3.1.1.1 Creatin fosfo kinasa (CPK

Lave and Wenger (1991) tendered that the key to ‘situated learning’ was the relationship between learning and the social situation or community. They proffered that learning did not occur in isolation, but was influenced by co- participation with more experienced individuals within the social context. Earlier Wenger et al., (2002) highlighted the benefits of ‘communities of practice’ where people with common interests could interact and share knowledge and expertise.

In the case of nursing students, the experienced individuals refer to educationalists and clinicians in equal measure, because learning takes place in academic and clinical environments (NMC 2010b). Situated learning has similarities to the apprenticeship model in that experienced practitioners in the form of academics and clinicians teach the learner. The students start by acquiring theoretical knowledge in the form of lectures and tutorials in the university setting, followed by exposure to the practical component through a mix of observation and application in a clinical simulated environment (SCE).

This mix of theory and practical application is particularly suited to the learning style of nursing students (Sewchuk 2005). The concept of learning styles will be discussed in greater detail later on in this chapter.

Following on from learning within the university setting the students’ progress to participating in clinical placement on a peripheral level; observing and working with an expert, in the form of the clinical mentor. The social interactions encountered provide the right environment for further learning to occur. Participating regularly with a group of like-minded individuals can help the learner to deepen and expand their knowledge base and expertise (cannon and Newbie 2000). There are links between this and the ‘novice to expert’ theories (Benner 1984) and ‘Social Learning Theory’ (SLT) (Bandura 1986).

Learning within an environment is the basis for Bandura’s Social Learning Theory (SLT) which purports that a person’s behaviour is the result of their interaction with the environment in terms of observing and modelling the behaviours, attitudes and reactions of others (Bahn 2001). It is believed that this is a much safer way to learn than mere ‘trial and error’. The learning development comprises four processes (Quinn and Hughes 2007), starting with ‘attentional’, which involves the learner observing practice followed by self- directed exploration of the observation by the observer.

The second component, ‘retention’ necessitates the learner remembering the modelled behaviour. There are a number of ways to do this such as reflection or practice, although knowing that performance of the behaviour is expected is a good motivation and is known to help in the retention process (Bahn 2001). Following on from this is the process of ‘motor reproduction’ whereby the learner must re-enact the observed behaviour. The final component is the ‘motivational process’ – there is more likelihood of modelled behaviour being learned if the learner feels there is some value to it; for example a reward of some kind; positive feedback or personal fulfilment. Bahn (2001) and Quinn and Hughes (2007) state the worth of ‘vicarious reinforcement’ whereby the learner is motivated to retain and adopt observed behaviour as a result of witnessing others who reproduce the observed behaviour receiving praise.

It is important to acknowledge the significance of the ‘expert’. It is recognised that the linchpin in progression from novice status sits with the clinical mentor (Gray 1997; Field 2004; Lauder et al., 2008). It is however crucial that mentors have the willingness, capability and time to facilitate the apprenticeship, to model good practice and to assess competence. These very issues can leave student’s feeling isolated and in danger of mis-education (negative learning).

On this issue, Aston and Molassiotis (2003) reported on a small UK evaluation exercise to judge the value of a student peer support supervision programme, introduced to improve the professional responsibility of senior students. The final year students were charged with providing supervision and support to junior students. Duties included helping them while they developed fundamental skills; understand the rationale for basic interventions and help them to reflect on their experiences. Mentors supervised senior students, participated as appropriate and provided feedback to the final year students.

Findings from the evaluation questionnaire, which included closed and open- ended questions, demonstrated that both groups of students derived benefit from this approach. Senior students (n=31) were able to develop skills in teaching and mentoring, which they may not otherwise have had an opportunity to do until qualified. Meanwhile, junior students (n=27) felt more supported and less anxious about placement. Free text comments suggested they really appreciated the help the senior students gave them. Of interest was that many of the negative issues raised by the student mentors such as lack of time to reflect with the junior student and lack of preparation for the role of mentor, were similar to those faced by qualified [RN] mentors (Lauder et al., 2008).

Despite 38.7% (n=12) of student mentors receiving excellent support and 45% (n=14) good feedback, mentor input was an issue, as 45% (n=14) of the student mentors received no support or feedback from their clinical mentor. Only 25% (n=3) of the mentors recruited to supervise the senior students completed the questionnaire. This may be related to the same issues that influence mentorship currently such as workload (Lauder et al., 2008).

However, the low response rate excluded their feedback from the evaluation (Robson 2010: in Gerrish and Lacey 2010). Student response rate was vague as only the respondent figure was provided. The findings, from an evaluation perspective, were incomplete due to absence of feedback from mentors who were charged with supervising and supporting senior students. Although senior students valued the opportunity, 58% (n=18) reported being unprepared or unclear about the role they were taking on.

Almost half (45%: n=14) received no support or feedback from mentors so would be unclear of what they had achieved from the process. Mentoring is an important role in the growth of competence and this could have implications for the students’ development due to the lack of ‘expert’ (Gray 1997; Field 2004). Aside from lack of mentor feedback, the findings of this small study (n=58) may be unique to that study site (Ritchie and Lewis 2003). A larger study inclusive of mentor feedback on their observations and reflective discussions with the senior students would have provide more robust findings to substantiate or refute the value of peer mentoring to a wider population.

Whilst SLT has its roots in behaviourism in terms of reinforcement, there is emphasis on the cognitive process through the use of reflection and critical analysis of observed behaviours. This notion links to Lave and Wengers Situated Learning Theory and the principle of ‘Legitimate Peripheral Participation’ (Lave and Wenger 1991).

Legitimate peripheral participation (LPP) is the core tenet of situated learning and can be described segmentally as follows:

 Legitimate: all parties accept the position of “unqualified” people as potential members of the community of practice.

 Peripheral: unqualified people hang around on the edges of the important stuff, do the peripheral jobs and gradually get entrusted with more important ones.

 Participation: it is through doing knowledge that they acquire it. Knowledge is situated within the practices of the community of practice, rather than existing “out there” in books’ (Atherton 2005: 1).

Lave and Wenger (1991) support the notion that understanding involves the whole person and that in order to be meaningful it must be specific to the situation in hand. Legitimate peripheral participation (LPP) relates to the relationship between “newcomers and old timers” and the skills, knowledge and identities resulting from the interaction (Lave and Wenger 1991:29). As can be seen LPP also stemmed from the notion of apprenticeship where the novice learned at the feet of a master.

Benner’s (1984) ‘novice to expert’ theory was based on Dreyfus’ earlier theory of skill acquisition. Dreyfus’ model - developed from a study of chess players and pilots performance - starts with the learner as ‘novice’ – with no experience of the situation they are in and reliant on rule-governed behaviour. Dreyfus (1996) proffered that although the novice follows the rules, it does not always equate to good performance. At this stage they lack any understanding of the complexities associated with the task and rely heavily on supervision and guidance.

The ‘advanced beginner’ stage sees the development of understanding and at stage three, ‘competence’ understanding deepens and decision-making starts to develop along with emotional responsibility for decisions made. ‘Proficiency’, the penultimate stage is where integration of new knowledge occurs although there is still deliberation over choices. Finally, stage five sees the emergence of ‘expertise’. The practitioner is able to intuitively identify tasks and make decisions based on a sound body of knowledge, experience of problem solving and development of decision-making skills. At this ultimate stage of the novice to expert continuum, however, the expert often lacks the language to describe their decision-making process to the non-expert (Benner 1984).

Benner’s (1984) phenomenological study aimed to determine if Dreyfus’ model of skill acquisition was applicable to the skills acquisition of nurses. She wanted to discover and comprehend the clinical judgement and performance differences between experienced and novice registered nurses. This US study, consisted of a mix of interviews and non-participant observation, with data collected and analysed by a team of researchers.

The sample (n=42), taken from multiple hospital sites in California consisted initially of newly qualified (n=21) and expert nurses (n=21) who undertook paired interviews. They were interviewed separately about shared clinical experiences, which had significant meaning to them and comparisons were made regarding descriptions of the events. Further group interviews and/ or participant observations were conducted with additional experienced nurses (n=51), newly qualified nurses (n=11) and senior nursing students (n=5) to enable the researcher to gain a sense of the characteristics of the nurses performance at the various stages of the skills development continuum.

A number of themes emerged from the data, which Benner categorised as domains: the helping role; the teaching-coaching function; the diagnostic and patient monitoring function; effective management of rapidly changing situations; administering and monitoring therapeutic interventions and regimens; monitoring and ensuring the quality of health care practices; organisational and work-role competencies. The supporting narratives of the participants (novice and expert nurses’) show the different levels of thinking and acting which occurred respectively in the shared significant events.

Benner’s findings, from the perspective of nurse education demonstrated that the development of expertise is dependent on various and numerous significant concrete experiences; without them it is difficult to advance. There was acknowledgement that nurses at point of registration rarely achieve more than ‘competence’. Benner asserts that in order to advance this, rather than students learning vicariously from others experiences they need to have the opportunity to rehearse similar situations for themselves. Learning with simulation was suggested as an effective way of addressing this discrepancy.

The issue of lack of opportunity for nursing students to gain experience was discussed earlier within this chapter. Simulation can provide concrete experiences in a controlled and guided manner (Ker and Bradley 2007). However, in line with andragogical theory, the experience and the outcomes are influenced by external factors, some personal to the learner, such as previous learning experiences and education and some cultural.

Whilst acknowledging the influence this valuable research has had on the advancement of contemporary nursing there are some issues worthy of note. First, as the sample consisted of five (n=5) nursing students, the findings in relation to nursing students were not robust enough to represent student nurses outwith the study site (Polit and Beck 2008). This was a US study undertaken in one state. Differences in nurse education and healthcare practice may render the findings non-representative in the UK. Similarly as less than a quarter (n=26) of the entire sample of 109 was subject to participant observation the findings could not be considered characteristic of the experience. The qualitative findings are generally context specific (Polit and Beck 2008).

In addition, Dreyfus’s model is constrained by the situation in which the ‘expert’ is based. Expert status is not always transferable to other areas. For example, a nurse clinician working as I did at advanced practitioner level in emergency trauma care, could be classed as an expert in that field. However, if that clinician moved to a coronary care unit they would in all likelihood not be able to work at that same level due to lack of expertise in that specific field and may have to work through the stages preceding ‘expert’ status.

Similarly, when a new learner joins a new learning environment, or community, as a new beginner they initially learn at the periphery by observing and discourse. As competence develops, through the acquisition of knowledge and skills, they move further into the community (Gray 1997). Eventually, as their knowledge and expertise increases and broadens they will become more participative, sharing their knowledge and expertise with new novices. As highlighted earlier, learners [nursing students included] are inevitably exposed to communities of experienced practitioners, both in the HEI and in clinical areas during the course of their journey from novice to expert. As in Dreyfus’ model, the expectation is that they will gradually move from the peripheral participation stage of the novice to full participation under the guidance of old timers who have acquired mastery. It is believed that using LPP may help to illuminate the learning processes behind social learning because it places importance on the whole person and the social context (Lave and Wenger 1991).

Lave and Wenger (1991) emphasised that learning should take place in a number of educational situations and that it must be meaningful. In terms of undergraduate education, the population of students in the HEI where my study is based were exposed to a variety of educational situations such as classroom- based lectures and tutorials, participatory skills workshops and clinical practice in placement areas. For example, when the nursing students’ were learning about the management of patients who have experienced trauma, they were exposed to wide and varied range of ‘expert’ multi-professionals.

Initially they attended lectures delivered by a lecturer experienced in trauma management; in placement they learned from experienced clinical practitioners; additional learning came from a simulated road traffic collision exercise with the Fire and Rescue Services and from a day spent with the Ambulance Paramedics’. As this illustrates, the student’s were exposed to a number of different communities of practitioners, all of which entailed initially participating on a peripheral level.

Similarly, Andrews et al., (2008) believe that communities of practice (CoP) facilitate dynamism in clinical practice and reasoning as they allow multifaceted involvement from research, education and clinical practice. It is vital that the university based knowledge and skills students are exposed to help prepare them for the ‘real world’ and are transferable (Lauder et al., 2004) and it is believed that teaching in simulated environments facilitates this (Issenberg et al., 2005).

As stated, legitimate peripheral participation (LPP) reflects aspects of the apprenticeship model with the premise that novices learn when working in the professional community, with time served professionals who have accrued expertise. This approach is well suited to nursing and similar in many ways to traditional nurse training. However, as previously discussed nurse education has progressed and now has a greater emphasis on underpinning theory and critical thinking skills, with nurses required to be ‘knowledgeable doers’ (UKCC 1986; Scholes et al., 2004; Longley et al., 2007; Bradshaw and Merriman 2008).

This chapter has thus far presented an account of the various educational theories, which have contributed to the development of nurse education over the past 30 years. All are relevant and applicable to the field of simulation, in particular to the simulated clinical environment (SCE). The theoretical underpinnings of many of them are concurrently evident in contemporary programmes. Further to this, an approach established with the HEI used within my study is that of the ‘Cognitive Apprenticeship Model’ (Collins et al., 2004).