Collaboration between the community and tertiary nurse education in bridging the gap between theory and practice

Piercey, C.

Category: Professional practice

Teaching and Learning Forum 2014 [ Refereed papers ]

Collaboration between the community and tertiary nurse education in bridging the gap between theory and practice

Carol Piercey
University of Notre Dame Australia
Email: Carol.Piercey1@ndu.edu.au

Nursing students must be prepared to practice safely, accurately and compassionately in a myriad of health care settings. Nurse educators are continually challenged in seeking strategies to facilitate students' transition to the practice setting. A quality improvement project conducted by final year, undergraduate nursing students, provided a unique opportunity to collaborate with the community. This paper will elucidate the sequence of events which took place from a teaching and learning perspective, including the partnership between the community and the nurse educators on the Broome campus of the University of Notre Dame Australia.

Introduction

Nursing is a practice discipline and as such nursing education has a mandate to prepare students to meet the challenges of providing quality health care. A population increase, diminishing resources, staff shortages, coupled with an increase in the aged, and people living longer with chronic diseases, and the introduction of technology, have all have conspired to change the work-world of the professional nurse. Similarly, in universities there has been an increase in student numbers and fewer resources. Opportunities to rethink strategies for bridging the perceived gap between theory and practice rarely present, but when they do they can be the impetus for innovation in teaching and learning. This paper will elucidate the sequence of events involving collaboration with a community aged care facility, a student quality improvement project and the integration of assessments. The events will be supported by teaching and learning concepts in the current literature.

Background

The University of Notre Dame Australia (UNDA), Broome campus is located in the north of Western Australia in the West Kimberley, 2230km north east of Perth and 1900km south west of Darwin. The township with its population of 14,000 has been classified as very remote by the Australian Government Department of Health and Ageing (ADoHA, 2012). Forty six per cent of the Kimberley population is Aboriginal and Torres Strait Islander origin, with as few as 50 residents living in communities scattered across the region (ABS, 2011b). Broome campus, in collaboration with the Fremantle campus as part of UNDA, is the only Western Australian University providing opportunities for regional and remote students to access a Bachelor of Nursing course. Other universities on the eastern seaboard offer similar courses, namely: James Cook University and Charles Darwin University, who have campuses in Mt Isa, Thursday Island and Alice Springs.

The initiative to establish a Broome campus, was seen as an opportunity to provide tertiary education to the otherwise neglected educational advancement of Indigenous people in the Kimberley. The traditional owners of the land are the Yawuru people. The Broome campus is viewed as providing a strong support between the Indigenous and non-Indigenous people within an environment that is rich in Aboriginal heritage and culture. Such an environment is conducive to sharing and fostering mutual respect and the recounting of stories laced with dispossession, mistreatment and systematic injustice. Support for reconciliation is valued within the UNDA Mission statement.

The remoteness of the Kimberley has consequences for the population's health status and the recruitment of health professionals. Studies have revealed that the health of people living in rural and remote areas is poorer than in urban areas, with health declining relative to remoteness and subsequent reduction in health care availability (ADoHA, 2008; Miller, 2011). The health care needs of this remote population are often complicated by chronic disease and co-morbidities, all of which require a high level of service from the health care workforce (Francis & Mills, 2011).

The number of health care professionals currently working in rural and remote areas is insufficient to meet the health care needs of the community (ADoHA, 2008). A limited workforce of nurses and midwives, perform a significant role in health care delivery and are the primary professional component of the Ôfront line' staff, where distances are measured in hours not kilometres. Of the 1534 health care workers in the Pilbara and Kimberley, 604 are nurses (ABS, 2011a).

Nursing education

Providing a safe efficient nursing work force is one strategy to assist in maintaining a health care service to the peoples of the Kimberley. The other strategy is to educate nursing students to become culturally competent. Culturally competence has been defined as a congruent set of behaviours, attitudes and policies that come together in a system, agency or among professionals that enables them to work efficiently in a cross-cultural setting (South-East Health, 2000. p. 2). Student nurses are obligated to demonstrate that they respect the values, customs, spiritual beliefs and practices of all groups (Australian Nursing and Midwifery Board, 2012).

Nursing education has a mandate to prepare students to practice safely, accurately and compassionately in a myriad of health care settings. Rural nurses are faced with challenges not experienced by nurses practicing in urban areas. Overcoming distances for health care resources, obtaining supplies including medications are some of the problems that rural nurses need to solve. Thus, rural nurses have to be creative in their problem solving (Boucher, 2005). Anecdotally, graduates from the Broome are noted to be self-directed, confident in their work, able to multi task, and are effective problem solvers. Significantly, these attributes are characteristics of rural nurses (Bushy, 2002). The literature confirms that providing exposure to regional and remote areas during education and training, increases the likelihood that graduates will return to these areas to continue to work (Courtney et al., 2002; Lea, Cruickshank, Paliadelis, Parmenter, Sanderson & Thornberry, 2008; Murphy, McEwan & Hays, 1995; Neill and Taylor, 2002; Playford, Larson and Wheatland, 2006).

From the outset the expectation of the Fremantle School of Nursing (later SoNM) was for the Broome campus to deliver an identical undergraduate curriculum. In the early days of the campus, this idea was fraught with many challenges as students were expected to attend lectures and tutorials in real time. This delivery method proved to be restrictive for the demographic of remote area students. Issues surrounding equity and access led to several methods of delivery, culminating in the use of web-based based technology. In 2011, Broome SoNM commenced mixed mode delivery to improve flexibility in learning. Using the technology "Blackboard Collaborate" they were able to deliver a system that provided students with the opportunity to watch recorded lectures and access tutorials in real time with tutor led activities and discussions. This flexibility enabled students, who relocated to another town part way through their courses, to continue their studies.

Demographics of students

The Broome campus can accommodate students from outlying Kimberley areas, including those who transfer from the Fremantle campus. Some of these students view Broome as a tourist town with plenty of sunshine, azure water and long stretches of sandy beaches. The close knit community of students living on campus provides many opportunities for both academic and social activities: an environment conducive to learning.

The typical demographic of Broome students, not including the Fremantle cross campus students or those able to live on campus, are mature aged women. Some of these students are single parents who manage domestic duties. Often students have to juggle employment, academic study and clinical practice, (Leung, Mok, & Wong, 2008). Between 2003 and 2012 there were 157 students. Some of these students studied on campus for one semester choosing to either commence or complete their studies on the Broome campus. All graduated with a Bachelor of Nursing.

Germanus Kent House

Students in Broome spend at least five weeks a semester on clinical placement in the Kimberley health care services. These can include acute hospitals, nursing homes, out-patient clinics and other health care agencies. Distances travelled can be local, as in the Broome township, or as far afield as: Derby; FitzRoy Crossing; Halls Creek; Kununurra; and Kalumbaru. Time taken to travel to these locations can be anything from ten minutes locally, to two days depending on connecting flights. Access to local communities can be difficult at times as most roads are not bitumen based these include: Looma; Lombadina; One Arm Point; and Beagle Bay.

One health care agency in Broome is the Germanus Kent House (GKH) with whom the SoNM has a Memorandum of Understanding. This facility is part of the Southern Cross Care network whose Mission is to provide "Compassionate, just and equitable service delivery which reflects the moral and ethical principles of the Catholic Church" (Southern Cross Care WA, 2011). The nursing home can accommodate 56 aged care residents, 80% of whom are Indigenous. It offers a range of services for residents requiring low to high level care (Southern Cross Care WA, 2011).

In 2012, the Manager of GKH approached the Broome SoNM to assist in reviewing and revising resident assessment forms. All the documents used in assessing residents were designed and developed by the central administration of Southern Cross Care for an English speaking population. In the Kimberley, however, currently there are 42 different languages with many people having a greater connectedness with traditional culture, land and ways of life (Government of WA Report, 2005). At the time of the project there were three forms that concerned the Manager as not being conducive to quality care. Since the SoNM Mission is to support community groups, in particular the advancement of the Kimberley region in terms of reconciliation of the Indigenous people, this request was met with optimism.

Identification of the problem

One of the foundation pillars of quality nursing care is the assessment of patient. This process is aided by completing documentation designed to provide continuity of individualised, patient-centred care. The Manager of GKH felt that the nutrition and hydration care plan, the menu and the personal social profile forms (PSP) were cumbersome and lengthy. The PSP was designed to elicit residents' personal background including family contacts, hobbies and interests. Of concern was the cultural inappropriateness of some of the questions on the PSP.

Ideally, culturally appropriate care, communication, safety, lifestyle and surrounding environments should be incorporated into the aged care sector where there is an Indigenous population (Brooke, 2011). At the GKH culturally sensitive care begins with the residents' admission and the documentation of the nursing assessment on the nine page long PSP form. Nurses are required to allow sufficient time for the resident to ask and answer questions, use appropriate eye contact and body language to assist the resident to feel comfortable when interviewed (Geldard & Geldard, 2012). Given the length of the PSP form, however, and the time it took to interview residents the PSP form was often incomplete.

An overriding problem of changing the forms and the provision of cultural training was the limited number and quick turnover of qualified staff. As expected there are few registered or enrolled nurses willing and able to work in the Kimberley, and even fewer who wanted to work in aged care. Many of the unqualified staff was international back packers seeking employment for a short of time. These people assisted residents with their activities daily living, but were unqualified to perform nursing care assessments. Whilst the physical nature of care was provided, the emotional, spiritual and psychosocial aspects may have been neglected at times due to language barriers, time constraints and a poor understanding of Aboriginal culture. Quality nursing care supports culturally sensitive care that considers individual beliefs, life experiences, background, family history and the community in which the individual belongs (Brookes, 2011).

Discussion between academic staff

Initial discussions between the Manager of GKH and the staff in the Broom SoNM culminated in a kernel of an idea about how the documents could be changed to better suit the staff and residents in their care. At the time third year students were studying two units in which the assessments had the potential to be integrated to help GKH with their problem. These units were "Aboriginal Health" and "Leadership and Management in the Nursing Profession". Apart from one student who was not enrolled in the Leadership and Management unit, all students were simultaneously studying in both units. According to Vanderheide & Walkington (2009) integration of assessments is a means of enhancing the link between theory and practice.

Aboriginal health

The Aboriginal health unit was designed for nursing students on the Broome campus to study Aboriginal and Torres Straight Islanders health as an essential element in shaping health professionals culturally sensitive care. One of the major outcomes of the unit was to "analyse and discuss the health professionals place in the delivery of health care to Aboriginal people" (Unit outline BSoNM, 2012). There were three pieces of Assessment for the unit, including a group presentation scheduled for the end of the semester. The lectures and tutorials for the unit were conducted on campus by a lecturer of Aboriginal decent.

Leadership and management in the nursing profession

The Leadership and management in the nursing profession unit, was designed to assist nursing students to develop their knowledge and understanding of leadership and the management of health care. Lectures for the unit were conducted on the Fremantle campus and delivered live to the Broome students via the web-based technology: Blackboard Collaborate. The tutorials were also facilitated via this technology and coordinated by a Broome tutor. The students, as part of their assessment, needed to undertake a quality improvement (QI) project and submit their report in a portfolio at the end of the semester. They were also expected to write a final three hour exam paper.

It was decided that the students would be given the opportunity to choose between conducting the project for GKH, or presenting the portfolio as per the unit outline. This choice gave students a sense of autonomy, but was balanced with tutor guidance (Chan, 2013; Kalischuk & Thorpe, 2002). There is a suggestion that fostering students' choice in assessments ensures the overall standards of assessment, whilst meeting the learning outcomes, but there is little evidence of the efficacy of this argument (Cowan, 2006). Control over learning resonates with student-centred-learning (Chan, 2013).

The Manager of GKH was invited to speak to the students to provide an overview of the issues surrounding assessment of the residents and the difficulty staff had with completing the complicated, unwieldy forms. The students were provided with a copy of the forms so they could decide if they wanted to undertake the task, and if so which form they wished to change. The tutor outlined how a QI project would play a significant part in not only helping the community, but also fulfilling the requirements of both Aboriginal Health and the Leadership/Management unit. More specifically how the students could learn and develop leadership skills as they partnered with GKH staff and each other in undertaking the project. Authentic preparation for practice is more likely when students make connections and identify relationships (Palmer, 2004). Out of 22 students enrolled in the unit, two elected not to undertake the QI project.

Setting the task

The students overwhelmingly decided to redesign the PSP form to make it culturally appropriate and user friendly. This was a QI project that had benefits for the students and the community. From the outset it was necessary to clearly define QI, which is a term describing a process that aims to reduce the gap between current practice and desired practice (Batalden & Davidoff, 2007). Following a lecture on the topic, all students were asked to submit a short 500 word essay on the concept. In essence, this essay was a formative assessment which according to Moore, Walsh and Risquez (2007) Ôsupports student development in ways that students' feel less threatened more benevolent and interactive' (p.119). Significantly, this small assignment enabled the students to gain a clearer idea of the concept and to start a dialogue about how the project should be undertaken. According to the unit outline the project was to be carried out in groups. The students decided who they would work with, forming three groups of four and one of five. It is suggested that small groups share new ideas and learn from each other (Chan, 2013). Other benefits to learning associated with small groups include the development of social skills, time management and a shared understanding of the subject matter (Bidgood, 2004). It must be acknowledged, however, that there may be a dominant member of the group who wants to control rather than provide democratic leadership.

The groups included students in remote areas who accessed the units via Blackboard Collaborate. This technology enabled group and tutor discussions to take place in real time. It is recommended that students participating in an innovative teaching strategy need clear instructions and explanations about the project as well as tutor expectations (Neuman, et al., 2009). Following a talk by the GKH Manager, a review of the text, current literature, and completion of the essay on QI, the class had a clearer idea about the process of QI. Constant discussion in class time with the tutor also enabled the students to plan their actions and roles.

Terms of assessment

From the outset the students were informed that by undertaking the QI project at GKH, the learning objectives from the Aboriginal Health and the Leadership/Management units would be combined. It is suggested that integrating assessments promotes a synthesis of learned ideas which reflects professional practice (Vanderheide and Walkington, 2009). Students were required to present the project to their peers, staff, and members of the community. The aim of the presentation was the provision of evidence that the students understood the concept of QI and its relationship to Aboriginal health. Furthermore, it would enable students to form a coherent whole and shed light on real clinical situations (Vanderheide & Walkington, 2009). According to Mansfield and Meyer (2007) nursing students' value assessments that have a practical component since they create a more meaningful experience. Additionally, it is suggested that deeper learning results from revisiting concepts learned in a variety of settings (Struyven, Dochy & Janssens, 2005). Significantly 97% of material is remembered if teaching and learning involves auditory, visual and experiential modes (Nilson, 2003).

Participation in role play can address all the various learning styles by the verbal and non-verbal acts of students and their ability to analyse and interpret the stories (Chan, 2012). The presentations were planned for week eight block of study, when all students would be on campus to attend their clinical skills unit. The tutor would be responsible for printing the program, organising the venue and inviting people to the presentations. The students were responsible for deciding what part they would play in the project and the sequence of the program of events. They were instructed that the presentations were to be creative and entertaining with marks being deducted for groups who presented their project by reading from a paper. The rationale underpinning this instruction was that nursing students need to think creatively to solve problems and express their thoughts in a coherent fashion (Chan, 2013). These instructions clarified the parameters of the assessment.

Implementing the project

From week three onwards the one hour tutorial in leadership/management unit was divided into discussions about the weeks lecture and progress in the project. The lecture was conducted on Blackboard by the unit coordinator in Fremantle and the tutorial by the tutor in Broome. Following submission of the essay on QI, the groups were clearer about their involvement and responsibilities in the project. The PSP form needed to be reviewed and changed to make it less cumbersome, culturally appropriate and user friendly.

The students understood that QI had been described as a continuous cycle involving assessment, planning, implementing and evaluating: a problem solving process that reflected the nursing process. Nevertheless, guidance was sought from the tutor concerning what part of the project the groups would take. The class concluded that each group would assess the problem of the PSP by focussing on different aspects of revising the form.

Valuable information about the culture and the variety of languages spoken by the residents was discussed between the students and their colleagues, one of whom worked at GKH as an enrolled nurse. This student although not enrolled in the leadership/management unit was studying Aboriginal health. Coincidentally, the student was of Aboriginal decent and thus able to provide important cultural information to assist in reviewing the PSP form. Having a colleague employed at GKH cemented some of the concepts learnt in class and from the literature. Each week the students huddled in their groups and had lively discussions about their project seeking clarification from the tutor where necessary. Students on Blackboard were also included in the conversations.

Group topics

It was decided that one group would take an in depth review of the GKH Mission statement to make sure it was congruent with the projects outcomes. Their part of the project was to conduct a literature review on mission statements in general, and the role such statements played in articulating to stakeholders the ethos of the health care organisation.

The second group decided that the fundamental problems with the PSP were twofold. Firstly, it posed questions that had little relevance to Aboriginal people, for example inappropriate questions asked:

Did you serve during the war?
Did you undertake higher education (e.g. university or TAFE)?
What were some of your former occupations? And what were the kinds of roles and tasks that you had to perform in these jobs?

Secondly, the language used had little or no meaning for an Aboriginal person. An example of the questions on the front page of the form asked:

How long have you lived in Australia?
Are you currently practicing a religion?
Can you describe some of the holidays or trips you have made that you may like to share with us?

Aboriginal people are known to be reserved and reluctant to admit difficulties in understanding English, and often say yes to a question, even though the answer should be no or don't know. Alternatively they may remain silent (Shahid, Finn, & Thomson, 2009). This group of students discussed with their peers findings from their experiences and information from the literature. Their aim was to facilitate a better understanding of the role communication played in using and interpreting the PSP form.

The third group of students decided they would conduct an audit on the PSP form to identify the questions that were culturally inappropriate. The Manager of GKH granted permission for the students to visit the facility and to randomly sample the PSP forms in the Indigenous and non-Indigenous residents' files. They concluded that there were ten questions vital to the residents' social well-being, five of which were culturally in-appropriate and could be reworded or deleted.

Group four took on the responsibility of designing the new PSP form. One of the members within this group was an Aboriginal student who lived on campus, which gave the group an advantage in terms of cultural appropriateness of the revised PSP. This group of students also visited GKH and discussed with the staff the rewording or deletion of some questions. Significantly, they reduced the nine page PSP form to three. The form, however, has yet to be piloted before its final revision.

Evaluation of learning

There is agreement that assessment is firmly located in the achievement of learning outcomes (Linn & Gronlund, 2000). Both Aboriginal health and the leadership unit fulfilled the competency standards stipulated by the Australian Nursing and Midwifery Board (ANMB, 2012). Furthermore, as part of the assessment, as stated on the unit outline for Aboriginal health, students were required to undertake a group presentation. This form of assessment was considered appropriate to evaluate the learning outcomes from the two units. The aim was for the students to present the process of QI incorporating Aboriginal health.

To accommodate the variety of learning styles in the class the students were required to not only present their project in role play, but also write report on the project. This again was a group assignment which required cooperation from all involved. Mixing assessments is thought to cater for most learning styles (Burksaitiene & Tereseviciene, 2007; Garside, Nhemachena, Williams & Topping, 2009; Struyven, Dochy, Janssens, 2005). Additional, engaging and reengaging in critical reflection, such as occurred in class, in the role play and then in writing the report, is associated with deep learning (Fowler, 2008; Moon, 2004).

Each group presented their part of the project by performing different, creative role plays. Assessment was based on how well the students understood the concept of cultural sensitivity, cultural competence and the importance of conducting QI in nursing care. Students actively participated in learning by visiting GKH and then presenting their project in the seminar. It also enabled them to put their knowledge into practice and convert their thoughts into action. The question time following the student presentations enabled the tutors to evaluate the students learning. The students demonstrated their ability to connect the concepts from both units, and had a deeper understanding of the links between quality nursing care and cultural awareness.

Nurses are constantly confronted with making decisions requiring critical thinking skills. It has been argued that creative approaches to teaching and learning, fosters critical thinking (Chan, 2012). Clearly, the students involved in making links between the outcomes of the two units used critical thinking and creativity skills; both of which are vital in problem solving. The student presentations were dynamic in terms of a learning activity and creativity. The presentations were recorded on a video, which provided evidence of the groups accomplishments in the QI project and the incorporation of culture sensitivity. Later the video gave richness to the role play in terms of the body language and sincerity of the students. It provided a true account of the students learning, in particular the bridge between theory and practice. The presentations were characterised by excitement and fun, with little evidence of stress about grades for the unit.

Conclusion

In conclusion, this paper described a unique QI project that nursing students undertook in collaboration with the local Broome aged care facility. It was also innovative in that assessments for two units of study were combined: both these initiatives were experiential in nature. The students' presentation, and their final examination, revealed that they had made connections with the process of conducting a QI project whilst being culturally sensitive to the Indigenous residents of the facility. The project also assisted students to develop an understanding of the relationship between theory and practice. The new PSP form, however, has yet to be piloted in GKH and final revisions made before implementation. It is anticipated that future students will take up this challenge.

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Please cite as: Piercey, C. (2014). Collaboration between the community and tertiary nurse education in bridging the gap between theory and practice. In Transformative, innovative and engaging. Proceedings of the 23rd Annual Teaching Learning Forum, 30-31 January 2014. Perth: The University of Western Australia. http://ctl.curtin.edu.au/professional_development/conferences/tlf/tlf2014/refereed/piercey.html

© Copyright 2014 Carol Piercey. The author assigns to the TL Forum and not for profit educational institutions a non-exclusive licence to reproduce this article for personal use or for institutional teaching and learning purposes, in any format, provided that the article is used and cited in accordance with the usual academic conventions.

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