Delegation and supervision of health care...

Delegation and supervision of health care assistants’ work in the daily management of uncertain and the unexpected in clinical practice: invisible learning among newly

qualified nursesAllan, H, Magnusson, C, Evans, K, Ball, E, Westwood, S, Curtis, K, Horton, K and

Johnson, M

http://dx.doi.org/10.1111/nin.12155

Title Delegation and supervision of health care assistants’ work in the daily management of uncertain and the unexpected in clinical practice: invisible learning among newly qualified nurses

Authors Allan, H, Magnusson, C, Evans, K, Ball, E, Westwood, S, Curtis, K, Horton, K and Johnson, M

Type Article

URL This version is available at: http://usir.salford.ac.uk/39450/

Published Date 2016

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INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES 1

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Authors’pre-publicationmanuscriptofacceptedpaper:

Allan,HelenT.andMagnusson,CarinandEvans,KarenandBall,ElaineandWestwood,SueandCurtis,KathyandHorton,KhimandJohnson,Martin(2016)Delegationandsupervisionofhealthcareassistants’workinthedailymanagementofuncertainandtheunexpectedinclinicalpractice:invisiblelearningamongnewlyqualifiednurses.NursingInquiry.ISSN1320-7881(Accepted/Inpress)InvisibleLearning15072016accepted.pdf

Abstract

The invisibility of nursing work has been discussed in the internationalliterature but not in relation to learning clinical skills. Evans and Guile’s(2012)theoryofrecontextualisation isusedtoexploretheways inwhichinvisible or unplanned and unrecognised learning takes place as newlyqualifiednurses learntodelegatetoandsupervisetheworkof thehealthcare assistant. In the British context, delegation and supervision arethoughtofasskillswhicharelearnt ‘onthejob’.Wesuggestthat learning‘on-the-job’ is the invisible construction of knowledge in clinical practiceandthatdelegation isaparticularlytellingareaofnursingpracticewhichillustratesinvisiblelearning.UsinganethnographiccasestudyapproachinthreehospitalsitesinEnglandfrom2011-2014,weundertookparticipantobservation, interviewswith newly qualified nurses,wardmanagers andhealthcareassistants.Wediscusstheinvisiblewaysnewlyqualifiednurseslearn in the practice environment and present the invisible steps tolearningwhichencompass theembodied, affectiveand social, asmuchasthe cognitive components to learning.We argue that there is a need forgreater understanding of the ‘invisible learning’ which occurs as newlyqualifiednurseslearntodelegateandsupervise.Key words: newly qualified nurses, delegation, invisible learning,preceptorship

INVISIBLELEARNINGANDNEWLYQUALIFIEDNURSES

Delegationandsupervisionofhealthcareassistants’workinthedailymanagementofuncertainandtheunexpectedinclinicalpractice:invisible

learningamongnewlyqualifiednurses

Theinvisibilityofnursingandcaringhasbeenconsideredintheliterature(Allan,

2002;Strauss,Fagerhaugh,Suczek&Wiener,1982;Wilkinson&Miers,1999)before.

Suchworkhastendedtofocusontheinvisibilityofnursingatthestructurallevelasa

feminisedoccupation(Gamarnikov,1978;Oakley,1993),orattheepistemologicallevel

whereitisargued,theknowingattheheartofnurses’workisoverlookedinfavourof

biomedicalknowledge(Allan&Barber,2005;Bjorklund,2004;Miers,2002).We

discussanaspectofinvisiblenursingwork,namelytheinvisiblelearningnewly

qualifiednurses(NQNs)engageinwhenlearningtodelegatebedsidenursingcareto

healthcareassistants(HCAs)andsupervisetheirperformance.Thedelegationofcaring

workbynursestoHCAshasevolvedovertimeandbedsidecareislargelyundertaken

byHCAs(atleastintheUK)(Francis,2013);yethownurseslearntodelegateand

supervisethisaspectofbedsidecareremainsaninvisiblepartofboththenursing

curriculumandpractice.Webuildonideasaroundtheinvisibilityoffeminisedworkin

nursing(Oakley,1993)andthedevaluationofbedsidenursingcare(Allan&Barber,

2005)todrawattentiontoinvisiblelearningoftheseformsofworkbynursesasthey

delegatetoandsuperviseHCAs.Thisinvisibleworkissometimesreferredtoas

comprising‘soft’,interpersonal(Bolton2004)skillsbasedon‘personalattributes’

(Windsor,Douglas&Harvey,2012);invisibility,femininesoft,personaland

interpersonalskillsarefrequentlyconflated.Thelearningoftheseskillshasnotbeen

studiedinnursing,anddelegationandsupervisionappearnottobetaughtorassessed

inthecurriculumorinclinicalpracticetothesameextentasotherskills.


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Inthispaper,weaddressthisgapintheliteraturetoconsiderdelegationand

supervisionofHCAsbynewlyqualifiednurses(NQNs)anddiscusstheirinvisible

learningastheybegintodelegateandsuperviseHCAs’work.Wedrawonempirical

datafromethnographiccasestudies(Magnusson,Horton,Curtis,Westwood,Ball,

Johnson,Evans&Allan,2014).

Literaturereview

Invisiblelearninghasbeendiscussedinrelationtothehiddencurriculumwhich

entailsthe‘processes,pressuresandconstraintswhichfalloutside…theformal

curriculumandwhichareoftenunarticulatedorunexplored’(Bignold&Cribb,1999;

24).Ithasalsobeenusedtodescribeasetofinfluencesthatfunctionatthelevelof

organisationalstructureandcultureincluding,forexample,implicitrulesforhowto

survivetheinstitution,suchascustoms,rituals,andtakenforgrantedaspects(Lempp&

Seale,2004).AccordingtoBjørnavold(2000)unplannedlearninginworksituationsis

invisibleinthesensethat‘itisdifficulttodetectandappreciate’;andthatmuchof

‘know-how’isinvisiblylearntthroughpracticeandthroughpainfulexperience.Wehave

arguedinapreviouspaperthatknowledgerecontextualisationdelineatesthewaysin

whichpreviouslyinvisibleandinter-relatedknowledge,knowledgewhichisunplanned

andunrecognised(EvansGuile,Harris&Allan,2010).Inthispaperwearguethatthis

learning,ifreflectedupon,becomesexplicitandlinkedforNQNs,enablingthemto

developconfidenceintheirabilitytomanagethestaffwithwhomtheywork

(Magnussonetal.,2014).Ourworkhascontributedtoadiscourseontherelationship

betweentheoryandpracticebycritiquingtheideaofknowledgetransferand

suggestingtheuseofrecontextualisationofknowledge.Here,wedevelopthis

perspectivefurther,toexplorethewaysinwhichinvisiblelearningtakesplaceasNQNs


encountertheuncertainandunexpectedastheylearntomanagepatientcareinclinical

areasthroughthedevelopmentoftheirdelegationandsupervisionskills.Indoingsowe

developanempiricallybaseddescriptionofinvisiblelearninginNQNs’practiceof

delegationandsupervision;onewhichcapturestheinvisible,unrecognisedand

unplannedstepstolearningandwhichencompassestheembodied,affectiveandsocial,

asmuchasthecognitive,componentstolearning.Wedescribefoursteps:1)learning

throughmistakes;2)learningfromdifficultexperiences;3)informallearningfrom

colleagues;and4)‘muddlingthrough’toillustrateinvisiblelearning.Wearguethat

invisiblelearningwasobservedamidstthepressuresandconstraintsofworkingina

teamwhichreliedheavilyonHCAs(Magnussonetal.,2014),andtherulesandrituals

(Allan,Magnusson,Ball,Evans,Horton,Curtis,&Johnson,2015)andexpectationsof

NQNs(Johnson,Magnusson,Allan,Evans,Ball,Horton,Curtis&Westwood,2014)which

formedanintegralpartoftheworkplaceculture.

ThisarticlereportsononeaspectofawiderUKresearchproject(Magnussonet

al.,2014)whichexploredhowNQNsrecontextualiseknowledgelearnedduringtraining

topracticeasaqualifiednurse.Akeythemewhichemergedfromthestudywas

‘invisiblelearning,’aninformallearningprocessdistinctfrommoreformallearning

mechanisms.Aparticularareawhereinvisiblelearningwasobservedwasnurse

delegationto,andsupervisionof,HCAsinperformingbedsidenursingcare.While

delegationandsupervisionofnursingcarearecrucialtothesafe,effectiveandefficient

deliveryofbedsidecare,andfailuresinsuchworkcanresultinriskstopatientsafety

andpatientoutcomes(Anthony&Vidal,2010;Standing&Anthony,2006),thisisthe

firstobservationalstudyoflearningtodelegateandsupervise.


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Despitetheincreasingrelevanceofdelegationandsupervisionfortheroleofthe

modernnurse(Gillen&Graffin,2010;Standing&Anthony,2008;Weydt,2010),these

skills do not form a central component of undergraduate nurse programmes or

preceptorshipprogrammesintheUK.Thesewereintroducedtosupportthetransition

fromstudent toregisterednurseusually in the first sixmonthsofqualifying (Hasson,

McKenna&Keeney, 2013). Preceptorship programmes are variable across individual

clinicalsettings(deWolfe,Perkin,Harrison,Laschinger,Petersen&Seaton,2010)with

aprogramme lasting frombetween twoweeks inonehospital tooneyear inanother

and NQNs entitled to one week of supernumerary practice to one month. The

preceptorshipphasecanbearealityshock(Hollywood,2011)withmanyNQNsfeeling

asiftheyhavebeen‘throwninatthedeepend’(Whitehead&Holmes,2011,19),leftto

‘sinkorswim’(Hughes&Fraser,2011,382)or‘fumblealong’(Gerrish,2000,473).Itis

therefore important to understand how NQNs make sense of (recontextualise)

knowledgelearntintheuniversityastheybegintheirnewroles,andalsotointerrogate

whether the knowledge taught serves NQNs’ self-perceived needs. This process of

learninginnewcontextsissometimesreferredtoasknowledgetransferorknowledge

translation(Kothari,Bickford,Edwards,Dobbins&Meyer,2011)thatis,thetransferof

knowledge taught inuniversity todifference clinical settings.However the conceptof

knowledgetransfer(KT)iscontentious(Evans&Guile,2012;Kotharietal.,2011)with

Kothari et al., (2011) suggesting that learners use an interaction-based approach to

knowledgetransferratherthanasimplesingleactoftransfer.Ithasbeensuggestedthat

‘invisiblelearning’canplayanimportantroleinnurses’informallearning(Eraut,2004)

andcanbecentraltowhether,andhow,NQNsareabletomakethesuccessfultransition

duringpreceptorship(BjørkTøien&Sørensen,2013).


We draw on Evans and Guile’s work (2012)which stresses a new approach to

understandingprofessionalknowledge, “onewhichconcentratesondifferent formsof

knowledge including those manifested in ‘skills’ and ‘know-how’ and embedded in

communities aswell as propositional knowledge” (2012, 245). This is not knowledge

transferredbutknowledgerecontextualised.EvansandGuile(2012)haveshownhow

curriculumdesigners recast disciplinary knowledge (from its disciplinary origins) and

workplace knowledge (from its professional and/or vocational contexts) and combine

theminlearningprogrammes,tolaythefoundationsforknowledgeablepractice.Inthe

classroom,teachersmaychoosepedagogicstrategies,suchas ‘real life’casestudiesor

problem-based learning topre-figure thedemandsofpractice fornewentrants (or to

simulate new situations through ‘learning labs’ for experienced workers). But, most

importantly, knowledgeable practice develops through learning in and through the

workplaceitself,throughobservationofothers;throughmentorship,coachingandpeer

learning and by drawing on new ideas and experiences accessed through work and,

often, beyond work. Timetabled sessions and instruction in nursing preceptorship

programmescanintroducecodified,proceduralandworkprocessknowledgebutunlike

disciplinaryorsubjectknowledge,wherethereareclearcriteria leadingtothegoalof

greater abstraction and depth in understanding, there are few rules about how to

structureandsequencethecontenttowardsthegoalofknowledgeablepractice,asthe

latter depends on invisible learning. The invisible learning is often triggered by the

activity and the context. Knowledge recontextualisation takes place when the NQN

recognises anewsituationas requiringa responseandusesknowledge– theoretical,

proceduralandtacit-inactsofinterpretationinanattempttobringtheactivityandits

settingunderconsciouscontrol(vanOers,1998).Whentheinterpretationinvolvesthe

enactment of a well-known activity in a new setting, an adaptive form of


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recontextualisationtakesplaceasexistingknowledgeisusedtoreproducearesponse

inparallelsituation.Wheretheinterpretationleadsthelearnertochangetheactivityor

itscontextinanattempttomakearesponse,aproductiveformofrecontextualisation

takes place, as new knowledge is produced. Knowledge recontextualisations are

fundamental toworkers beginning to enact existingworkplace activities; orworking

withexperiencedotherstomodifychangetheminthefaceofunexpectedoccurrences

or the need to find new solutions. In the clinical context, forms of knowledge are

embedded in routines,protocolsandartefactsaswellas inorganisationalhierarchies

and power structures (Allan et al., 2015; Evans et al., 2010). As well as learning to

participate inworkplace activities and to useprotocols and artefacts, newly qualified

practitioners use work problems as a further ‘test–bed’ for theoretical and subject-

basedknowledge.Thisisfacilitatedwhenworkplacescreatestretchingbutsupportive

environmentsforworkingandlearningandlearnerstakeresponsibilityforobserving,

inquiringandacting.Learners,throughaseriesofsuchknowledgerecontextualisations,

come to self-embody knowledge cognitively and practically. This is a process that is

invisibleinthesenseintroducedearlier,asitisdifficulttodetectandappreciate.

Methods

Our research aimwas to understand howNQNs recontextualise knowledge to

allowthemtodelegateandsupervisenursingcareonthewardswhenworkingwithand

supervising healthcare assistants. Ethnographic case studies (Burawoy, 1998) were

conductedacrossthreehospitalsitesselectedformaximumvariability(seetable1).

<PleaseinsertTable1aroundhere>

Ethical approval was obtained from the National Health Service Research

Authority (NRES), each participating hospital research and development committee,


andeach teammember’suniversity ethics committee.The research teammet toplan

sharedobservationandinterviewschedules;datawerecollectedbyallmembersofthe

research teamthroughparticipantobservations(approximately230hours)andsemi-

structured interviews,withNQNs,HCAs, andWardManagers/Matrons.Observations

werelocatedinhospitalwards,followingaNQNforashiftass\heworkedwiththeHCA

assigned to the same group of patients and in particular focusing on their delegation

andsupervisionpractices.Observationsincludedallnursingactivitiesundertakenona

shift fromarrangingdischarges,washingand toiletingpatients tomakingbeds,doing

thedrugroundsandwritingupnursingnotes.Shifts includednightshifts,handovers,

andtransferofpatientsbetweenclinicalareas;threeteammemberswhowerenurses

worked alongside NQNs as participant-observers while two non-nurse observers

maintaineda fullyobserverrole.Asmuchaspossible, interviewswithNQNs followed

observations of those sameNQNsworkingwith HCAs and interviewswere also held

with theHCAs they hadworkedwith and theirwardmanagers. (See Table 2 for full

detailsofdatacollection).Staffwereinvitedtoparticipatebyletterandwereconsented

toparticipatebeforeeachobservationandinterview.Patients,whilenotthefocusofthe

research,wereconsentedtoparticipateintheobservations.

<PleaseinsertTable2aroundhere>

Observationsnotesand interviewsweretranscribedverbatimbya transcriber.

Datawere analysed using thematic analysis (Guest, MacQueen & Namey, 2012) both

manuallyandwiththequalitativesoftwareNVivobyoneresearcherandthenrawdata

andthemessharedattwodataanalysisworkshopswithalltheresearchers.


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Findings

Our findings highlight the importance of both visible and invisible learning to

NQNs.Visiblelearningwasevidentintime-tabledpreceptorshipactivities,assessments

andmentorship.However,asweobservedNQNsacrossthreehospitalsforsubstantial

periods(230hours),weobservednumerousexamplesofinvisiblelearninginpractice,

aswell as examples of visible, formal learning.According to our analysis, this largely

invisible learning took four main forms: learning through mistakes; learning from

difficultexperiences;informallearningfromcolleagues;and‘muddlingthrough.’

Learningthroughmistakes

The NQNs encountered unexpected situations on a daily basis, and as part of

recontextualising knowledge learnt at university, they also learnt through making

mistakes.ThefindingsdemonstratethattheNQNsmademistakesrangingfromminor

tomoreserious,andthatthiswasconstantlyontheirmindsastheywerechargedwith

takingonmoreresponsibility:

I think you learn from your own mistakes and other people’s mistakes as well

because youknow, there’s a lot of ‘this couldgowrong, this couldgowrong’ but

whenlikeyou’reactuallyfacedwithityourselfyousortofrealiseitandit’sthelittle

thingsthathappenlikethatcauselikeabiggererrorandthenthat’sityouhaveto

takeastepbackthenandthink‘god,whatelsecouldgowrong?’(SiteANQN14)

WardmanagerswereawarethatmakingmistakeswasapartoflearningforNQNs.On

wards where nurses felt well-supported, there were strategies which provided them

withasafetynetduringthisperiodof‘trialanderror’asthiswardmanagersuggests:


I’mnotgoingtoletyoumakeamistake,…..soit’sabouthavingsafechallenge,it’s

aboutifIseeyoudoingsomethingwrongI’mgoingtellyaandI’mnottellingyouto

getatyouI’mtellingyoubecauseoneIdon’twantyoutohurtthepatientsandtwo

Idon’twantyouasaperson tomakeamistakeand it’sabouthaving that safety

backup(SiteAwardmanager3)

Thisextracthighlightstheapproachofwardmanagerswhopracticeda‘safechallenge’

strategywhichempoweredNQNstotalkopenlyaboutwhenthingsnearlywentwrong;

in a sense thesewardmanagers carried the burdenwith them and supported them.

Allowing health professionals to reflect and learn from patient safety incidents is

supportedbycurrenthealthcarepolicy.However,so-called ‘blameandshame’patient

safety cultures are still common in healthcare organizations which obstruct the

possibilityoflearningfromerrors(Feng,Bobay&Weiss,2008).Onwardswherethere

wasa ‘safe challenge’ approach,NQNs feltmoreable to learn frommistakes ina safe

way:

Ifyoukeepthinking‘I’mgoingtomakeamistake’thenyouwillmakeamistakebut

Iknowthesupport’salwaysthereandthesupportworkersandtheHCAshereare

reallygoodso, Iknowthat if Iwas, if I’daproblemthat there’s themandthere’s

othernurses intheotherteamsaswellso IknowIcangotothem,so Iknowthe

supporthereisreallygoodonthisward.(SiteANQN12)

But in some cases, where a mistake had been made and an even more serious one

averted, the learning was painful as this nurse describes. She had relied upon a

healthcareassistanttocheckthatthepatientgoingtotheatrehadthecorrectnameon

thewristband,andconsequently,hadsignedoffthepaperwork.


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I’ve had lessons along theway that Iwon’t trust themagain to, to do something

correct,yeah,becauseI’velearntthehardwayreally…theanaesthetistcameback

andtheysaid‘thepatienthadawrongwristbandonherleg’,‘shehadthepatient’s

nameofanotherpatientonher leg’andthecareassistanthadput[it]onher leg

andIhadn’tdoublecheckedit(SiteBNQN2)

Amistakehadobviouslybeenmade and a seriousuntoward event reportwas raised

againstthisnurse.Sheexpresseddeepregretaboutthis incident,butfeltthatshehad

learntandwouldnevermakethesamemistakeagain.Theriskofunsafemistakescan

beprofound,forbothpatientandnurse,aswashighlightedbythiswardmanager:

I’veworked in other placeswherenewly qualifiednurses because they’veworked

thereastheirlastplacement,peopleseeitasanautomatictransitionthattheywill

justcomeinandfitontheoffdutyandbeaqualifiednurseallofasudden…that

willknocktheirconfidencecompletely if theypickupbadpracticesstraightaway,

they’ll start cuttingcorners, theywon’tdeliveronwhat’sbeenaskedof themand

they’llfail,youknowandwearesettingthemuptofailifwedothat,soabigbelief

ofmineistoembedwhatthey’velearntinthelastthreeyearsandtryandsortof

easethemintothat,youknow,andembedgoodpracticefromthebeginningreally.

(SiteAwardmanager1)

Wesuggest thatgoodsupport structuresat the levelof thewardwerecrucial for the

NQNs as they navigated through their new status as staff nurses with its attendant

greater responsibly and higher levels of authority. It was evident that the risk of

makingmistakesandpotentiallyharmingpatientsmadeNQNsscared,andforsomethe

emotionalburdenwassogreatthattheymovedintodenial:


Likefear,likeyou’restraightawayscaredandthenlikeyoufeelbadifthepatients’

beenhurtandthenif,anythingworseIdon’tthink,Ican’tthinkaboutit,because

causingharm to a patient that’swhatwe’re not supposed to do,we’re to do the

oppositesoifyoudocauseharmevenifit’sjustbymistakeit’snot,its,Ijustdon’t

wanttothinkaboutitreally.(SiteANQN14)

Learning from mistakes can be a powerful learning tool where knowledge may be

effectivelyrecontextualisedfrompracticeexperiences.Howeverourfindingsindicated

that experiential learning can also be traumatic, particularly if there is little or no

reflective space and can, in turn, produce poor practice ‘cutting corners’. It can also

resultinpatientsafetybeingcompromised.

Learningfromdifficultexperiences

Our findings suggest that some of the NQNs were under-prepared for

particularly demanding situations, including major emergencies, and the deaths of

patients. Experiencing such situations, coming to terms with them, and developing

confidenceintheabilitytohandlethem,arecrucialtotheNQNs’successfultransitionto

qualifiednurse:

A lot of student nurses have never been exposed to cardiac arrest, so in that

situationthenursesstrugglebecauseitisadifficultsituationandit’snotonethat

youhavealotofthetime[with]…(SiteCwardmanager4)

Ihadmy firstcardiacarrestacoupleofmonths,wellat leastacoupleofmonths

agonow,butitsounds,thissoundsawfulbutbecauseI’vehadthatI’mnotscaredof

ithappeningagainnow.(SiteBNQN9)


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ThesetwoextractshighlightthesignificanceofNQNsencountering,andlearningtocope

with,cardiacarrests,andhowtheexperiencingofsuccessfullydealingwithonecanbea

significantconfidence-builder.HoweverforsomeNQNsamajorincidentwhichdoesnot

have a successful outcome, and/orwhere there has been inadequate support, can be

traumaticasanobservationfield-notesuggests:

NQNtellsmesheisnervouswhenlightsareoffinbayatnightbecauseshecan’tsee

thepatients.Shewouldliketohavethelightonbyeverybed.Butluckilythepatient

withatrachy[eostomy]whichneedsclearingisbyawindowandlightison,good.

Sheexplainstomethatthispatientcoulddieifshedoesnotlookafterherproperly

–bigresponsibility.Shealsotalksaboutsomethingthathappenedlastyearwherea

youngpersondied inher sleepduring thenightwhen itwasdark. Iasked if they

knewwhypatientdied.Nursesaysheneverheardaboutthecauseofdeath.(SiteA

obs1)

ItwasevidentthatthelackoflightinthenightmadethisNQNveryanxious,asshefelt

that she could not effectively observe the patients in her care. She used a torch to

illuminatethefacesofpatientsasshewalkedaroundthebedsinthedark.Inaddition,

sheassociateddarknesswiththedeathofanotheryoungpatientwhohadsadlydiedon

herward and thisworriedher. TheNQNexpressed fear that this couldhappen again

withoneofherpatients.Whatappearstohavebeenamajorfactorforthenursewasnot

justthepatient’sdeath,butalsonotknowingwhythepatienthaddied,andnothaving

hadtheopportunitytodebriefaboutitafterwards.

ThedatasuggestthatgoodsupportstructuresatwardlevelarecrucialforNQNs

duringtheirpreceptorshipperiod.Itwasevidentthatmajoreventshadthepotentialto

eitherbuildorundermineconfidence,dependentuponboththeoutcomeandalsohow


theincidentwasdealtwith,andwhethertheNQNwassupportedinmakingsenseofthe

experience,orinotherwords,recontextualisingknowledge.

Informallearningfromcolleagues

Our analysis suggests that invisible learning with and from colleagues takes

three main forms: observation, informal discussion, and ‘osmosis’ (unconsciously

absorbingpractice styles and skills fromothers).Thisnursedescribeshowmuch she

learnedfromwatchingapatientbeingtoldshehadaterminalcondition:

Yeah,andIwatched,Iwasinoncewithaladywhowasmypatientandshe’djust

been told that she had terminal bowel cancer and the bowel specialist nurses in

thereandtheyhadaconsultantin,soIwentinaswell,butIwaswatchinghow,I

was using it, because I didn’t, I didn’t say anything because you know, I was

watching it, how they dealt with, and I picked up a lot of really good

communicationskillsfrom,fromthem.(SiteCNQNS1)

ThisNQNishighlightingtheimportanceofbeingabletowitness,anddrawknowledge

fromthehandlingofaparticularlydifficult,andsensitive,situation.

Participants alsodescribed learning frommoreexperiencedHCAsas thisHCAherself

observes:

They[NQNs]needsupport,theyneedalotmoresupportthanobviouslythestaff

thathavebeenherealongtime.ButweareagoodteamIthink,andwedogive

themallthesupporttheyneed…I’veknownrecentones[that]haveaskedme

things,whichIthink,‘Whyareyouaskingme?’ButobviouslybecauseI’vegot

experienceandI’vedonethejobforawhiletheyknowtheyIknowquitealotof

things….(SiteAHCA3)


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NQNsinourstudywerethemselvesawarethattheycouldlearnfromHCASalso:

‘Ithink,whatI’venoticedisthesesupportworkersknowmorethingsthanwedo,

theyknowalot,it’slikeyouthinkalltheydoismakingbedsbutwhenyou’redoing

awarddressing,theywilldobestdressings,becausethey’vebeenhereforlongtime

…betterthanus,and…asanewlyqualifiedIfoundalotofhelpfromthesupport

workers.’(SiteCNQN8)

Boththeseextractshighlightthevalueofinformalsupportwithcolleagueswhether

qualifiednursesornot.However,whileitwasrecognisedthatNQNscouldpotentially

learnalotfromHCAs,someparticipantswereconcernedaboutthesafetyaspects,as

thisHCAobserved:

Iwaswithanotherstaffnursewho’dbeenhereforawhileaswellandthisnewly

qualifiednursewastakingoutapatient’sdrainandshewasn’tsurehowtodoit,

butIknewhowtodoitanywaybecauseI’veobserved,Idon’tdothatmyselfbutwe

weretellingherandIwastellingher‘thisishowyoudoit’,I’mnoteven,I’mnot

evenqualifiedtodothatbecauseIdon’tdothatbutwhenI’mtellingherthisishow

youdoit–Ishouldn’tbetellingherlikesheshouldknowalready…because

otherwiseyou’rekindof,you’rewalkinginthedarkotherwiseandyouknow,you’re

putting,you’reputtingpatientsatriskifyoudon’tknow.(SiteAHCA2)

Thisextractshowsthattheremayberisksattachedwithlessstructuredlearning,and,

inparticularlearningfromlessqualifiedcolleagues.ManyNQNsspokeofthebenefitsof

informaldiscussionswiththeirpeers:


…andpeoplejusttalkaboutitandyou’llbelike‘yeah,yeah,I’vedonethesame’or

‘I’vedonesimilar’or‘howhaveyoudonethat’,youjustsortof,youknow,peersI

suppose,learningfrompeers….(SiteANQN9)

So,herewecanseetheimportanceofbeingabletoinformallydiscussscenarioswith

peers,andofexchangingideasandexperiences,andalsoofmutualidentification.

Invisiblelearningby‘osmosis’involvesabsorbinggoodpracticefromcolleagues

withoutbeingfullyawareofdoingso:

Ensuringthatthey’vegotqualifiedstaffworkingwiththemandwhatwetrytodo

iswetrytomixthestaffthattheyworkwith,soalthoughtheyhaveapreceptorwe

tryandgetthemtoworkwithdifferentstaffsotheycanseehowdifferentpeople

workandtheycanpickthebesttraitsoutofeachofmembersofstaff.(SiteAward

manager2)

Thistypeoflearningalsohasitsadvantagesanddisadvantages:nursescould

potentiallypickup‘bad’aswellas‘goodpractices’byunreflectiveworkingwithmore

experiencedcolleagues.Thishighlightstheimportanceofreflectivespacestoencourage

criticalthinkingamongnurses,especiallyNQNs.

Muddlingthrough

Despitethepresenceofformalpreceptorshipprogrammes,participants

nonethelessdescribedtheirexperienceofpreceptorshipas‘muddlingthrough’

uncertaintyindelegatingandsupervisingworkdelegatedtoHCAs;theydescribedusing

routinestomanagethismuddle,tomakethings‘fitintoplace’:

Itjustseemslikeamuddlewhenyoustartandthenaftersixmonthsitallseemsto

fitintoplace.(SiteBNQN2)


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This‘muddlingthrough’involvedaperiodofstruggleastheNQNstriedtogainmastery

overdelegatingandsupervisingHCAs;masterywhichoverwhatwasastressful

experience,a‘struggle’astheylearnttheworkroutineandcopedwithlowstaffing:

Ididstruggle[at]first,likemaybemonth,twomonthsnearly,untilIgotmyselfa

roundroutineandthen,thenit’sgonebetterandbetternow,nowit’s,ifwe’vegot

enoughstaffthenifthestaffinglevelsaregood,thenyeahyoucangetajobdone,

withouttoomuchstressandIcanactuallyfinishontime.(SiteANQNS2)

ManyNQNsthoughttheperiodof‘muddlingthrough’wasanecessarypartoftheir

adjustmenttobecominganeffectivedelegator,aconfident,nursewhocouldsupervise

HCAsintheirwork:

Theydid,theydidsortofgiveyoulecturesaboutyouknow,howto,todelegateand

whathaveyouandhowtousethosekindsofskillsbutIdon’tthinkanything

preparesyouforituntilyoucomeinthejobbecauseyoucan,youcankindof

theoriseabouthowyou’regoingtodoitbutits,youhavetoadapttoyour

surroundingsandwhoyou’reworkingwithandIthinkonlybydoingthejoband

gettingyourconfidenceupasaqualifiednursethat’showyoukindoflearntodoit

andhowtodoitreally.(SiteBNQN7)

Forsomenurses,‘muddlingthrough’astheylearnttodelegateandsupervisefora

groupofpatientswasnotasuccessfulexperience,‘you’regiventoomany

responsibilitiestoosoon.‘Muddlingthrough’couldcontributetoattritionratesamongst

theirpeers.

It'sreallysadyouknow,alotofmyfriendswhoqualifiedasnursesthesametime

asmehaveleftnursingaltogether.There'snotenoughsupportontheward,not


enoughseniorstaff,newlyqualifiednursesareputuponandgiventoomany

responsibilitiestoosoon...It'swornmedown.Youdon'texpecttobeworndownin

yourfirstsixmonths,youknow.Youcomeinallenthusiastic,youwanttomakea

difference,youwanttobethebestnursethatyoucan,butthenthere'snosupport,

andsomuchpressure,andyou'renotallowedtoflourish.(SiteBNQNF)

Forothernurses,however,the‘muddlingthrough’eventuallyledtoasuccessful

transition.HeretheNQNreflectsonbecomingmoreconfidentassherealisesthatshe

hastheknowledgetodelegateandsupervise‘whereveritwasstored’andshedoesthis

throughpersonalreflectionandthroughdiscussionwithothers:

TheknowledgewasthereIjustdidn’tfeelthatitwasthereandIdidn’tfeelthatI

knewenoughbutthenwhenIstartedtalkingaboutitanddoingitandpulling

thingsyouknowfromwhereveritwasstoredIthought‘wow,Idoknowthis’,you

know,‘wow,wheredidthatcomefrom?’,Idoknowwhatitistobeanurse…you

lookatyourselfinthemirrorandthink‘Icandothis,Iamanurse’,youknowIam

agoodnurse’(SiteANQN13)

ThesedatawouldsuggestthatNQNsneedextensivesupport,bothformalandinformal,

duringtheirperiodof‘muddlingthrough’tolearntodelegateadsuperviseHCAs.

Withoutthissupport,qualityofcareandpatientsafetymaybecompromised.

Discussion

Inthefourtypesofinvisiblelearningidentified,wesuggestthatNQNsstriveto

manageuncertaintyandbringordertounexpectedandnewsituationsinwayswhich

use,stretchandchallengetheirknowledgeinallofitsforms.TheNQNslearnnotonly

toenactestablishedworkplacepracticesandproceduresbutalsotomodifytheir

responsesinthesearchforsolutionstounexpectedoccurrencesorinthelightof


19

experiencesofmistakesthey,orothersaroundthem,havemade.Theylearnthrough

thisprocesstodeveloptheirjudgmentofwhatconstitutessafepractice,andenactit

througheffectivedelegationorappropriatesituationsforlearningfromco-workers.

Learningthroughdifficultexperiencesandmistakesaremostreadilyassociatedwith

productiveformsofknowledgerecontextualisation.Inlearningthroughmaking

mistakes,forexample,productiveformsofknowledgerecontextualisationaretaking

placewhennewknowledgeorinsightsareproducedinrespondingtounexpectedor

unpredictablesituations.Butinpracticebothadaptiveandproductivemodesco-exist.

Adaptiveaswellasproductiveformsofknowledgerecontextualisationcanresultfrom

mistakes,asNQNsadjusttheirapproachtousingexistingprotocolsorproceduresin

differentcontexts.Theseadaptationscanbeeitherbeneficialordetrimentaltopractice:

theexampleshaveshownhowdefensivepracticescansometimesbetracedtoadaptive

learningthathasresultedfrommakingmistakesordifficultexperiences.The

deepeningofadaptivetoproductivelearningthroughknowledgerecontextualisationis

crucialforactivitiessuchasdelegation,wheretherearefewpre-existingguidelinesand

wherethedevelopmentofattunedjudgementiscrucialtoeffectivepractice.

SupportingNQNstoworkingthroughdilemmasabouttrustingco-workersordifficult

experiencessuchasthedeathofpatients,potentiallybenefitsfromaknowledge-

awareapproachtopreceptorship,onethatenablestheNQNandpreceptorto

articulatewhatislearnedandtoconnectitwithpriorlearningtodevelopcurrent

practiceandmovefromadaptivetoproductiveknowledge.Thesesocio-cognitive

processescontributetothedevelopmentoftheattunedjudgmentsthatdefine

knowledgeablepracticeandsupporttheprocessbywhichNQNsthinkandfeeltheir

wayintoprofessionalidentities.Intheiraccountsof‘muddlingthrough’,newly

qualifiednursesareadaptingexistingknowledgeofmanydifferenttypestorespondin


thecontingenciesofthepresentmomenttomultiplepressuresanddemands.Their

responsesarethemselvescontextualizedintheroutinesandprotocolsofrecord

keeping,patientconfidentialityandsafetychecks.Theyarealsomodifiedaccordingto

workplacerelationsandtheorganisationalhierarchiesthatinfluencehowNQNs

communicatewithHCAs,doctorsandtheirpreceptor.Knowingwhen,howandwith

whomtocommunicateinanemergencyorunpredictablesituationcanbecriticalto

theoutcome.TheNQNisthusbuildingproductiveknowledgeofhowtoworkwiththe

protocolsandmanagetheworkplacerelationsthatareembeddedinclinicalpractice,

towardsthegoalofknowledgeablepracticeandattunedjudgment.Thefindingsshow

howNQNscometoembodyknowledgecognitivelyandpracticallyandsuggestarange

ofpracticesthatcouldimprovesupportfortheseimportantformsoflearning.

Conclusion

Inthisarticle,wehavedescribedfourtypesof‘invisiblelearning’asNQNsmake

thetransitionfromstudenttofullyoperationalqualifiednurse.Thisinvisiblelearning

canbemadevisibleandamenabletointerventionandsupportwhenitisunderstoodas

morethantheexperiencesthatinevitablyoccurwhenNQNsencounterthepressures

anddemandsofthe‘realworld’ofpractice.Thefourtypesallentailtheinterplay,inthe

contingenciesofthemoment,ofsubjectknowledge,proceduralknowledgeandformsof

personalknowledgethatarecontinuouslyused,refinedandreworkedinthepractice

context.Productiveandadaptiveformsofknowledgerecontextualisationco-exist.

Adaptiveformsarenotalwaysbeneficialtopracticeandproductiveformsare

strengthenedbyaccessto,andsupportfrom,expertandintellectualresourcesthat

enabletheNQNto‘standback’fromchallengingsituationsandthinkabouttheminnew

ways.


21

Inthecontextofdelegationandsupervision,theknowledgerecontextualisation

processesinherentin‘invisiblelearning’havearangeofpracticeimplications.Learning

throughmistakesindelegationandsupervisionraisesquestionsaboutthedistinction

betweenmistakesthatcanpotentiallybeharmfultopatientsandstaff,andmistakes

thatareperhapslessrisky.Itmightbepossibletohavecontrolsinplacewhichassess

thelevelofriskinvolvedindecision-makingsuchas‘flagging’areasofHCAbedsidecare

whichrequiregreaterorlessermonitoringbytheNQN.Theuseofsimulatedsituations

aspartofnursetrainingandpost-qualifyingtransitionmightoffertheopportunityto

make‘safemistakes’inthecontextofdelegationandsupervisionofHCAswhichcanbe

usefulforlearningpurposes.

LearningfromchallengingexperiencescanbeextremelyhelpfultoNQNsin

buildingtheirconfidenceinbeingabletohandlepotentiallyfrightening,challengingand

emotionallystressfulsituations.However,withoutadequatesupportandreflective

spacethisopportunityforpositivelearningcanhavetheoppositeeffect,increasing

NQNfearsandanxieties,anddecreasingtheirconfidencelevels.Itisimportanttohave

mechanismsinplacetoensureNQNsareofferedappropriatesupportanddebriefs

followingsuchmajorevents.ProvidingNQNswithadequatesupportswillalsoenable

themtoprovideadequatesupporttotheHCAstowhomtheydelegateandsupervise.

Learningfromcolleaguesinformally,viaobservation,discussionandosmosis,

canbeinvaluabletotheNQNduringtransition.However,again,thereisthepossibility

for‘bad’aswellas‘good’learning.ItisimportanttosupportNQNsindevelopingtheir

ownreflectiveandcriticalthinkingskills,inordertoensurethatwhattheylearnis

beneficial,ratherthandetrimental,totheirpractice.Itisalsoessentialtodistinguish

betweeninformalcollegialsupportbetweenexperiencedHCAsandNQNs,and


situationswherethereisanover-relianceuponHCAstosupportNQNs,andalmosta

‘reversedelegation’betweenthem,inwayswhichmightbeinappropriateandwhich

couldhavepatientsafetyimplications.

Thesenseof‘muddlingthrough’maybeaninevitablepartoftheNQNexperience

astheytransitionfromstudenttofullyfunctioningqualifiednurse.However,itis

importanttothinkaboutthepossibleimpactonHCAsofthis‘muddlingthrough,’to

ensurethatthisdoesnotleadtoaconfusing,negativeandpossiblyburdensomework

experienceforHCAs.Moreover,althoughNQNsmightfeelasiftheyare‘muddling

through,’itisimportantthatthisshouldnotactuallybethecase.Thereshouldbeaclear

pathwayandpurposetotheNQNs’preceptorship,closelymonitoredandsupported,

andwithrobust,reliableandeffectivementoringpractices.Ourstudydidnotfindthat

thiswashappeningconsistently.Thereneedstobeagreatemphasison‘visible

learning,’particularlyeffectivesupportatwardlevel,aswellascloserscrutinyand

supportfor‘informallearning’ontheground.


23

References

Allan,H.T.(2002).NursingTheClinic,BeingThere,Hovering:WaysOfCaringInA

BritishFertilityUnit.JournalOfAdvancedNursing,38(1)86-93.

Allan,H.T.,&Barber,D.(2005).EmotionBoundaryWorkInAdvancedFertilityNursing

Roles.NursingEthics,12(4),391-400.

Allan,H.T.,Magnusson,C.,Ball,E.,Evans,K.,Horton,K.Curtis,K.&Johnson,M.(2015).

People,LiminalSpacesAndExperience:UnderstandingRecontextualisationOf

KnowledgeForNewlyQualifiedNurses.NurseEducationToday,35(2),E78-E83

Anthony,M.K.,&Vidal,K.(2010).MindfulCommunication:ANovelApproachTo

ImprovingDelegationAndIncreasingPatientSafety.OnlineJournalofIssuesin

Nursing,15(2),Doi:10.3912/Ojin.Vol15no2man02

Bjørk,I.T.,Tøien,M.,&Sørensen,A.L.(2013).ExploringInformalLearningAmong

HospitalNurses.JournalofWorkplaceLearning,25(7),426-440.

Bjørklund,P.(2004).Invisibility,MoralKnowledgeAndNursingWorkInTheWritings

OfJoanLiaschenkoAndPatriciaRodney.NursingEthics,11(2),110-21

Bjørnvold,J.(2000).MakingLearningVisible:Identification,AssessmentAndRecognition

OfNon-FormalLearningInEurope.KeyReferenceSeries3013.OfficeForOfficial

PublicationsOfTheEuropeanCommunities.Luxembourg/Thessaloniki

Bolton,S.C.(2004).ConceptualConfusions:Emotionworkasskilledwork.InTheSkills

ThatMatter,EdsWarhurst,C.,Grugulis,I.,&Keep,E.19–37.Hampshire:Palgrave

Mac-Millan.


Burawoy,M.(1998).TheExtendedCaseMethod.SociologicalTheory,16(1),4-33

Bignold,S.,&Cribb,A.(1999).TowardsTheReflexiveMedicalSchool:Thehidden

curriculumandmedicaleducationresearch.StudiesinHigherEducation.24(2),195

-209.

Dewolfe,J.,Perkin,C.,Harrison,M,.Laschinger,S.,Petersen,J.,Seaton,F.(2010).

StrategiestoPrepareandSupportPreceptorsandStudentsforPreceptorship:A

systematicreview.NurseEducator,35(3),98-100

Eraut,M.(2004).InformalLearningintheWorkplace.StudiesinContinuingEducation.

26(2),247-273.

Evans,K.,Guile,D.,Harris,J.,Allan,H.T.(2010).PuttingKnowledgeToWork:Anew

approach.NurseEducationToday,30,245-51

Evans,K.,&Guile,D.(2012).PuttingDifferentFormsOfKnowledgeToWorkInPractice.

InPractice-BasedEducation:PerspectivesAndStrategies,EdsHiggs,J.,Billett,S.,

Hutchings,M.,&Trede,F.113–136.Rotterdam:SensePublishers

Feng,X.,Bobay,K.,&Weiss,M.(2008).PatientSafetyCultureinNursing:Adimensional

conceptanalysis.JournalofAdvancedNursing,63(3),310-319

Gerrish,K.(2000).StillFumblingAlong?AComparativeStudyoftheNewlyQualified

Nurse'sPerceptionoftheTransitionfromStudenttoQualifiedNurse.Journalof

AdvancedNursing,32(2),473-80


25

Gillen,P.,&Graffin,S.(2010).NursingDelegationInTheUnitedKingdom.Ojin:The

OnlineJournalOfIssuesInNursing,15(2),Doi:10.3912/Ojin.Vol15no02man06

Gordon,S.,&Nelson,S.(2006).MovingBeyondtheVirtueScriptinNursing:Creatinga

knoweldge-basedidentityfornurses.InComplexitiesOfCare:Nursing

Reconsidered,EdsGordon,S.,andNelson,S.,13-29.NewYork:CornellUniversity

Press

Guest,G.S.,Macqueen,K.M.,&Namey,E.E.(2012).AppliedThematicAnalysis.London:

Sage.

Hasson,F.,Mckenna,H.P.,&Keeney,S.(2013).DelegatingandSupervisingUnregistered

Professionals:Thestudentnurseexperience.NurseEducationToday,33(3),229-

235.

Hollywood,E.(2011).TheLivedExperiencesOfNewlyQualifiedChildren'sNurses.

BritishJournalOfNursing,20(11),661-669

Hughes,A.J.&Fraser,D.M.(2011).SinkOrSwim:TheExperienceOfNewlyQualified

MidwivesInEngland.Midwifery,27(3),382-386.

Johnson,M,Magnusson,C,Allan,HT,Evans,K,Ball,E,Horton,KCurtis,KAnd

Westwood,S.(2015).DoingtheWritingandWorkinginParallel:Issueswith

learningdelegationandsupervisionintheemergingroleofthenewlyqualified

nurse.NurseEducationToday,35(2),E29-33Doi:10.1016/J.Nedt.2014.11.020

Kothari,A.R.,Bickford,J.J.,Edwards,N.,Dobbins,M.J.,Meyer,M.(2011).Uncovering

TacitKnowledge:Apilotstudytobroadentheconceptofknowledgein

knowledgetranslation.BMCHealthServicesResearch,11,198-206.

Doi:10.1186/1472-6963-11-198


Lempp,H.,&Seale,C.(2004).TheHiddenCurriculumInUndergraduateMedical

Education:QualitativeStudyOfMedicalStudents'PerceptionsOfTeaching.

BritishMedicalJournal,329(7469),770-3

Magnusson,C.,Horton,K.,Westwood,S.,Curtis,K.,Ball,E.,Johnson,M.,Evans,K.,&Allan,

H.T.(2014).AnInvestigationIntoNewlyQualifiedNurses'AbilityToRecontextualise

KnowledgeToAllowThemToDelegateAndSuperviseCare(Aark):ProjectSummary

Report,August2014.Guildford:UniversityOfSurrey.

Miers,M.(2002).NurseEducationInHigherEducation:UnderstandingCulturalBarriers

ToProgress.NurseEducationToday,22(3),212-219

Oakley,A.(1993).EssaysOnWomen,MedicineAndHealth.Edinburgh:Edinburgh

UniversityPress

Standing,T.S.,&Anthony,M.K.(2008).Delegation:Whatitmeanstoacutecarenurses.

AppliedNursingResearch21(1),8-14

Steven,A.,Magnusson,C.,Smith,P.A.,&Pearson,P.H.(2014).PatientSafetyInNursing

Education:Contexts,TensionsAndFeelingSafeToLearn.NurseEducationToday,

34(2),277-284.

Strauss,A.,Fagerhaugh,S.,Suczek,B.,&Wiener,C.(1982).SentimentalWorkInThe

TechnologisedHospital.SociologyOfHealthAndIllness.4(3),254-78

Street,AF.(1992).InsideNursing:ACriticalEthnographyOfClinicalNursingPractice.

NewYork:State:UniversityOfNewYork

Villeneuve,M.(1994).RecruitingandRetainingMeninNursing:Areviewofthe

literature.JournalofProfessionalNursing,10(4),217–28


27

VanOers,B.(1998).TheFallacyOfDecontextualisation.Mind,CultureAndActivity,5(2),143-52.

TheMidStaffordshireNHSFoundationPublicInquiryChairedByLordRobertFrancis2013.

Http://Webarchive.Nationalarchives.Gov.Uk/20150407084003/Http://Www.Midstaffspublicin

quiry.Com/Accessed12thJanuary2016

Weydt,A.(2010).DevelopingDelegationSkills.OJIN:TheOnlineJournalofIssuesin

Nursing,15(2),Doi:10.3912/Ojin.Vol15no02man01

Whitehead,B.,&Holmes,D.(2011).AreNewlyQualifiedNursePreparedforPractice?

NursingTimes.107(19)20-23.

Wilkinson,G.,&Miers,M.(1999).PowerandNursingPractice.Basingstoke:Macmillan

PressLtd

Windsor,C.,Douglas,C.,&Harvey,T.(2012).NursingandCompetencies—ANaturalFit:

ThePoliticsofSkill⁄CompetencyFormationinNursing.NursingInquiry,19,213–

222


Datacollectionmethod SiteA SiteB SiteC Total

Observationofnurses

(twice/nurse)

17nurses

34obs.

6nurses

12obs.

10nurses

20obs.

33nurses

66obs.

(approx.

230hours)

NurseInterviews 16 4 8 28

HCAInterviews 6 2 2 10

WardManager/

MatronInterviews

5 3 4 12

TOTAL(Interviewsand

Observations)

61 21 34 116

Table2.Summaryofdatacollected(November2011toMay2012)


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SiteA SiteB SiteC

Wardspecialities

where

participants

worked

• EAU

• Elderly

• Medicine

• Trauma

• HDU

• Surgical

• Adult

• General

• EAU

• Medical

• ADU

• Surgical

• Adult

• General

• Surgical

• Respiratory

• Medicine

• Gastro

• Adult

• General

Approximate

numberofbeds

700 700 450

Preceptorship

programme

Yes Yes Yes

Table1Overviewofthethreehospitalsiteswhichparticipatedinthestudy

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