Taranaki’s ‘modern apprenticeship’ September 2013

18 months on, FIONA CASSIE checks up on Taranaki’s radical new ‘hands-on’ nursing degrees to see how the ‘modern apprenticeship’ is bedding in.

Putting nursing students at the patient bedside from just week two of their degree appears to be paying off.

Eighteen months on from launching the new nursing degree, Taranaki’s nursing school is reporting higher student retention, and preceptors are reporting second year students appear more useful, confident and knowledgeable.

The inaugural cohort of 54 students who started out in February last year is now down to 47 – an 87 per cent retention rate after five per cent attrition through family and personal issues and 8 per cent through failing academically. Which is less than previous years, says Diana Fergusson, head of the nursing school at Western Institute of Technology at Taranaki (WITT).

Fergusson says placing students at the patient bedside from week two, so they can experience clinical theory in practice, is far from putting them off nursing.

“Going into practice each week is actually keeping them highly motivated to keep studying and keep exploring the knowledge underpinning nursing – it was really quite motivating for them.”

Gail Geange, associate director of nursing at Taranaki District Health Board with responsibility for professional development, agrees the early hands-on clinical experience is making a difference.

She says the concern in the past was that students didn’t get out into clinical practice until the end of their first year and some students had never been in a hospital setting before starting training.

“It’s very hard to hang theory on anything until you’ve been out there imbedded in the actual clinical environment – understanding what it is like to be working with a variety of patients in different clinical areas,” says Geange. They also get an early understanding of what it is to be a nurse on the ward.

“And that it’s not quite the same as you might see on TV,” adds Geange.

First year students were now on the ward a day a week, seeing and putting in practice the nursing tasks and theory they are taught that week in the classroom. Geange says the benefits of having nursing students immersed early in nursing culture is paying off in the second year. She has been “really impressed” with the second year students links between theory and practice and preceptors were reporting the students had a “very good” knowledge base.

“The preceptors are noticing their (2nd year students) knowledge is different than if they hadn’t been out experiencing what it is to be a nurse. Working those short hours in year one certainly pays off in year two, says Geange.

“They’ve got the tasks they can go out and confidently do, while looking more holistically at the patients they are caring for with their preceptors.”

They are also being introduced early to nursing culture, from observing RNs at work through to sharing the cafeteria.

Modern apprenticeship

It was the DHB, and other clinical partners, sending a strong message to WITT that they wanted a nursing curriculum centred on clinical practice that led to Fergusson developing the new degree. The programme she wrote draws on US theorist Patricia Benner’s ‘modern apprenticeship’ philosophy and

Christine Tanner’s case-based and concept-based learning theories. The total number of clinical hours offered to the students is similar to the old curriculum, but it is the timing and placement of those hours that is different.

The first year sees the students starting the week with lectures on a concept, putting the concept into practice in the ward in the middle of the week, and then ending the week with tutorials, clinical scenarios, and labs to draw together and embed that week’s clinical knowledge.

The students are placed into teams of four to six and each semester have a home base at either a medical or surgical ward and swap bases midway through the year.

Each semester they also have a three-week placement in a mental health or paediatric ward, so by the end of the first year, they have experienced four different clinical settings.

Whatever the concept they are learning that week – whether it is hygiene, vital signs, safe patient handling or fluid balance – they focus on it during their four to five hours on the ward with their clinical practice tutor. Fergusson says when they return to campus for tutorials, the student teams are reshuffled so that they get to hear and learn from the experiences of students in mental health and paediatric placements as well as medical and surgical.

That first year was rounded of with a ‘consolidation week’ where students got to work four shifts with their preceptors in readiness for the second year curriculum of one week in the classroom, followed by one week on the ward.

The second year kicks off with students experiencing the full reality of shift work, as the new degree was keen to have students ideally follow just one or two preceptors whenever possible.

“Which means they are doing night shifts pretty much from beginning of year two,” says Fergusson.

Night shift has been known to be a turn-off to hospital nursing for some young nurses.

“It is a big shock to the system in transition to suddenly be working shift work,” says Geange. But both she and Fergusson say students have adapted well to being on rotating shifts.

“They’ve also learnt that the night shift has actually got its advantages as well – in terms of having more time with the preceptor and being able to do a bit more learning and also caring for patients during a night shift,” says Fergusson.

She adds that students largely having just one or two preceptors has made an “enormous difference” to their sense of belonging and achieving competence and the preceptors also prefer getting to know their student rather than having “different students every day”.

“Because the students in year two have a much higher level of knowledge and skill base, they are actually working as part of the team because they can contribute to patient care pretty significantly now we’ve come to the end of the third semester (i.e. half way through degree).”

A work in progress

The second year introduces the concept of learning through case studies, in which a case study involving both physical and mental health concepts is gradually ‘unfolded’ to the students through lectures, teamwork, science and simulation labs, and online learning.

The first semester’s learning was built around three case studies including one centred on a man with diabetes and depression which – by introducing a Māori cousin, a niece with type 1 diabetes, and an aunt with gestational diabetes – can be widened to look at depression and diabetes across the lifespan and taking in different cultural aspects.

The second year clinical placements sees the students based in a medical or surgical ward for eight weeks of one 17 week semester. The other semester is split one-third between mental health and the remainder in new clinical areas like day surgery, the emergency department, and high dependency unit.

With the new degree still a work in progress, it has been decided for the second half of the year to shift from the previous one week in the classroom/one week on the ward to trial a two weekly rotation.

Geange says preceptors found that the on- week turnaround didn’t provide enough time to embed skills and knowledge and sometimes students had forgotten what they had learnt by the time they returned.

“It was quite disruptive for both the clinical practice settings and the students.”

Fergusson says another tweak the degree is undergoing is to improve the information flow to preceptors, including setting up a website on the DHB’s intranet for preceptors to access what the students are being taught.

Meanwhile, both the nursing school and DHB are feeling confident that the skills built under the more hands-on degree programme means students are ready to be give IV (intravenous) drugs under supervision at the end of the second year.

“That used to be purely a third year transition time skill,” says Fergusson.

“Our feeling is that (IV management) can be done earlier as their knowledge is acceptable,” says Geange. “As long as they meet the theory and assessment requirements obviously,” she adds.

100% teaching staff turnover

Back on the WITT campus, the new degree is being delivered by a 100 per cent new teaching staff, with only Ferguson and her associate head of school still remaining from the old staff.

“All of our eight lecturers are new in the last 18 months,” says Fergusson.

She says rather than it showing a crisis of faith in the new curriculum, the 100 per cent turnover was largely due to a number of very experienced lecturers already close to retirement deciding to retire, believing it was time for new people to come on board.

Fergusson says the new staff “really, really like” the new curriculum, with many of them coming to the school from clinical or non-education settings but with clinical education backgrounds.

Next year will see the rolling out of the third year of the programme, which will concentrate on care in the community, including primary health care and residential aged care.

The proof of the pudding of the new degree will be the successful passing of state finals and the ease in which the graduates transition into practice as registered nurses. Fergusson is confident to date that the first cohort will pass that transition with relative ease.

“They (students) tell me that they feel like nurses and they feel like they belong and they are really contributing to patient care and they really feel like part of the team.”