DISEÑO DEL SISTEMA 1. Generalidades

In this thesis it is important to acknowledge the limitations that inevitably arise in research of this nature. The first one is the characteristics of the participants across all groups within Phase two. The number of female participants were higher

compared to male student nurses. This reflects the wider prevalence and progress of male students into nursing, which is limited (Maykut et al., 2016), and thus, can be seen as a contributory factor to this limitation. A similar limitation was noted in a

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recent study exploring peer mentorship amongst nursing students (Smith et al., 2015).

Secondly, the timing of data collection within Phase two must be considered as a limitation. When the observational data were collected, not all student year groups were out on placement. Therefore, this imposed natural limitations on the PAL dyads, in the stage of training of the dyads depended on the placement allocation. This needs to be considered when implementing the conceptual model in the future to ensure all levels of study are able to access PAL.

A third limitation relates to the potential influence of the observer. Participants across all stages of data collection within Phase two were aware that the observer was a lecturer in the field of nursing. This was initially presented to the students as part of the PIS to ensure transparency. Furthermore, this was acknowledged within the research protocol and considered strategies to minimize a power influence.

Following the signing of the consent forms the observer (myself as PhD student) met with participants to answer any queries. At this time the observer acknowledged his lecturer role, but stressed the point of their clinical background and the interest in PAL as the focus for observations and not to ‘assess’ them in relation to the

academic role. The observer initially conducted practice observations within each of the sites to provide time to build rapport with the participants. The observer also spread their time across all settings across the two research sites. This enabled participants and clinical staff to become familiar in my presence and conduct within observations.

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A fourth limitation arises from the material synthesized within the meta-ethnography.

The research acknowledges that the conceptual model was developed largely from constructs within the thesis and not all published material. However, aspects of these constructs derived from external evidence, in the form of qualitative papers included within the systematic review. Furthermore, the research acknowledges the limited evidence surrounding PAL in clinical practice, which influences this.

A final consideration acknowledges the limitation related to the nature of qualitative study methodology. It is known that the qualitative research presents challenges in reliability and replicability in the process and generation of results compared with quantitative methods (Leung, 2015). Maintaining rigor can be challenging to ensure that the research is not influenced by the researcher’s bias (Anderson, 2010). It is therefore the role of the researcher to give careful consideration to ensure that these factors have been addressed. Furthermore, the researcher’s presence during data collection is often unavoidable, which can affect participant responses (Pope and Mays, 2006). Findings that are generated through qualitative research can be challenging and time consuming to characterize in a visual way (Anderson, 2010). However, within this study I, as the PhD student had attempted to demonstrate this where possible through the creation of a Framework and the generation of the conceptual model. Despite some these challenges strength is maintained in the ability of qualitative research to explore research questions in greater detail and depth. This methodology has also demonstrated to obtain rich data from human experience and observation, which is powerful and sometimes more compelling than quantitative data (Anderson, 2010).

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7.6 Implications for practice

Within the introduction to the thesis, it was highlighted that minimal consideration had been given to PAL in relation to clinical practice, particularly for nursing

students. Furthermore, in the UK, growing pressures on registered nurses to provide adequate mentorship were resulting in shortages in clinical placements as well as issues relating to the quality of the supervision that did take place (Lloyd-Jones et al., 2001, Hurley et al., 2008). This was also highlighted through the systematic review, which reinforced the need to further explore how PAL worked in practice with student nurses in clinical practice (Carey et al., 2018b). Interestingly, the initial challenges of mentorship and student support are still present and unlikely to be resolved in the short term. Mentors within the clinical practice setting are still faced with their own issues, related to lack of value within the role and having protected time to support student learning (Clark and Casey, 2016). Through the research, the exploration of PAL has led to new evidence and subsequent contributions to the body of

knowledge in its application to the field of nursing and in the generation of a new conceptual model. Given the need to increase the numbers of nurses in practice world-wide, these findings are both timely and relevant.

Within the UK, the number of vacancies within nursing is rising, further compounded by a steady decline in figures of nurses joining the register and international nurses leaving due to uncertainty within the European Union (Nursing and Midwifery

Council, NMC, 2018b). Unfortunately nursing has never been before been seen in such a poor light. A recent review by the Royal College of Nursing (RCN, 2017b) presented the consideration of impending crisis in the future supply of nursing staff,

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due to a lack of adequate workforce planning and workforce strategies. More specific points highlighted nursing staff leaving the profession due to workload and pay

pressures, and cumulative impact on the supply of new nursing staff resulting from restrictions on the commission of student numbers (RCN, 2017b). This puts pressure upon the existing workforce of mentors in practice and offers little attraction to those who are considering entering nursing as a career. Furthermore, studies have shown the emotional stress for mentors who feel unable to balance the commitment of student learning and patient care, as well as stress caused in supporting struggling students in clinical practice (Black et al., 2014, Clark and Casey, 2016).

The professional regulator for nursing in the UK, the Nursing and Midwifery Council, is responding to the pressures in practice, and have made changes to structured approaches to and revision of the term mentorship. New standards for pre-

registration education and to the role of assessors in clinical practice have been released (NMC, 2018b). Despite the need to change models of student support, this does not come without its challenges or address the issue related to the number of mentors and pressures in clinical practice.

It is important that students are well prepared to face the challenges of practice today and so it was important to ask the question how does PAL and the conceptual model support students to learn within a stressful environment? The stress

experienced by students was clear within the study, however, much of this was alleviated through PAL, as students rely upon each other to survive and support one another in clinical practice. This was highlighted within the conceptual model, which

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noted the importance of PAL in reducing the stress and anxiety of students.

Furthermore, social interaction and support has been proven as an effective means to reducing stress on well-being (Yildirim et al., 2017). Addressing these factors

enables for learning to take place, as discussed in the previous chapter. Adding to

this is the importance of the conceptual model to support students within a

community of practice, encouraging shared knowledge and experience to foster new learning and develop professional skills as expressed by Wenger and Snyder (2000).