Practice knowledge, which needed to be articulated, explained and passed on (‘brokered’), comprised another seemingly fragmented entity in the mentor lifeworld. The mentors, observing that students arrived with expectations of gaining practice knowledge and expertise, accepted their responsibility to facilitate the process. This section shows how the mentors were immersed in working with fragments of practice knowledge as zuhanden entities, and brokered these fragments as commodities of mentoring. Practice
knowledge included interactions with patients, technical skills, ward management and theoretical knowledge. The participants operated as knowledge brokers, making
connections between the educational needs of students and these fragments of practice knowledge.
Table 7.4 outlines the fragments discussed here, along with their features and their appearance in the mentors’ practice.
--- A world of fragments ---
Table 7.4 Fragments of practice knowledge: features and appearance
Fragments of practice knowledge
Features Appearing in:
Interactions with patients Hands-on skills
Ward management Theoretical knowledge
Judged as appropriate or inappropriate for students to engage with
Nursing or non-nursing work
Hierarchy
Declarative, procedural and embodied
Sometimes concealed Context-dependent
Mentors as knowledge brokers
Identifying gaps in knowledge Offering practice knowledge according to need
Attention to detail Division of labour Disassembling practice knowledge for teaching
The vocative text below illustrates some of these fragments of knowledge. It shows the mentor as broker considering knowledge gaps, making judgements about what it is appropriate for a student to learn, and providing ways for the student to acquire knowledge.
Being a broker of practice knowledge (vocative text)
I give them the student pack when they arrive, to say, this is what can be learned here. I say ‘I don't expect you to achieve everything, but I want you to pick out things that are gaps in your knowledge’. Having said that, it’s very difficult, it’s like sending a kid into a sweetie shop and saying, ‘there you go, get yourself a ten-penny mix’. How can you choose what you need to know when it’s all there in front of you?
We can offer aspects of dermatology that a student might not learn anywhere else, such as dealing with the embarrassment that comes with disfiguring skin conditions. I made sure that Ellie came with me on the doctors’ round so that she could learn about this and other things from the interactions going on between doctors and patients, but when it came to the clinical skills, doing dressings and that kind of thing, she needed to get hands on – preparing trolleys, handling patients, developing dexterity with dressings and bandages. I also made sure she came with me when I was attending to our diabetic
patients, to see what she needed to learn about the skill of injections.
I tried to get her involved as much as I could in what I was doing, but the day to day running of the ward is really for later on when she’s doing her management
--- A world of fragments ---
placement. Some of the paperwork and stuff isn’t really applicable before then. She should be doing basic nursing care and learning what it is to wash
someone and remembering all the little bits that make the difference between a nurse and a good nurse. When I was a student, I learnt as much from the healthcare assistants as from the actual registered nurses, who were more tied up with management.
This narrative is rich with ‘significations’ about specialist (‘dermatology’) and generic (‘dressings’, ‘injections’, ‘management’) expertise, although generic knowledge would also have been shaped by the specialist context. Gauging, and then providing, what a student needed was a complex enterprise. The mentor offered a menu of available practice knowledge in the student information pack, but she knew as knowledge broker, that she had a key mediating role. She activated a ‘need-to-know hierarchy’, prioritising specialist practice knowledge which was unlikely to be learned anywhere else. The students’ individual needs came next, identified according to the stage in the course and any visible knowledge gaps, and interpreted according to the mentor’s own experience and beliefs. Students might watch and observe, but practice knowledge included being skilful using one’s own hands and interacting directly with patients. She believed that ‘paperwork’, the signifier for administration and management, could wait until the student had mastered the skills of direct care.
In addition to instigating a hierarchy of practice knowledge for the student, the mentor above recognised that knowledge holders were not necessarily nurses. Hence, students could learn from observing doctors and from working with healthcare assistants (HCAs). The division of labour was such that students needed to learn from HCAs if they were to have sufficient exposure to the practical delivery of care. A glimpse into the attention to detail required for good nursing care was also revealed in the reference to ‘all the little bits that make the difference’, which may have signalled the often unspoken aspects of practice that nurses can learn by watching and doing.
The mentors seemed to have the intuition that simply being immersed in practice could equate with having a learning experience. They recognised that their students needed to learn through immersion in practice and also that the learning needs were
--- A world of fragments ---
similarly only properly known in the context of the practice itself. Moreover, practice involving equipment could only be revealed when the equipment was put to use with patients. Therefore, everything only became meaningful within the ‘referential totality’ of the mentors’ Umwelt. In this way, as the vocative text suggested, learning to manipulate the equipment for giving injections and applying dressings and bandages could only become possible and assessable in the full clinical context.
Although they believed immersion in practice was a good way to learn, the mentors also encountered situations that required them to organise and present their practice knowledge to students verbally. For example, Lisa realised that her student had not learned the basics of patient observations that she would have expected:
I'd sent her off to do some blood pressure, and just general observations on the ward, just simple, pulse, and she said she hadn't done them before and didn't know, which kind of took me a bit - ooh, okay - and we went through the ... why are we taking blood pressures, normal range, and charting it, and even
approaching your patient requesting, can you take it, we just went through all the, you know, what is in my mind, what normal blood pressure is, and of course what you do with it, figure out .... we did a whole bay of them, which was quite good, because […] she spent a whole shift doing them. She was quite full of confidence by the end of it. (Lisa, interview 2)
Lisa first needed to disassemble her practice knowledge, and subsequently offered it to her student as declarative (reasons for taking the blood pressure and normal range), procedural (how to approach the patient and chart the measurements) (Schaap et al., 2009) and embodied knowledge (Benner et al., 1996) that took practice to learn. It
required uprooting from her usual zuhanden engagement with patients and equipment, to make her knowledge visible to the student. She needed agility to grasp an unexpected opportunity to focus on teaching a specific skill, and to broker this knowledge. Hence, she shifted from being absorbed zuhanden in the practice, to recognising
circumspectively and unzuhanden, the different elements of knowledge that made up her competence in taking blood pressures, to articulating this to the student, which would have required some vorhanden contemplation (Packer, 1989).
--- A world of fragments ---
The context bestowed meaning on the fragments of knowledge. Recognising the differences between practice knowledge in different settings, Flossie spoke with some pride and satisfaction about what made her practice special:
Patients are treated different in the community. They're people in their own right, you have to be invited in, in the hospital, it's the hospital rules, in the community it’s the patients' rules. And I think it's just so different, and you've got so much more autonomy, you make decisions, where in hospital you go to somebody else, or a doctor will come round and make the decisions. Here, it's up to you. […] being involved in the family, you're treating the whole family, you don't go in and treat the patient, you have to think about the whole family. And very often, it's the family you're treating and not the patient. (Flossie, interview 1)
She could work autonomously, and with the whole family, rather than the more regimented work and narrower clinical focus that she saw as the norm in hospitals. Flossie seemed to be engaging on a deep emotional level. By contrast, Gina offered a more utilitarian perspective on some of the differences in practice:
I suppose in the hospital they do a lot more hands on – they do the bathing we don’t do, because obviously social services – and even our health care
assistant she doesn’t do any bathing, just basic wounds, I expect the complex wounds in the hospital they’re seen by the tissue viability nurse; they aren’t here, we just see them [tissue viability nurses] if we have non-healing wounds, or if we want just a little bit of advice. (Gina, interview 1)
This indicated the increased complexity of knowledge and expertise that community teams needed to develop in the area of wound care and also that, in contrast with hospital practice, bathing patients was not a nursing responsibility in the community. In this way, nursing knowledge occupied shifting boundaries: what passed for everyday nursing knowledge in one context might belong to a specialist practitioner or a different agency in another. The mentors were aware of the contrasts their students would encounter, differentiating between nursing knowledge that was central and fundamental and that which lay outside this boundary. They constantly contextualised themselves and their practice for the benefit of students.
--- A world of fragments ---
Some practice knowledge was less visible to students because it entailed, for example, action over a prolonged period of time, between different settings, or private conversations with patients. Mentors in non-acute settings were aware that their practice areas lacked the kudos of the fast pace of work and high-visibility technical nursing interventions that students witnessed in hospital settings. Hence, they felt the need to justify their practice and emphasise to students the particular expertise concealed within their work. Similarly, in the hospital wards, the mentors recognised they could offer their students a range of nuanced learning situations. Below, Trudy declared some skilled nursing activity – giving patients advice – that might go unnoticed to the casual observer:
We have lots of patients, for example, with diverticulitis, irritable bowel, a lot of patients with diabetic ... and there's opportunities there to expand their
knowledge and give patients advice. So, they can observe me giving advice to patients ... dietary and other issues, and that's learning as well. (Trudy,
interview 1)
Additionally, knowledge about the outcomes of practice could be hidden when patients moved between settings. Therefore, Marion rated highly the opportunity for a student to witness the outcomes when patients were referred to community nurses upon discharge from hospital. She was certain that this knowledge would enhance practice:
They see what goes into a patient being discharged sometimes as well which is quite good because I’m always keen for them to see that. Because then they know when they’re a staff nurse on a ward and they ring up and they say I’m going to discharge Mr Bloggs tomorrow and you need a hospital bed and you need this, that and the other, and they need to see that that isn’t going to happen. Not tomorrow. (Marion interview 1)
This presented a valuable opportunity for improving care, because the fate of a patient discharged from hospital and the impact on community teams was often invisible to the hospital ward staff.
This section has illustrated the mentors’ engagement with fragments of practice knowledge as they pertained to students’ learning needs. Through being highly attuned to context and aware of contextual differences, they were able to interpret and prioritise student learning needs. They displayed agility in the way they could translate their
--- A world of fragments ---
practical zuhanden knowledge into something that was accessible to students. The next section explores how mentors gained knowledge about students.