The use of simulation in healthcare education has dramatically increased in popularity over the last two decades. It is thought to provide a standardised way of exposing learners to clinical situations where they can safely learn from mistakes. However, there is a lack of evidence to suggest whether simulation-based training offers significant benefits for clinical care over more traditional educational techniques, especially when the objective is a clinical judgement or diagnosis rather than a practical skill. This thesis explores whether the use of a high-fidelity patient simulator during training has an effect on the self-efficacy beliefs and clinical practice of learners, and whether this varies according to learners’ prior experience with simulation training or the clinical topic. Data were collected through semi-structured interviews with 16 qualified nurses, all of whom had attended a simulation-based training programme designed to improve clinical judgement skills. Analysis and data collection were iterative. Using a social constructionist epistemology, a thematic analysis approach was employed. High-fidelity simulation was perceived to be valuable by participants, who reported that it helped them to contextualize their knowledge and feel more confident about relevant clinical judgements. The reported impact on self-efficacy varied according to how much personal experience learners had in either the relevant clinical domain or with simulation as a training technique. However, greater belief in personal clinical judgement skills did not necessarily change reported clinical behaviour. The need for psychological fidelity during training appeared to be inversely related to clinical experience, reflecting the importance of contextual sensitivity in the planning of simulation-assisted training. Future research should examine whether these findings are reproducible in other settings, and consider whether simulation fidelity should be tailored to specific learner profiles.

This study was undertaken in response to concerns that mentors who assessed practical competence were reluctant to fail student nurses in assessments which generated doubts about the fitness to practice of some registered nurses. This study set out to investigate mentor’s experiences of failing students in England and was undertaken in two phases. In phase one comparative failure rates obtained from 27 universities indicated that, over a three year period, a very small proportion of students failed practical assessments; failure rates for theory outstripped practice by a ratio of 5:1. A quarter of the universities failed no students in practice. These findings appeared to support the initial concerns and raised a number of questions about practical assessment systems and practices. In phase two, a grounded theory approach was used to explore the experiences of thirty one participants who had been involved in failing student nurses in practice and the factors which enabled them to do this. Findings revealed that a clash of priorities and cultures between universities and health care organisations generated significant obstacles to failing students. The practical assessment process itself functioned on the mentors’ goodwill, their informal social support network and local arrangements rather than on timely, formal, organisational systems. A number of effective interventions were identified which, when combined, supported a three stage process that enabled mentors to fail an underperforming student. This study is the first to examine mentors’ perspectives of how and why they were enabled to fail student nurses in practical assessments in England, and resonates with those reported by other vocationally-based professions. The challenges faced by mentors that this study identifies contribute to national understanding of the processes and context which combine to facilitate robust assessment of the future nursing workforce, ensuring patient safety and public confidence in professions which provide essential care and services.

The clinical competency of pre-registration nursing students has raised questions about the proficiency of teaching strategies used to teach clinical skills in the undergraduate nursing programme. This study aimed to test the effectiveness of teaching clinical skills using a multiple intelligences teaching approach (MITA), which is underpinned by Gardner’s theory (1983) of multiple intelligences. This study employed a randomised controlled trial with first year nursing students (n=90) in one third-level institute in Ireland. Participants were randomly allocated to a control group (conventional teaching) (n=44) and an experimental group (MITA intervention) (n=46) to learn clinical skills. From a suite of twelve clinical skills taught, three clinical skills were assessed and included hand washing, sub cutaneous injection and nebuliser therapy. The outcome was skill performance measured by the results in an objective structured clinical examination (OSCE).Participant preference for learning was measured by the Index of Learning Styles (ILS). Participants’ multiple intelligence (MI) preferences were measured with a multiple intelligences development assessment scale (MIDAS), which included intellectual styles. MI assessment preferences were measured by a multiple intelligences assessment preferences questionnaire. The MITA intervention was evaluated using a questionnaire. Results showed that participants in the experimental group had higher scores in all three OSCEs examined (p<0.05) at Time 1, suggesting that MITA had a positive effect on clinical skill acquisition. The strongest preference on ILS for both groups was the sensing style. The highest MI on the MIDAS questionnaire for both groups was interpersonal intelligence. The assessment preferences questionnaire results showed that the majority of students favoured practical examinations, followed by multiple choice questions and short answer questions, as methods of assessment. The participants in the experimental group were positive about the MITA intervention. The findings of this study support the use of MITA for clinical skills teaching and advance the understanding of how MI approaches to teaching may be used in nursing education. This study builds upon the limited body of knowledge regarding the use of MI teaching strategies in a third level setting for clinical skills teaching. The findings may assist nurse educators in their choice of teaching strategies for clinical skills teaching that meets learner needs and promotes effective learning. Future research is needed to test the effectiveness of using the MITA intervention in practice placement settings to augment clinical skills laboratory teaching.

Change was introduced in the form of a new programme for pre- registration nurses. The Primary Care Pathway was the first of its kind nationally and had not featured in higher education until now, and thus involved major organisational change. A study was undertaken to explore how this change was managed throughout the organisation. Interviews took place with the senior management teams both at the strategic and operational level in an HE institution, with academic colleagues and learners undertaking the PCP. Documents relevant to the development and subsequent implementation of the PCP were also used for documentary analysis. Findings reveal that there were differences in how this change was managed. Whilst there was empowerment, engagement, commitment and ‘Buy In’ to the new PCP programme at the strategic level both in academia and the PCT, the same could not be said for the frontline. Leadership was a critical factor in gaining the support of strategic managers in the relevant organisations for this new programme. Many issues arose in the frontline. In particular, communication failed to get ‘Buy In’ from most mentors in the clinical setting. The vision was not shared by all across the academic and clinical setting, and the conception of nurse education was perceived as acute based and acute skills focused. In academia there was a culture of resistance to change, and the concept of the new PCP did not appear to embed in that setting. There was a lack of empowerment during the curriculum planning of the PCP and managers simply managed the change instead of leading and managing. Short term wins were not used to keep the momentum of change and the credibility of the change in relation to the conception of nurse education was under challenge. The approach to managing change was a top down approach. Change was envisioned and planned and managers were directed to implement the new programme. The need to take due account of the emotional aspects of change did not seem to be accorded sufficient importance by those leading this change.

A core component of nurse education is clinical practice in order to support the development of clinical skills and competence. Assessment and measurement of the clinical competence of nursing students is important to gauge their professional development and educational needs. An important educational function for both Schools of Nursing and clinically based mentors is to support nursing students to achieve the competencies required to complete a comprehensive patient assessment. The study is reported in three discrete stages. Stage one identified and tested the psychometric properties of two self-report competence scales; the Nursing Competencies Questionnaire (NCQ) and the Self-Efficacy in Clinical Performance (SECP) with a sample of second year pre-registration adult nursing students. Testing the reliability and validity of the two scales confirmed their suitability for use as outcome measures in stage two of the study. In stage two a ‘before and after’ design was used to determine if there was a relationship between score changes in the scales tested and use of an Older Persons’ Educational Assessment Workbook among a sample of second year adult nursing students. A content analysis of completed workbooks and a survey of opinions regarding the usefulness of the workbook were undertaken in stage three of the study.

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The gap between what is taught in college, and its application in practice, is the subject of much debate in the nursing literature. The reform of pre-registration nursing education, known as Project 2000, was the latest professional attempt to close this gap. There has, however, been very little in-depth debate about the degree of curriculum integration, the extent to which the internal logic of the contributing disciplines should be maintained, and the responsibility for teaching them. This study seeks to illuminate this problem by using research methods which will uncover student and teacher conceptions of learning to integrate theory and practice. Contextual analysis, a methodology within the phenomenographic tradition developed by Svensson (1976), was chosen as the research approach. It assumes that the meaning of the data depends on the context in which they were collected. The students in the study say that their learning is enhanced by teachers who have subject expertise, whether in nursing or the contributing disciplines; that they can learn better from their peers than from their teachers; and that they need to develop a base of knowledge of the contributing disciplines before they can go on to integrate them. These are complex issues, however, and there is a need for further exploration and clarification but the conclusions from this study will contribute to the debate and can help the development of nursing curricula which will present theory and practice as an integrated whole.

Aim: This thesis sets out to explore and understand how nursing students learn in the clinical environment, specifically through the influence of registered nurses. Background: At a time when public confidence in the quality of health and nursing care is called into question, the United Kingdom Nursing and Midwifery Council’s (NMC) new standards for pre-registration nursing education are intended to prepare the UK nursing workforce of the future to provide high quality nursing care across a range of health care environments (NMC, 2010b). While existing UK nursing research has examined learning in the clinical environment, little work has been undertaken to understand how nursing students on placement learn in the clinical environment and specifically the influence of others. Methods: Using Yin’s (2009) case study approach, this thesis explored the learning experiences of a group of five final year nursing students through descriptions of their learning within the clinical environment. In keeping with Yin’s (2009) case study approach of gathering a richness and depth of understanding, additional data were collected from a focus group with eight registered nurses. The collection of two types of data from both learners and registered nurses allowed for an exploration from both perspectives and experiences of these two groups. The interviews and focus group were conducted between October 2010 and January 2011. Findings: The study identified three specific overall themes relating to the influence of registered nurses on student learning in the clinical environment; responsiveness to student learning needs; creating a sense of belonging; and influencing professional identity development. A fourth theme identified was the importance of the clinical environment in that it allows students to learn what cannot be facilitated elsewhere. Discussion: The findings while supporting previous research also provide new understanding. The nursing student participants had and wanted to actively manage their learning in the clinical environment. As a result of this active management the students did not passively acquire knowledge or simply replicate what they observed from others. There was evidence that the students had strong and established perceptions of what constituted ‘good’ nursing and described an ability to discriminate between differing levels of nursing practice. Student nursing knowledge was gained from respected registered nurses who were best able to describe and demonstrate the ‘tricks of the trade’ and ‘little things that matter’ when providing ‘good’ nursing. Conclusions: The findings have informed a number of suggestions on how to support nursing students and clinical staff to enhance and improve the learning experience in the clinical environment. Curriculum design and preparation of registered nurses and mentors needs to stress the strong social aspects of clinical learning while raising awareness of the importance of creating a sense of belonging and respect for students as individuals. Pre registration curricula need to explicitly explore concepts such as caring, professionalism and support learners to articulate and examine their developing concepts of nursing and what constitutes ‘good’ and ‘bad’ nursing.

This study explores academics' experiences of their research role in one Irish university nursing department. Since 2002, nursing has been an all-graduate profession. This policy change means that nurse education is now based in higher education institutes. For the study, interviews were conducted with eighteen academics, ranging from lecturer to senior lecturer and above from several disciplinary backgrounds using a phenomenographic approach, to enable an understanding of the range and variation in experiences. Three categories of experience emerged from the data: 'getting a foothold on research'; 'navigating an early research career' and 'research as core to the academic role'. In each category there is variation in the focus of awareness concerning involvement in research and research networks, individuals' research aims, and research as a component of the overall academic role. Three dimensions of variation were discerned in the analysis. These relate to involvement in research, identity as a researcher, and control over the nature of work. A critical boundary area concerning membership of the community of research practice is PhD study. The findings indicate that sustained and structured support is required in order to promote the visibility of research within the department and to facilitate continuity of research activity.

This thesis describes the findings of an evaluation study designed to examine the development of ten healthcare practitioners (nurses) through action learning. The study explored how action learning can be used as a learning strategy to help nurses in their professional practice. The study aimed to investigate how one approach to work-based learning, action learning, potentially influences how nurses learn. The study adopts a stakeholder-evaluation approach, which involves discovering how participants experience action learning through being a set facilitator, set presenter, and set member. This evaluation strategy is located within the interpretive/constructivist paradigm and draws from social research evaluation methods, including fourth-generation evaluation (Guba and Lincoln, 1989). This study views evaluation as the systematic exploration and judgement of working practices, experiences and outcomes through a process of dialogue. Therefore, rather than defining evaluation in terms of measurement, the research focus is one of qualitative enquiry. Based on the findings of a range of evaluation methods, it is suggested that action learning could be used as part of a strategy to enable participants to learn from experience and develop techniques for using action learning and its associated processes for the purposes of facilitating learning in the workplace and, thus, become more effective in their learning and development role. In addition, the findings suggest that an individual’s learning style is an important consideration when setting up action-learning programmes. The value of using action-learning techniques to enable individuals to explore and develop their learning and development skills is evidenced. The contribution that facilitation expertise can make to personal development, supporting and developing others and enabling quality patient care is outlined. Recommendations indicate the need for organisations to share a common vision and strategy for embedding learning and development into the workplace. The study concludes by recommending eight learning principles to guide participants, facilitators and organisations in their use of action learning.