INFLUENCIA DE LOS FACTORES AMBIENTALES SOBRE EL CRECIMIENTO BACTERIANO

The TCF has had a significant impact upon research within higher education (Tight, 2014) with a substantial body of research across a diverse range of academic subjects. Much of the early work related to TCs focused on identification within the disciplines, with the field of economics particularly leading the way (e.g. Shanahan & Meyer, 2006; Reimann & Jackson, 2006).

Examples from other academic areas include biology (Taylor, 2006), geography (Fouberg, 2013) mathematics (Scheja & Pettersson, 2010), engineering (Male & Baillie, 2011) and literature (Abbott, 2013). Whilst Meyer and Land (2003) suggested that TCs may be more readily identifiable in disciplines where there is relative agreement on that disciplines body of knowledge, Boustedt et al. (2007) and Zander et al. (2008) both reported on identification of TCs in the relatively newer discipline of computer science where there has been rapidly developing and changing body of knowledge. Whilst Cousin (2006) in cultural studies and Wimshurst (2011) in the multi- disciplinary field of criminal justice both suggested that where the disciplinary knowledge is contested, specific TCs are still identifiable. Whilst the discipline specific nature of TCs is highlighted by many authors, Wimshurst’s study suggested that there are generic TCs across different disciplines where the students are studying the same

concepts, giving the examples of ‘theoretical engagement’ and ‘rule of law’. Similarly research into doctoral studies has illustrated how although students may come from different subject areas, in relation to their doctoral studies there are common TCs that students experience difficulty in understanding but which must be mastered. Trafford (2008) identified ‘using conceptual frameworks’ as a non- discipline specific TC within the research process.

Supporting this view Kiley and Wisker (2009) identified six potential generic doctoral level TCs: argument, theorising, framework, knowledge creation, analysis and interpretation, and research paradigm.

Despite the body of published literature utilising the TCF, there has been limited application to disciplines within health and social care, particularly nursing. To date there is no published literature using empirical data to explore the concept of recovery in mental health nursing utilising the TCF. Of most relevance to this study is a robust theoretical article by Stacey and Stickley (2012) who explored recovery as a threshold concept in mental health nurse education. Using relevant disciplinary literature the authors described how recovery can be

seen to meet the five defining characteristics of a TC as described by Meyer and Land (2003). Using their own observations the authors described transformational learning as having taken place when students are able to critique nursing practice which contradicts the values of ROP and through the use of reflective practice they connect on an emotional and behavioural level, demonstrating both a conceptual and ontological shift. The integrative nature of recovery is described as being realised when students articulate how recovery underpins all areas of their nursing practice. It is further argued that the bounded nature of recovery can be seen in the clash of perspectives, with understanding of personal recovery demonstrated when students accept its ambiguous and subjectively determined meaning. Again drawing on personal experiences, the authors suggested that the troublesome nature of recovery can be seen in students’ difficulties in applying ROP. Whilst they may articulate the principles of recovery, it is argued that these are not implemented in a sustained way in practice. They go on to suggest a number of epistemological and ontological reasons for this and recommend educational forums which include recovery narratives, problem based learning, group supervision and debates as approaches to stimulate the necessary transformational learning.

While Stacey and Stickley (2012) focused on the experiences of student mental health nurses in relation to recovery as a TC, Marsland and Pollock (2010) described how the development of an accredited recovery programme provided an illustration of recovery as a TC. The authors described having no doubts of the irreversible transformational power of recovery as it is assimilated into individuals’ personal narratives, with group members and facilitators experiencing a sense of solidarity and commitment to the recovery approach. Its integrative nature is described in the way different aspects such as person- centeredness, self-direction and positive risk- taking are united under recovery as a concept. In relation to the bounded nature of recovery, Marsland and Pollock (2010) warned against viewing recovery as

understanding, but rather something more creative and open to questioning. This supports Baillie et al.’s (2013) position discussed earlier that TCs should not be viewed as having a fixed set of criteria. The specific concept of recovery in this context highlights discipline specific differences where strict application of all defining characteristics are not supported. Marsland and Pollock (2010) identify the troublesome nature of recovery as evident in the way some people struggle to accept recovery from mental health problems is possible, or that recovery does not mean a return to a former state of health. The paper also highlights how recovery involves examining issues of power and how this may be particularly difficult for some people to address. Although offering a convincing argument, both these papers relating to recovery are based on the thinking of the authors, therefore lack empirical data to support the claims made.

Martindale (2014) considered student learning in relation to research and evidence based practice in pre-registration nursing curricula and the troublesome nature of this subject. This in- depth narrative research study involved 17 participants from two UK universities. Following in-depth interviews and analysis findings illustrated how troublesomeness is related not only to knowledge, but also to the learning environments in which students are placed and intrinsic factors such as attitudes and perceptions of research. This suggests a multi-faceted aspect to professional learning where difficulties are not only linked to the concept itself, but to the cultures, practices and relationships students are exposed to as part of their learning in clinical contexts (Martindale, 2014).

The notion of troublesomeness was also a focus of Blackburn and Nestle’s (2014) investigation within paediatric surgery training programmes. Following semi-structured interviews with eight trainees, thematic analysis identified five troublesome themes relating to knowledge, clinical judgement, technical skills, transition of roles and increasing responsibility, and

relationships with trainees. Although somewhat limited in terms of discussion, the authors argued such identification using the TCF provides important insights into the need for a holistic approach to curriculum development. This echoes findings from Martindale (2014) on the complex nature of troublesome aspects in professional programmes.

Smith, Blackburn and Nestel (2018) also considered the learning journeys in relation to junior cardiothoracic surgeons, with troublesomeness again being identified. In a well reported study, thematic analysis from data generated from the junior surgeons themselves, identified three TCs of uncertainty, speed of operating, and complexity of care. All TC defining characteristics were considered with troublesome, transformative and the reconstitutive nature of the concepts being most prominent. The characteristics of integrative, irreversible and bounded were reported to be less evident. Smith et al (2018) also identified one potential TC as change, although only its troublesome nature is offered as a defining characteristic. In terms of the learning journey, it was commencement of consultant practice that participants experienced as particularly challenging. However, once the liminal space had been traversed, positive professional identity and a sense of self-worth was reported, suggesting a transformed ontological state.

The troublesome nature of care in Smith et al.’s (2018) study discussed above related to the technical nature of cardiothoracic procedures, previous technical experience and confidence to carry out the procedure. A further study by Wilkinson (2018) highlighted how non- technical aspects of care were also experienced as troublesome. Wilkinson considered the troublesome nature of training for junior doctors in older people’s medicine. Gathering data from a

combination of interviews and questionnaires with medical educators and trainees, a number of concepts were identified as troublesome. Following a concept mapping exercise these were grouped into two themes, which the author equates to TCs; the complexity of care, related to

what is delivered; and nurturing care, related to how it is delivered. Whilst complexity of care was based on traditional medical care, nurturing care was considered to be concerned with seeing the patient as a person, providing holistic care and showing empathy. Further thematic analysis identified the tacit nature of nurturing care as being particularly troublesome,

although other aspects of troublesome knowledge are not reported on. It is also unclear if other defining characteristics of a TC were considered. Wilkinson identified that the thresholds are crossed at different times in the trainees’ careers, suggesting that the catalyst for

transformational learning is observing someone else providing care. He therefore highlights the need for appropriate role- modelling and encouragement from senior clinicians to enable journeys through the liminal space.

Clouder (2005) also considered how student healthcare professionals experience troublesome learning with the notion of ‘caring’, which she put forward as a TC. This research utilised data previously gained from two different research projects. Data was drawn from interviews with 12 occupational therapy students and analysis of critical incidents posted to an online

discussion forum involving 256 physiotherapy students. Focusing on the troublesome and transformational characteristics, findings suggested that as students experience caring in practice, common sense understandings are challenged by the ethical, moral and personal challenges caring presents with, hence making it troublesome. As students engage in caring discourses and achieve threshold crossing, it is argued that they undergo a transformed professional identity related to professional understanding of caring. Clouder therefore recommends a rethink on how students are prepared for practice, with attention given to the affective domain of learning. Strategies are recommended to immerse student in the realities of practice and provide opportunities for them to express uncertainties in a supportive way. Carlisle (2016) considered troublesome knowledge in relation to social work, highlighting the concepts of religion and spirituality as presenting with significant challenges. Presenting the

results of a combined narrative and grounded theory approach, Carlisle considered religion and spirituality within social work practice in Northern Ireland. The concepts were not specifically referred to as TCs, but the author focused on tacit knowledge related to the concepts as particularly troublesome. Findings suggested that whilst participants recognised the role of religion and spirituality in mental health recovery, its inclusion in social work practice was problematic, marked with ambivalence and controversy. From the narratives, the history of sectarianism within Northern Ireland was highlighted as creating contextual

difficulties because of the emotion the concepts provoked, highlighting a social dimension to TCs. The author argued for legitimacy to be given to the subject, with ‘safe places’ for exploration of the concept enabling service users to express this aspect of their lives, should they wish to do so. The specific context of this study may limit its transferability outside of Northern Ireland; however, other areas may have specific contextual issues that also provoke troublesome knowledge. The study does highlight the troublesome nature of tacit knowledge and the impact of this on practice, demonstrating that tacit knowledge needs to be exposed to address the difficulties.

The troublesome nature of knowledge in social work was also considered by Morgan (2012) who argued that when students are faced with a social model of disability, this challenges their lay perspective of disability as personal misfortune. Learning is considered troublesome in that it requires a radical repositioning both conceptually and ontologically, where cultural

processes and societal structures are deconstructed to promote more inclusive environments and practices. Whilst this argument is supported with discipline specific and educational literature, the notion of the social model of disability as a TC is not empirically supported. However, Morgan utilises the TCF to encourage social work educators to make explicit what it is students are expected to know and to identify the potential points at which they become stuck.

The use of the TCF to promote curriculum re-design has been a feature of published health related papers, notably in the field of occupational therapy. Using an action research approach Rodger and Turpin (2011) identified five concepts meeting all the defining characteristics of a TC which underpinned their curriculum re- design process. Evaluation of this found staff to be engaged with the TCF, finding it a useful approach to understanding the whole curriculum and in turn developing learning and assessment activities. Shared benefits for staff and students included the provision of a shared language, consistency of approach making learning more integrated, making explicit troublesome knowledge, and cohesive integration of concepts within the curricula (Rodger, Turpin & O’Brien, 2013). Although reported to be helpful in guiding the process of curriculum reform, none of the four cycles of the action research process included students or other stakeholders, with only those teaching on curriculum involved, hence not delivering on the notion of transactional curriculum inquiry advocated by Cousin (2008a, 2008b).

In contrast, Nicola- Richmond et al. (2016) identified 10 TCs for occupational therapy to inform curriculum design from a delphi study involving students, academics and clinicians. Notably statistically significant differences were found between academic, student and clinician responses, therefore highlighting multi-stakeholder involvement as an important factor in TC identification. A follow up study by the same authors (Nicola- Richmond, Pepin, & Larkin, 2018) sought to identify if these identified TCs were being taught within occupational therapy, and if so how. Findings from focus groups of 12 occupational therapy educators suggested that although TCs were not explicit within the curriculum, they were present in the teaching and learning philosophy. The five themes of professional identity, time, the impact of the learning environment, explicit versus implicit content and language, and the value and understanding of the TCF emerged. Practice learning was identified as pivotal in facilitating acquisition of TCs.

Participants also believed it to be unlikely that all students had crossed the threshold for all TCs at the point of programme completion, suggesting that further clinical practice experience is required after graduation to complete the process of TC acquisition, although student views on this were not determined. Given the differences in responses in the authors’ 2015 study, significant differences in interpretation of this may be unrecognised.

Further consideration of a professional higher education programme with radiology students (Hudson, Engel- Hills, & Winberg, 2018) also argued for the significance of practice to

threshold acquisition. In this study, transactional curriculum inquiry was adopted with nine BSc students and four educators. The authors noted the difficulty in identification of TCs as

different to key concepts, with several concepts initially identified. Only one, ‘the inverse- square rule’ was selected for further investigation as it was determined to be difficult to define and apply. In terms of TC characteristics, the authors identified the presence of troublesome, bounded and integrative; however, transformative and irreversible were found to be not evident in learning. Given the non-negotiable status of transformation this brings into question the concept’s legitimacy as a TC. However, Hudson et al. (2018) argued that it is the reciprocal relationship between concept and practice where the transformative and irreversible

characteristics can be seen, as inverse -square law underpins radiology practice, “but equally it is practice that makes visible the abstract nature of the concept and which helps students to integrate and internalise the concept (thus rendering it irreversible)“ (p.60). Hence making practice essential for threshold acquisition. This highlights the importance of the role of clinical educators to student education and is a point applicable to other professional programmes where elements of theory and practice integration are required.

Also recognising the importance of clinical practitioners to student education, Tanner (2011) carried out an explorative study with 24 occupational therapists based in practice. Data from

two focus groups identified three TCs facing students in practice education, client-centred practice, developing professional identity and practising in the ‘real world’. However, whilst practitioners who support students in practice were engaged in a productive dialogue regarding curriculum content, students themselves were not included. It is therefore not known how the perceptions of students regarding their troublesome experiences of learning in practice compared to those of the practitioners. Nevertheless the inclusion of clinical

educators provides a different perspective, potentially capturing an element of student learning not accessible to university based educators.

Clinical educators were included in Barradell and Peseta’s (2018) case study regarding curriculum design. Their detailed account described how threshold concepts and ‘ways of thinking and practising’ were combined to support physiotherapy students in gaining a

connected understanding of what knowledge is required and how this knowledge is put to use within professional practice. Adopting a nominal group technique, clinical educators developed 13 statements identifying what was considered clinically important for students to learn. These statements were further developed by the researchers using related scholarly literature to produce eight ‘framing ideas’, which were considered to represent a mix of TCs and ‘ways of thinking and practising’, involving knowledge and the elements that made knowledge work. These were then used as a basis in developing teaching activity and the learning environment. Students were asked to complete concepts maps to explore their understanding of these framing ideas. Analysis of 100 maps indicated significant student variation from sophisticated conceptual understanding and integration, to the production of descriptive processes

demonstrating superficial understanding only. The authors linked the variation found to students occupying varying positions within the liminal space, although the reasons for such student variation was not empirically determined. However, the combined use of TCs and

‘ways of thinking and practising’ offered an approach whereby student learning associated with professional knowledge, skills and attitudes could be considered in an integrated way.

Fortune and Kennedy Jones (2014) argued that many TCs identified within studies across the discipline of occupational therapy can be viewed as cross- disciplinary concerns and therefore to not hold the characteristic of ‘bounded’, defining the boundaries of occupational therapy as a discipline. There may therefore be TCs applicable across disciplines related to professional practice, particularly in disciplines closely aligned such as those concerned with professional practice in healthcare. In a theoretical paper, Brasic Royeen, Jensen, Chapman and Ciccone (2016) put forward interprofessionality within healthcare education and practice as a TC, suggesting misunderstandings occur when inter-professional issues are only considered from a uni- disciplinary position. They consider issues of professional identity may be most

troublesome in preventing threshold crossing in relation to inter-professional practice. Professional identity was also considered by Nambiar- Greenwood (2010) in relation to inter- professional learning who drew upon experiences from running inter- professional student seminars. Understanding of mental health was included in the seminar work as vital to the centrality of the patient and as part of skill development within a multi- disciplinary team.