Nanopartículas basadas en sílice mesoporosa

Bridges and Bridges (2009) describes the second phase of transition (the neutral zone) as being accompanied by a sense of feeling overwhelmed and of chaos as the individual occupies a no-mans-land between their old and new states. There is a clear sense of this in the literature with many students feeling overwhelmed by the lack of role identity and the conflict arising between the roles of HCA and student nurse (Watts and Waraker, 2008; Beretta et al, 2012). These issues are compounded by the lack of a clearly defined role for the student nurse, and ambiguous boundaries between that of HCA and student nurse.

Whilst the HCA may be defined by the task-oriented nature of their role (Ahmed and Kitson, 1997; Poole, 1998) there are several skills, particularly for those in assistant practitioner roles, in which they have demonstrated competence and can undertake independently. As a student nurse, these same individuals would need to be re-assessed as competent at the level of their training (Beretta et al, 2012). This would include demonstrating the underpinning knowledge and awareness of the wider implications relating to the task. Therefore, they may both carry out the same task, but the expected level and understanding with which the task is carried out varies between the two roles.

To further complicate the issue, some employers will allow the HCA to extend their employed HCA role to incorporate those tasks they are able to undertake as a student, whereas other employers will not. As a result, there is no clear role definition between the function of the HCA and the student nurse beyond the obvious supernumerary student status and need for demonstration of competence against the student’s learning objectives leading to registration.

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The literature indicates that role confusion issues can emerge from the learner’s difficulty in establishing a clear understanding between their employed worker and learner roles (Kevern and Webb, 2004; Watts and Waraker, 2008). This confusion was compounded by the challenge students encountered in moving away from their previous HCA role, particularly where they were employed or seconded students (Wareing, 2008, Watts and Waraker, 2008). Students with previous HCA experience were often relied upon to support service needs in clinical areas (Kevern and Webb, 2004) or ‘utilised as a HCA’ rather than as a student (Brennan and McSherry, 2007, p.211). Some students found the emphasis on their worker identity to be overwhelming, based on their sense of obligation to the employer (Watts and Waraker, 2008). Worker/learners appear to suffer a culture shock of competing expectations and conflicting demands (Kevern and Webb, 2004; Watts and Waraker, 2008), where work sets the direction for learning, rather than work being focused on meeting the defined learning needs of the student (Wareing, 2008).

Confusion concerning role boundaries and role definition was not confined to the students themselves. Swallow et al (2007) identified confusion amongst other clinical staff regarding the identity of HCA/students. This resulted in a lack of recognition of their student status and students not getting protected time. In a study of foundation degree students, staff not only forgot the former HCA was a learner, but also expressed uncertainty around what they could do in their learner role (Wareing, 2010a). In addition, lack of clarity around the dual roles of student and employed worker can cause confusion around who is responsible for them, particularly regarding performance issues (Kenny et al, 2012). This can have an impact in relation to support for, or management of, the HCA/student.

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The literature identified strategies students developed to help avoid being used as an HCA, including not disclosing their HCA background while on placement (Gould, Carr and Kelly, 2006; Brennan and McSherry, 2007). However, whilst students did not want to be used as a pair of (HCA) hands, they often wanted to be recognised and valued for their prior knowledge and experience (Ryan, 2001; Melrose and Gordon, 2008). Some felt frustrated by having to be supervised as students in skills they had undertaken independently in their previous employed roles (Brennan and McSherry, 2007). This did not just relate to HCA roles, but also to transferable skills from other related occupations such as management, cancer screening and elderly care (Melrose and Gordon, 2008).

In contrast, Gould et al (2004), in a longitudinal study of two consecutive cohorts of HCA secondees to a pre-registration nursing programme, found that participants did not feel undervalued in terms of their previous experience, nor did they express concerns about being used as HCAs. This might be due to a greater sense of obligation to their employers as funded secondees. Furthermore, employers valued the additional skills and knowledge that these HCA/students brought to the programme with them (Beretta et al, 2012), whilst recognising that the dual roles of worker and learner could lead to exploitation of this where the programme itself was poorly understood. Whilst students found it hard to differentiate between the roles, Brennan and McSherry (2007) found that the students associated their increased recognition of responsibility and accountability in nursing as a key signifier of change from their previous HCA perceptions.

From the literature it is clear there are issues of confusion around the student identity, both for the students and for those supporting them in practice. This is compounded by a recognition that student nurses are often used to underpin service needs, rather than having

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service provision support their learning in practice. The introduction of supernumerary status as part of the Project 2000 initiative (UKCC, 1986) was intended to protect students from being used to supplement the nursing workforce. The issue of students being used ‘as a pair of hands’ is compounded by confusion about what is meant by supernumerary status, leading to difficulties for both students and mentors which can further challenge student identity. Therefore, protecting supernumerary status in WBL programmes, with an ethos of learning from, through and at work (Quality Support Centre, 1996), appears to have been particularly challenging.

Confusion over what is meant by ‘supernumerary,’ combined with competing service pressures, challenges the ability to protect student identity in the workplace. In a mixed methods (MM) study of traditional pre-registration nursing students, 59% (n=1425) of students reported being ‘used as an extra pair of hands' (Jack et al, 2017, p.4). This was characterised by lack of respect for their supernumerary status, resulting in allocation of what were perceived by the students to be non-learning related menial tasks and being used as workers rather than learners (Jack et al, 2017).

Similarly, in a study of sixty traditional second year student nurses, students understood that supernumerary status prevented them from being counted as part of the ward staffing numbers, but this was not the reality they experienced when on placement (McGowan, 2005). Students identified that the Ward Sister's (or Charge Nurse’s) stance in protecting supernumerary status was crucial to influencing the team and that where supernumerary status was protected, learning was felt to be enhanced (McGowan, 2005). Furthermore, where it was not protected, students found that their learning needs were compromised in order to meet service needs and they felt used (McGowan, 2005). Protecting supernumerary

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status can also be an issue in the immediate pre-qualifying period. Six out of eight final placement traditional nursing students perceived that they were still being used as an 'extra pair of hands' which led to feelings of anger and frustration about being used to fill service gaps and a craving for the learning they felt they were missing out on (Morrell and Ridgway, 2014, p.519). Students felt that being used as a pair of hands had a negative impact on their ability to learn and to achieve their competencies in practice (Morrell and Ridgeway, 2014; Jack et al, 2017). Hence this issue is not isolated to HCAs undertaking these WBL nursing programmes.

The ability to maintain a student’s supernumerary status, given the need to deliver a healthcare service, is an on-going challenge. This confusion was recognised by stakeholders responding to the NMC’s consultation around the new Education Standards for pre- registration nursing programmes (NMC, 2018c) and resulted in further clarification through the new Standards framework for nursing and midwifery education (NMC, 2018a):

‘Supernumerary status applies to pre-registration students; students in practice or work placed learning must be supported to learn without being counted as part of the staffing required for safe and effective care in that setting.’ (NMC, 2018a, Glossary).

However, the NMC (2018b) acknowledges that this definition is deliberately broad to allow some flexibility for decreasing supervision in response to students’ increasing level of proficiency during their training. This may, as a result, provide a continued challenge in protecting supernumerary status and student role reinforcement.

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Billett (2004b) recognises that workplaces provide access to learning providing doing so supports the workplace needs and interests. Whilst supporting supernumerary status does not guarantee greater learning in the workplace, it has the potential to facilitate a better learner experience. Experiential learning has a risk of being ad-hoc, failing to focus on the specific learning needs of the student, and therefore an inability for them to develop the required competencies. This is further compounded by student reports of the primacy of the worker role over the learner role in practice (Watts and Waraker, 2008).

Whilst it was recognised in Section 2.4 that students needed to make themselves useful in order to gain entry and acceptance into the COP (Brennan and McSherry, 2007), this should not be at the expense of meeting their learning needs. Although patient care quality is paramount, staffing levels and ability to provide adequate support and supervision to student nurses (including WBL programmes) is a key consideration before approving clinical placements.

While HCAs undertaking WBL nursing programmes are not alone in experiencing difficulty protecting supernumerary status, these issues are compounded by confusion and lack of boundaries between the roles of student and HCA and the primacy of their employed worker roles. A summary of the key barriers and enablers which act as transition rites through the neutral zone are set out in Table 2.3.

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Table 2.3: Key transition rites through the neutral zone The Neutral Zone – Transition Rites

Barriers Enablers

Primacy of worker role Relevant pre-existing skills and knowledge Role confusion Role identification and reinforcement Competing expectations Protecting supernumerary status

The following section will explore the transition to the new beginning, the students’ progression towards adoption of the student role and acceptance of the student identity.