical practice.

I am aware from discussions with students, and overhearing their conversations in the classroom setting that they perceive their placements to vary in quality, with some feeling they have benefitted from very strong, beneficial placements, through to others who do not feel so advantaged educationally. Some students perceive that they may have had an experience that was inequitable in comparison with peers, whilst others may comment that they don’t feel they learnt as much when comparing with previous placements. As such, I am aware that a perception exists that there are “good” and “bad” placements in the eyes of students. Having been a student myself, I am fully conversant with the fact that students will compare one placement experience with another and will also discuss their experiences with peers (Foster et al., 2014). The NMC dictates that the nursing course is built on 50% theory, and 50% clinical placements – thus ensuring that students gain an opportunity to gain experience in a range of clinical settings (Nursing and Midwifery Council, 2008). A dedicated team within the university is responsible for the allocation of a broad range of placement experiences (community and hospital) to all students on a nursing course.

Placement learning opportunities vary significantly in context, and it must be noted that no two placement settings are easily comparable. It is important to note the uniqueness of students and mentors, as all have a preferred way in which to teach and learn, and as such this factor must also be considered a significant variable.

In my mind, the key features of a work placement are to provide students with an experience similar to that of qualified status, as placements allow them to immerse themselves into the clinical setting. They are able to practice, under supervision, the skills they have been taught in the classroom setting and to develop their practice in readiness for qualification. Placements should also develop confidence and provide an opportunity to demonstrate competency to mentors.

Literature Search Process

A dual approach was taken to source literature to support the identification of a suitable research problem. Initially I undertook a systematic search of a number of recognised repositories, using specific search terms and a number of initial inclusion and exclusion criteria to ensure that the literature identified was relevant to my area of focus. Search engines included Google Scholar, the British Nursing Index (BNI) and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). This process proved very fruitful in terms of the quality and quantity of literature identified. The limited word count for this article does not permit a full overview of the search terms used and resultant number of “hits”.

Alongside this process, I also undertook what can be classified as a serendipitous search. This involved using my own knowledge of the topic area to ensure that key policy and regulatory documentation was identified, along with material that I currently use within my teaching practice. I also ensured that I followed up material found in the reference listings of articles I have read. On reflection, although this process goes against the traditional process for systematic literature searching that I am used to, it was extremely beneficial in giving assurance that I had reached saturation point as the majority of literature cited in the articles I was reading had already been covered. This provided confidence that I had not missed any key literature in the field I am focussing upon.

Literature was predominantly included if it originated in the UK, and was published within the last 15 years. Nursing is regulated differently across the globe and mentoring and placement requirements vary depending upon the country you are in.

If relevant, literature from overseas was included after careful consideration was given, if it supported the identification of a research problem by offering a perspective that varied from the UK based material. Literature was only included if it originated from credible sources, which for the majority were peer reviewed journals.

Overview of the Literature

From the outset, it became apparent that there was very little literature focussed on the “poor” placement, and particularly any that discusses the potential advantages of a perceived negative placement experience. The majority of the literature sourced has a firm focus around guidance to mentors, and how to make a placement learning experience as positive as possible.

The makeup of the identified literature can also be categorised for significance. The over-riding majority of identified literature was research based, having undertaken studies examining the experience of learners in practice. This was then published in credible journals. Secondly, “policy” documents were identified – these predominantly originated from the nursing regulator, the NMC (Nursing and Midwifery Council, 2008), as well as guidance from the Royal College of Nursing (RCN) based upon the regulators document and combined with advice from existing mentors (Royal College of Nursing, 2007). Finally, a number of handbooks, or toolkits covering guidance for staff involved in supporting students are concerned with the “best practice” approach (Brockbank and McGill, 2012; Shaw and Fulton, 2012).

The literature acknowledges that although in placement settings the mentor has a lead responsibility for facilitating education, there are other factors that significantly impact on the overall educational quality of the experience.

For the purpose of this review, a total of 59 articles or sources were read, and a number of key themes were evident. I utilised a matrix as recommended by Oliver (Oliver, 2012) to summarise each piece of literature and to conduct a mini thematic analysis. Upon saturation being reached, a review of the matrix enabled the identification of a number of themes that were consistent across numerous articles and sources.

The literature that was identified, as previously mentioned, all originated from credible sources – predominantly journals that are widely recognised in the field of healthcare and healthcare education. A critical approach was taken in reading each article, with a particular emphasis around critical analysis to understand what within the source was not being said. As an example, the majority of literature focussed on good examples of placements and an emphasis on positive experiences; there was a lack of literature that specifically examined the impact of negative placement experiences.

The overriding strand that ran throughout the majority of articles was the importance of the learning environment itself (Beskine, 2009; Gopee, 2011; Stuart, 2007; Walsh, 2010; Papp et al., 2003; Willis Commission, 2012; Royal College of Nursing, 2007; West et al., 2007; Burns and Paterson, 2005). Gray (2014, p65) defines the learning environment as “an interactive network of forces within clinical settings that influence students’ clinical and professional learning outcomes”. Other key foci of the literature sourced were concerned with examining relationships between mentors and mentee (Foster et al., 2014; Andrews and Chilton, 2000; Cahill, 1996; Gray and Smith, 2000; Jokelainen et al., 2011; Butler, 2012; Henderson and Eaton, 2013), and the importance of ensuring that these were effective on a professional level.

As would be expected, a considerable amount of literature exists on the assessment element of the mentor’s role, and a number of studies have been undertaken to look at the ways in which assessment is undertaken (Beskine, 2009; Aston and Hallam, 2014; Gopee, 2011; Stuart, 2007; Walsh, 2010; Robinson et al., 2012; McNair et al., 2007).

On reflection, I was surprised that there was a minimal amount of literature with a focus around the support provided by universities to mentors supporting learners in practice (Henderson and Eaton, 2013; Foster et al., 2014). Mentoring is recognised as an often challenging role, and for new mentors in particular, supporting students in practice placements can be difficult and could potentially impact upon the experience of the learner.

The Student / Learner

Perceptions

As students’ progress through their course, they will naturally compare their placements with their own previous experiences (Foster et al., 2014), and also with that of other students. It is only natural that they will perceive differences to exist between one area to the next, and likewise between the educational gain they have identified. The literature states that students will emulate and role-model qualified staff who they perceive to be good examples of the nursing profession, and will compare staff in one area to the next (Beskine, 2009; Brockbank and McGill, 2012). The literature does not highlight that practice varies in terms of standards and the evidence on which it is based, and as such role modelling can be problematic if the practice demonstrated is not current and credible.

Expectations

Student nurses will naturally expect every placement to be a positive experience, through which they can develop their knowledge and gain a greater understanding of the role of the nurse. Many will argue that placements are the way in which they develop competency, and that positive or “good” placements are the only way in which they can complete their training and qualify in a state ready for practice (Andrews and Chilton, 2000; Gopee, 2011; Jokelainen et al., 2011). The literature covered would agree with this in the main, however an Australian article (Green and Jackson, 2014) discusses the negative aspects of placements and associated mentoring. This negative aspect of placements is a weakness in the literature and needs further exploration, as there is a need to explore how student can be prepared to deal with placements that they feel are not conducive to learning and to explore the benefits of being placed in a setting that is not supportive.

Resilience

Refreshingly, Green and Jackson (2014) acknowledge that poor mentoring and negative placements do occur regularly in practice, and for a number of reasons. This paper led me to reflect and think about what was stated within it. Most of the literature reviewed outlines the importance of effective relationships between mentors and students (Henderson et al., 2012; Henderson et al., 2010); the need for learning environments to be set up as effectively as possible to facilitate high quality education and the guiding hands of experienced clinical and mentoring staff to ensure that the clinical education pathway of student nurses is as clear of obstructions as possible throughout the three years of training.

Theoretically, such an experience sounds very beneficial, and most students would be grateful to progress in such a manner. But is a poor placement also as beneficial to the education process? In my view, it is, as it introduces the student to the complexities of life as a healthcare professional. In reality, shifts as qualified practitioners will be challenging on a regular basis (Wallace and Gravells, 2007), and by gaining experience of challenging situations as a student, it assists in the development of building resilience and coping strategies (Papp et al., 2003).

‘Poor’ placement experiences also enable students to develop skills in resilience, and through working through challenging situations, leaves them better equipped to cope with similar situations either in future placements, or in practice as a qualified nurse. The university plays a significant part in supporting students in practice (Foster et al., 2014) and has a duty to liaise with practice colleagues if a placement learning experience has the potential to cause significant harm to the development of a student (Burns and Paterson, 2005).

Past Experiences

All students enter the course from a range of backgrounds many will have previous healthcare experience gained through previous employment in a support role, whilst others commence their nurse training with no previous experience at all. In some cases, this experience can be helpful, as an existing understanding of an area can assist the student to build upon their current knowledge base. For others, they enter a placement not knowing what they do or don’t know. The literature discusses in depth the importance of mentors and placement colleagues providing a positive, conducive setting in which all students can thrive and develop their knowledge and skills (Beskine, 2009; Royal College of Nursing, 2007; Aston and Hallam, 2014).

The motivation of students to enter the profession may also be a factor to consider – as some students could be classed as “healthy” having had little or no contact with the profession and whose motivation is to help others and care for the sick. As a result, they may have very few expectations of their placements. Others may have experience of the profession through previous employment or as a patient, and may make comparisons to first-hand experience.

Mentoring

Critique of the NMC Standards

The NMC (Nursing and Midwifery Council, 2008a) defines a mentor as one who ‘facilitates learning, and supervises and assesses students in a practice setting.’This definition is akin to frequently quoted definitions used in healthcare mentoring texts (Shaw and Fulton, 2012; Walsh, 2010; Gray, 2014) who speak of mentoring as being closely linked to skill and practice development.

As the regulatory body, the NMC have published guidance, which is frequently referred to as the “bible” for mentoring (Nursing and Midwifery Council, 2008). Idealistically, this document would provide a succinct set of instructions to mentors around how to manage a placement experience for students, and how to deal with potentially challenging situations. Unfortunately this is not provided, and the document is based around eight domains which set out the key areas of significance for mentoring students in practice placement settings.

Supporter versus Assessor

As students’ progress through their three year programme, they become more and more aware of the split responsibilities of the role of their mentors and for many, see them primarily as somebody who will judge their practice and influence the decision as to whether they will progress in their training (Bray and Nettleton, 2007). Interestingly, the study undertaken by Bray and Nettleton (2007) highlighted that the majority of mentors see their role as being fundamentally that of a teacher or supporter. Assessment is a key, but complicated process to manage for mentors, and the consequences of a wrong decision are huge for students. Stuart (2007) speaks of the importance of assessment being conducted fairly and in the best interests of students.

An observational study undertaken in a critical care setting identified the importance of the mentor offering support to students, as this led to reduced stress levels and opened up avenues for increased learning (Cochrane et al., 2008).

It is encouraging to observe more parity in this area around the balance between literature that covers both positive and negative aspects of mentoring and the relationship students have with their qualified colleagues. I have frequently reflected upon the benefits of splitting the role and having two mentors allocated, one to support and the other to assess.

Very few articles seek the views of students, and do not address any perceived difficulties from their position.

On reflection, this dual aspect of the role has infrequently been an issue for myself in a mentoring role, nor immediate colleagues. In many situations, if the mentor has been acting as a teacher and has been working with a student to develop skills in a particular area, the assessment process naturally falls within this role. It could also be highlighted, that if a student receives poor assessment results within a placement, this may potentially cloud their perception of the overall experience – irrespective of the quality of teaching received.

Benefits of shared responsibility in a larger department

As already mentioned, there are distinct advantages to the student and mentor who are based in a larger department. The responsibility for providing the guidance to students can be shared. The NMC guidance states that qualified mentors must spend 40% of practice time directly working with their student (NMC, 2008) which leaves a considerable amount of time during which a student may work with other colleagues. “Associate mentoring” is increasingly being used in practice to facilitate the educational experiences of students – as many registered nurses may not necessarily hold the mentoring qualification, but do have extensive clinical experience that will benefit all learners. Through the involvement of the whole team, expertise will benefit all learners and pressure is taken away from the qualified mentor to facilitate all learning opportunities. The literature does not discuss who should be teaching learners in practice, and this is wholly relevant to the above point. With many expert practitioners working in the placement settings, there is huge educational potential for students through working alongside such individuals.

In smaller teams, and where practitioners work autonomously, working alongside a range of colleagues is not possible. In such situations students are limited to the one mentor and can sometimes see this as a disadvantage when making comparisons to other placements.

Integration of the literature

A commission into the future of nursing education (Willis Commission, 2012) reinforces the pivotal role mentors will continue to hold in educating the next workforce generation, but does not analyse the competing roles of supporter and assessor a mentor must undertaken when carrying out the role in practice.

The literature in existence to support all those involved in educating in practice, as previously discussed, is a combination of research and advice in the form of toolkits. This is based upon the lived experiences of authors in the field of mentoring and is not necessarily research based (Wallace and Gravells, 2007; West et al., 2007; Brockbank and McGill, 2012)

The majority of the literature sourced on the mentoring element of placements is heavily biased towards the positive experience. There is a range of books and published research that discusses the “gold” standard, and provides advice on managing an effective placement experience. There is limited material that discusses the potential benefits of a negative or “poor” placement experience from a mentoring perspective. On reflection, my experiences as a mentor and as a mentee have generally been very positive – no mentor intentionally sets out to facilitate a poor placement experience for their allocated learner.

The Learning Environment

Learning cultures

A learning culture is defined by Gill(2009) as a setting in which all barriers that prevent learning from occurring are removed, and staff are rewarded for promoting learning in the setting – ultimately education should be the rule and not the exception.

It is recognised that each placement setting will differ due to the individuals that make up the team, and to the nature of the work undertaken. By default, some areas are more stressful than others due to the un-predictable nature of the setting. However, each of the above are insignificant if there is a shared culture of learning held by the whole team – if the whole team are motivated and committed to the facilitation of learning, all students should thrive.

Beskine (2009) links the environment to the staff working in an area at all levels, and discusses the importance of role modelling positive behaviour from ward manager through to cleaner. She advocates the significance of a shared philosophy towards learning, and promotes cohesive learning across a whole team, which potentially eliminates the “toxic mentor” (Green and Jackson, 2014) situation whereby one or more individuals are not keen to teach and assess students in practice. The role-model concept is supported (Brockbank and McGill, 2012) in mentoring texts as being the difference between mentoring and simply coaching an individual.

Positive and negative impacts on learning

Whilst the literature speaks generally around the learning environment as a whole, I can breakdown the focus area into separate areas of consideration: the physical environment; the individuals working within it and the philosophy held by the individuals towards learning. The physical environment will be discussed in the next section, focussed upon the work environment.

The literature agrees that the learning environment in which students are allocated clinical placements vary considerably due to the nature of the services they provide (Andrews and Chilton, 2000). Walsh (2010) notes the limitations affecting mentors and learners in that a ward or assessment unit’s primary role is to deliver healthcare, but suggests that at regular intervals the mentor and student takes a step back to review the area from their respective role in order to suggest improvement. For example, the process of giving feedback or undertaking a knowledge assessment requires a quiet area with minimal interruptions, a commonly reported issue, and sometimes the use of office space or examination rooms can be negotiated to allow such dialogue to occur. Duffy (Duffy, 2003) identified the increasingly common issue of mentors failing to fail students, but made the link to the importance of a positive learning environment in which student nurses can thrive and excel. It must also be recognised that the healthcare settings vary significantly, which for some can mean learning on a ward setting, whilst others may be in the home of a patient, or in a clinic setting (Eller et al., 2014)

Shaw and Fulton (2012) discuss another action that students often comment on as making the difference between beneficial and disadvantageous placements – a welcome and education pack. Such documents are collected by students in advance of a new practice learning experience and provides information around the work of the ward or department and some pre-reading material to support learners when they are working with mentors.

Philosophy of the wider team

For placements to be effective there is a need for the whole team to share a philosophy that education involves everybody, no matter how closely they are to be working with a learner.
With many expert practitioners working in the placement settings, there is huge educational potential for students through working alongside such individuals – irrespective of whether they hold a formal mentoring qualification.

In recent years, there has been increasing debate around the practicalities of making all registered nurses mentors (Anonymous, 2014). This is a very contentious issue, as is the suggestion that mentors should receive additional pay. I feel that a mentor requires a number of personality traits, such as patience, resilience, creativity and an interest in education that not all nurses necessarily possess. My professional opinion is that mentoring and supporting education in practice requires specialist skills, and not all staff are cut out for the role. This view is supported by the findings of the Willis Commission (2013) into the future of nursing education and discusses the complexities and demands of the mentoring role. At the current time, there is no personal selection criteria for mentors, as there is a requirement to increase the numbers of mentors in the practice setting (Anonymous, 2014).

My current role as a lecturer involves me leading tutorial sessions that outline the expectations of students prior to entering placement settings for the first time. If placement areas can be encouraged to develop and expand upon the learning opportunities available in practice with the support of the Higher Education Institutions (HEI), the benefit to students will be far reaching.
Furthermore, each HEI will have their own approach to managing the placement element of courses – and in particular the support offered and provided to students and mentors in such settings.

Conclusion

Having undertaken the literature search, and been surprised around the literature leaning towards the “gold standards”, I believe that there are advantages to exploring how students benefit from a perceived negative, or poor placement experience. There is also an understanding to be gained from students as to what their perception is of good and bad placements. By this I mean that a good educational placement experience for one student may be viewed differently by the next.

Placements are a stipulation of a nurse training programme, but also need to provide the student with opportunities to learn the role they are being prepared for. As the function and outlook of a placement varies from the outlook of a student, mentor, lecturer and workplace, it is likely that some students will perceive their experience to less than ideal. It can be argued that as the body with overall responsibility for students, the HEI must much better prepare students for placement experiences.

Having undertaken a review of this literature in this area, I perceive the following to be potential researchable problems.

In the eyes of nursing students, what is a good or bad educational placement experience?
What are the benefits to student nurses of a perceived negative educational placement experience?
What is the role of the university in preparing students for placement learning opportunities?

From a methodological perspective, there is scope for an ethnographical approach in order to undertake observations in practice. This would allow me to gain an understanding of the factors in a range of placement settings that contribute to the overall educational experience.

Darren Brand, Senior Lecturer, School of Health Sciences

References

Andrews, M. and Chilton, F. (2000) “Student and Mentor Perceptions of Mentoring Effectiveness”, Nurse Education Today, 20 (7) pp. 555-562.

Anonymous (2014) ‘Should All Nurses Be Mentors?’, 110 (Generic) 22.

Aston, L. and Hallam, P. (2014) Successful Mentoring in Nursing, London: Learning Matters.

Beskine, D. (2009) “Mentoring Students: Establishing Effective Working Relationships”, Nursing Standard, 23 (30) pp. 35-40.

Bray, L. and Nettleton, P. (2007) “Assessor or Mentor? Role Confusion in Professional Education”, Nurse Education Today, 27 (8) pp. 848-855.

Brockbank, A. and McGill, I. (2012) Facilitating Reflective Learning: Coaching, Mentoring and Supervison, London; Philadelphia: Kogan Page.

Burns, I. and Paterson, I. M. (2005) “Clinical Practice and Placement Support: Supporting Learning in Practice”, Nurse Education in Practice, 5 (1) pp. 3-9.

Butler, K. (2012) ‘Benefits of a Peripatetic Support Mentor’, 108 (Generic) 23-25.

Cahill, H. A. (1996) “A Qualitative Analysis of Student Nurses’ Experiences of Mentorship”, Journal of Advanced Nursing, 24 (4) pp. 791-799.

Cochrane, J., Heron, A. and Lawlor, K. (2008) “Reflections on Student Nurse Placements in the Picu”, Paediatric nursing, 20 (1) pp. 26-28.

Duffy, K. (2003) Failing Students: A Qualitative Study of Factors That Influence the Decisions Regarding Assessment of Students’ Competence in Practice, Glasgow: Glasgow Caledonian University [online]. Available:<http://www.nm.stir.ac.uk/documents/failing-students-kathleen-duffy.pdf> [Accessed 19th December 2014].

Eller, L. S., Lev, E. L. and Feurer, A. (2014) “Key Components of an Effective Mentoring Relationship: A Qualitative Study”, Nurse Education Today, 34 (5) p. 815.

Foster, H., Ooms, A. and Marks-Maran, D. (2014) “Nursing Students’ Expectations and Experiences of Mentorship”, Nurse Education Today. 35 (1) 18 – 24

Gill, S. J. (2009) Developing a Learning Culture in Nonprofit Organisations, London: SAGE Publications.

Gopee, N. (2011) Mentoring and Supervision in Healthcare, London: SAGE.

Gray, M. (2014) Practical Skills for Mentoring in Healthcare: A Guide for Busy Practitioners, London: Palgrave Macmillan.

Gray, M. A. and Smith, L. N. (2000) “The Qualities of an Effective Mentor from the Student Nurse’s Perspective: Findings from a Longitudinal Qualitative Study”, Journal of advanced nursing, 32 (6) pp. 1542-1549.

Green, J. and Jackson, D. (2014) “Mentoring: Some Cautionary Notes for the Nursing Profession”, Contemporary nurse, 47 (1-2) p. 79.

Henderson, A., Cooke, M., Creedy, D. K., et al. (2012) “Nursing Students’ Perceptions of Learning in Practice Environments: A Review”, Nurse education today, 32 (3) pp. 299-302.

Henderson, A. and Eaton, E. (2013) “Assisting Nurses to Facilitate Student and New Graduate Learning in Practice Settings: What ‘Support’ Do Nurses at the Bedside Need?”, Nurse education in practice, 13 (3) pp. 197-201.

Henderson, A., Twentyman, M., Eaton, E., et al. (2010) “Creating Supportive Clinical Learning Environments: An Intervention Study”, Journal of Clinical Nursing, 19 (1-2) pp. 177-182.

Jokelainen, M., Turunen, H., Tossavainen, K., et al. (2011) “A Systematic Review of Mentoring Nursing Students in Clinical Placements”, Journal of Clinical Nursing, 20 (19-20) pp. 2854-2867.

McNair, W., Smith, B. and Ellis, J. (2007) “A Vision of Mentorship in Practice”, Journal of perioperative practice, 17 (9) pp. 421-430.

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Robinson, S., Cornish, J., Driscoll, C., et al. (2012) Sustaining and Managing the Delivery of Student Nurse Mentorship: Roles, Resources, Standards and Debates, London: King’s College London.

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Stuart, C. C. (2007) Assessment, Supervision and Support in Clinical Practice: A Guide for Nurses, Midwives and Other Health Professionals, Edinburgh: Churchill Livingstone Elsevier.

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May
21

By David Bauckham

The Impact of Volunteering on Nurse Education

Category: issue 2, volume 1 Tags: Community Engagement, Student Nurse, Student Reflection, Volunteering 1 Comment

Abstract

This article describes some of the experiences of a small group of second year adult nursing students during an optional module – Student Community Engagement (SCE), at the School of Health Sciences, University of Brighton. Their experience was reflected on in the context of being a volunteer and working with socially excluded groups of children and young people. Their reflections are discussed in relation to the importation of new skills into their wider course work and are interpreted using educational and communication theory.

Introduction

In year two of the BSc Nursing undergraduate curricula students are able to choose between a range of optional modules. Students electing to participate with the SCE module are then invited to a ‘matching event’ which is jointly coordinated by staff from the Active Student Volunteering Service, based with University of Brighton’s Careers Service. Local voluntary organizations are invited to discuss potential learning opportunities within their organizations and to attract motivated volunteers. Significantly, many of the volunteering placements are not for profit organizations with a social care orientation, this offers the students a distinct change from their usual health based organizations.

Early in the placement students are asked to complete a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis and a learning agreement which are later reflected upon. One of the key aims of the module is the recognition and importation of transferable skills and knowledge back into their existing repertoire of professional nursing skills. The module’s summative assessment constitutes a short report describing the host organization and its function, an account of how they have spent their time, an impression of their effectiveness in their volunteering role, the benefits of their activity to the community and the skills and attributes developed while volunteering within the organization. The module is supported by six theoretical sessions looking at volunteering, active citizenship, relevant social policy and project planning. Two action learning sets are facilitated by senior lecturers, making use of narratives, story-telling and the use of reflective dialogue.

The Volunteering Learning Opportunity

At our matching event a range of volunteering options was presented, including the opportunity to volunteer with CCHF – All About Kids (previously Children’s Country Holiday Fund). As students training in the adult branch of nursing we rarely get to work with directly with children, this experience was viewed as an opportunity to broaden our skill-set with this specific group and to challenge ourselves by working with children from disadvantaged backgrounds with potentially difficult behavior.

CCHF was established in 1884 and is a registered charity. It aims to give disadvantaged children respite and residential breaks in order to improve their quality of life and to help them to recognize their own potential (CCHF 2013). It focuses on children aged seven to eleven living mainly within London or the immediate surrounding areas; it relies totally on donations from the public and corporate partners to fund their activities. Children can be referred by anyone who works with disadvantaged children such as teachers and social workers; their eligibility is then assessed against the CCHF criteria. This criteria includes a range of factors such as poverty, abuse, low self-esteem, children that care for a family member, or other family factors such as having a parent who abuses substances or who has a mental health issue. Each child is gently monitored for the duration of the camp due to their circumstances. CCHF works closely with statutory organizations in order to address any issues or concerns encountered throughout the duration of the camp. As such the experience represented our first opportunity to patrol the tensions of a safeguarding role.

It is estimated that of the 1.1million families living on low income in London in 2010 / 11; 60% could not afford to take their children away for a week’s holiday (London’s poverty profile, 2011). Cummins et al (2013) suggest that children that are brought up in poverty can be at greater risk of suffering from low self-esteem. This is one of the key areas that the charity works to improve. Their annual report demonstrates that many of the children that arrive on camp with low self-esteem and leave feeling much happier and far more confident (CCHF All About Kids, 2013).

The wider community also benefits from those accessing the opportunity as children with greater confidence and self-belief are more likely to have better health and are also less likely to engage in criminal activities (Chen et al 2013). Knapp et al (2011) supports this notion by suggesting that individuals who suffer from low self-esteem in childhood are likely to have worse economic prospects in adulthood. Conversely research by the Child Poverty Action Group (2013) using Department of Education data, suggests that children receiving free school meals attain an average of 1.7 grades lower than wealthier students.

A King’s Fund report (Buck et al 2013) suggests that in our modern society volunteers are sometimes under appreciated and used instead of paid workers – however this was found not be the case at CCHF where they have always relied upon the goodwill of volunteers to enable their existence. The role of the volunteer in society has become ever more important as a result of reforms put in place by the Health and Social Care Act, 2012, (Naylor et al 2013). As such, volunteering is now a key part of the current governmental strategy, and is included in their ‘Big Society’ vision. This aims to encourage people to participate in local projects, by giving them more power to influence the running of services and facilities in their community (Cabinet Office 2010). It believes that the inhabitants of communities understand the needs of the local area most, and this will help create “attractive and thriving” neighbourhoods.

Volunteering is traditionally associated with the concept of altruism (Haski-Leventhal 2009) – the motivational selfless desire to increase the wellbeing of others. Alternatively, Carpenter and Myers (2010) argue that the main drive for volunteering is not altruism, but the perceived benefits, whether these are career benefits or purely self-satisfaction. Sigmund and Hauert (2002) take this point further, suggesting that any act in which both parties gain is more co-operation than altruism, as both the volunteer and the organization benefit from the partnership. CCHF utilize this sense of co-operation in their organization; the vast majority of the workforce is made up from volunteers. Most of them are students who are hoping to both enjoy the experience and improve their future career prospects.

Personal Reflections

Amy’s reflection Before camp I had little experience of working with children or even managing large groups of people. At one point I managed a group of 15 challenging children for an hour with another first time volunteer. The children were well behaved, safe and actually enjoyed themselves, and at no point did I find myself worrying or panicing. Later on in the day, the senior leader praised at CCHF this activity, which helped to build my confidence for future situations on camp. Although these individuals were children, my confidence in leading larger groups of adults has definitely improved and this has made a noticeable difference in clinical practice, for example, when managing a bay of patients in a ward.

A potential weakness that I discovered during the camp that I had not previously identified in the SWOT analysis was my hesitance when trying to find the words to set and enforce interpersonal boundaries with the children and young people. As the week progressed I began to see the consequences of not doing so, I therefore realized that I needed to take some advice from our senior leader, who encouraged a certain amount of careful risk taking. This gave me the confidence to gradually experiment by trying different approaches within the interaction’s, in doing so I eventually over-rode my fears of causing offence or humiliating myself. I found that upholding boundaries did not alter the relationship that I had with the child, nor reduce their respect for my position; it was mostly accepted and often helped to harmonize power structures in the group. Reflecting on this process has helped me in subsequent nursing roles, for example, at timely moments I am more confident when offering health promotion advice, such as advice to reduce smoking, drinking or other harmful activities that I anticipated I would be perceived in an authoritarian or negative light.

One of the most significant experiences that occurred to me during the camp was dealing with a disobedient child and their parents. A particular child had consistently demonstrated aggressive behavior towards others in the early days of the camp. Bullying is not tolerated and so it became my responsibility to liaise with the parent about the child’s behavior and return them to home ahead of schedule. The parents were understandably upset and concerned when I contacted them; I myself felt awkward and did not want to exacerbate the situation further. I tried to remain calm, be professional and listened attentively to the parents; eventually we came to a mutual agreement. The way in which I dealt with this situation and the camp as a whole, reinforced my own ‘self-efficacy’, this is the belief in one’s own capabilities to produce a desired effect by one’s own actions (Lopez and Snyder 2011).

Laura’s reflection Although quite personal, my experience and subsequent reflections have helped me to surface, confront and alter some unconscious attitudes, raising my self-awareness in the process. The demographics of children on the camp was incredibly diverse as was their range of ethnicities and socio-economic backgrounds. This was in contrast to my own quite stable upbringing and I felt a little under confident in my abilities to engage and relate to them. One of the competencies for entry to their register, the NMC requires that:

“All nurses must practice in a holistic, non-judgmental, caring and sensitive manner that avoids assumptions, supports social inclusion; recognizes and respects individual choice; and acknowledges diversity.” (NMC 2013)

At first I found the encounters quite difficult, I just wasn’t consciously judging the children and young people, just uncertain as whether they would accept me and how the interactions would go. However, after I had spent some time with the children I realized that most of my pre-conceived fears were in fact unfounded, and by the end of the camp my I sensed that my confidence had changed. During my nursing career I will encounter people from all walks of life; this episode forced me to think about my own attitude and values. I believe this realisation equates to a shift in values which will stay with me for years to come.

I feel that working with children that may be distressed or upset during the camp has improved my communication skills, insight and confidence in clinical areas where I might encounter and treat children on a regular basis. Having not previously worked with children, I found being able to interact and to make appropriate interventions, a valuable leap for me which in turn forms a valuable part of a child’s development.

Sam’s reflection By the end of the camp I felt proud to be a part of each child’s accomplishments and saying goodbye to them was one of the hardest things that I experienced. As a caring professional it is vital to maintain healthy relationships with the patients and people that you work with. Making use of attachment theory Skovholt and Trotter-Mathison (2011), helpfully describe the ‘caring cycle’ as consisting of four stages: Empathetic Attachment, Active Involvement, Felt Separation and finally, Re-creation. I related this model to the time with the children and it is directly transferable to the relationships I form in my nursing practice.

Knowledge and use of the model has helped me to think differently about the process of attachment. Failure to reach the recreation stage of the caring cycle may indicate an unwanted level of attachment or unprofessional attitudes. My belief is that I will now be able to take part in further camps, being able to recreate healthy, professional relationships again and again.

My experience of volunteering has brought to the fore many considerations into my own education as a student nurse and responsibilities as a future health care practitioner and leader. Due to the personal circumstances of the children at CCHF, I became more aware the importance of safeguarding practices, namely remaining vigilant for possible signs abuse and malnourishment. Being responsible for a group of children meant observing for any issues and reporting them immediately; this aspect of social care applies more broadly to nursing and the responsibility nurses have to the wellbeing of their patients. I have found this experience correlates with my current placement in a Community Nursing Team as we regularly see vulnerable adult patients in their own homes.

Facilitator’s reflection Having supported the students during other academic sessions over the previous year I felt I understood the students well enough to sense the impact that volunteering had on them personally and on their learning. Their sheer enthusiasm evoked a positive sense of dissonance which inspired me to try and capture and analyse their experiences. In our action learning set I probed their narratives, asking what it was about the experience that so differed to other experiences on their course. My overriding sense was that it was the immersive nature of the summer camp combined with their interactions with the young people that had helped to transform their attitudes towards themselves, their practice and their ability to form and maintain relationships.
To interpret the students’ experience I have found it helpful to locate their experience on a two dimensional map of ‘reality’ and ‘learning outcomes’, created by Morgan and Burrell, (1979, cited by Brockbank and McGill, 2006). It is my view that their collective experience moved the group away from the objectivism and towards the subjectivism end of the reality dimension, and from the equilibrium towards the transformation end of the learning outcomes dimension.
Arguably, much of the learning taking place on the adult pre-registration nursing programme, such as clinical skills or anatomy and physiology, depends heavily on notions of an objective reality and maintaining the equilibrium of power structures, as per the conceptual dimensions. Such learning reflects ‘imposed objectives, based on perceived objective reality’ (Brockbank and McGill, 2006). At the ‘equilibrium’ end of the dimension, the status quo and ‘taken for granted’ ideas go unchallenged and are therefore upheld by the prevailing discourses and scripts.

My analysis is, the summer camp experience nudged the students towards the subjectivist end of the continuum as they were immersed in a new social world and a common language became ‘understood and continuously reconstructed, reproduced and transformed through interaction’ with the children and young people, (Brockbank and McGill, 2006). The students’ perspectives appear to have been altered as a consequence of the developmental experience, pushing them away from the stability of the equilibrium element towards the transformative end of the scale.

This is consistent with a symbolic interactionist perspective on perceptions of self and on developing relationships. Symbolic interactionism can be defined as ‘a theory of human communication that can account for the process by which everyday nursing situations become defined and redefined’, (Stevenson, Grieves and Stein-Parbury, 2004). Symbolic exchanges occurred during their interactions and these appear to have shaped understandings and cemented social relationships. For a short time they had been thrown off their usual student nurse ‘script’ (Stevenson, Grieves and Stein-Parbury, 2004), into a completely different domain and the students had adapted to the challenge and risen to the responsibility. In doing so they had achieved new understandings by being part of the young people’s world, using their language, interpreting and making meaning of their communication.

Conclusion

Johnson and Webb (1995, cited by Stevenson, Grieves and Stein-Parbury, 2004) found that ‘nurses do judge the social worth of people and that such judgments do have moral consequences’. However, in our students’ case we have seen these relatively negative evaluations were negotiated and renegotiated throughout their interactions. Once such attitudes are brought into awareness through the process of reflection, corrective thoughts were assumed. In thinking about the collective experience of the group, all three students have processed their experience and engaged with their inner dialogue to make meaning of what occurred in their week with CCHF. Significantly, by processing the subjective cues that occurred, small and hopefully lasting shifts and transformations of attitude occurred impacting on their outlook and learning.

Warren Stewart Senior Lecturer School of Health Sciences, University of Brighton, Laura Brown Adult Nursing BSc (Hons) student, Sam Harris Adult Nursing BSc (Hons) student and Amy Isaac Adult Nursing BSc (Hons) student

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