Re-generating the ‘self’ in learning: developing a culture of supportive learning in practice

© 2006 The Authors Journal compilation © 2006 Blackwell Publishing Ltd.

Learning in Health and Social Care

,

5

, 2, 90–105

Original article

Blackwell Publishing Ltd

Re-generating the ‘self ’ in learning: developing a culture of supportive learning in practice

Valerie

Wilson

RSCN RN BEdSt. MN PhD

1

*

,

Brendan

McCormack

DPhil BSc Nursing PGCEA RGN RMN

2

& Glenice

Ives

PhD MEdSt. BAppSc (AdvNsg) DipAppSc (NsgEd) DHNWM RN

3

1

Director of Nursing Research and Practice Development, Nursing Research & Practice Development Unit, CHW School of Nursing, Monash University, Australia

2

Director of Nursing Research and Practice Development, University of Ulster at Jordanstown, Northern Ireland and Royal Hospital Trust, Belfast & School of Nursing, Monash University

3

Associate Professor of Nursing, School of Nursing, Monash University, Australia

Abstract

This article presents the findings of a project that focused on developing a culture of learning where practitioners were able to engage in supported work-based learning in a Special Care Nursery (SCN). The project was part of a larger study focusing on the implementation and evaluation of an emancipatory practice development programme in an SCN. The aim of this phase of the study was to gain an in-depth understanding of how the implementation of practice-development strategies could enable the creation of a culture of supportive learning in practice. The methodological and philosophical structure of the study was based on emancipatory practice development (ePD). The ePD strategies used are aimed at promoting the empowerment of nursing staff, utilizing staff knowledge and expertise to identify the need for change, encouraging reflection on and in practice, incorporating the views of service users in the change process, and supporting staff to challenge themselves and each other. Questions are framed to evaluate systematically the processes and outcomes of the study with a view to identifying changes in the learning culture that may have occurred as a result of PD strategies. Pre-intervention findings highlighted that tensions existed between what people espoused about learning and what actually occurred in practice. Through the use of PD processes, participants in the study began to focus on the learning environment. Key themes identified in the data included ‘learning about learning’, ‘movement from subservience to partnership’, movement from rituals to reflective questions’ and ‘movement from self-immersed to working with one another’. Taking self-responsibility for learning and ‘regenerating the self ’ in learning emerged as key issues underpinning these themes and are subthemes of ‘values and beliefs about learning’. It is argued that developing ‘responsible self ’ is key to the creation of a culture of learning where practitioners are able to develop mutually supportive relationships in order to learn in and from their practice. In conclusion, learning culture has a significant impact on how nurses go about their

Keywords

culture, learning,

nursing, practice

development

*Corresponding author. Tel.: +61 298453093; fax: +61 298451317; e-mail: [email protected]

Re-generating the ‘self ’ in learning 91

© 2006 The AuthorsJournal compilation © 2006 Blackwell Publishing Ltd.

everyday practice. The implementation of PD processes enabled a cultural shift to occur. As a result of this, a supportive learning culture embedded within the workplace emerged. Learning about learning was seen as an important part of the context that

enabled the development of the responsible self.

Introduction

This article presents the findings of one component

of a research study focusing on the implementation

and evaluation of emancipatory practice development

(ePD) processes (Manley & McCormack 2003) in a

Special Care Nursery (SCN). The intent of ePD is to

increase effectiveness in patient-centred care through

enabling healthcare teams to transform the culture

and context of care (Garbett & McCormack 2002).

Reflective learning processes are central to an ePD

approach. Reflective processes are integrated with

other developmental processes and thus achieving

practice development is enabled through the changes

in the perspectives of individual practitioners to

recognize the need for change. Thus, unlike technical

approaches to practice development where learning

is a consequence of the work, in ePD, learning is

integrated with development activities and is a

primary intended outcome of development activities

(Manley & McCormack 2003). A study of the culture

was initially undertaken to evaluate, in a critical

manner, changes that may take place in the SCN as

a result of the implementation. These findings

have previously been reported (Wilson

et al

. 2005).

The present article presents the postintervention

findings related to the learning culture of the SCN

and draws upon findings of the previous work.

Learning culture

Learning is a process by which we gain knowledge

and proficiency (Knowles, Holton & Swanson 1998).

It is personally meaningful, makes sense of our

experiences and leads to changes in behaviour

(Knapper & Croppley 1999). However, sustained

learning only occurs within contexts that are

supportive and where learning is viewed as important

(Senge 1990). Thus, workplace culture and learning

culture are closely intertwined. An investment in

grass roots learning can influence cultural change

(Platzer

et al

. 2000; Clark 2001) and develop an

exciting workplace environment, where challenge is

part of everyday practice (Titchen & Binnie 1995;

Kaye & Jordan-Evans 2000) and learning extends

beyond the boundaries of the clinical unit (Platzer

et al

. 2000).

The key goal in the development of a positive

learning culture is to recognize and overcome

individual, group and organizational barriers (Hoff

et al

. 2004). Such barriers include the need to ‘fit in’

and ‘learn the rules’ of the workplace (Melia 1987;

Nolan 1998); inadequate facilitation and challenge

(Miller

et al

. 1994); practitioners who own routines

and rituals rather than embrace the notion of

reflection in practice (Johns 1994); team members

who dominate or disparage each other (Wade 1994);

and a perceived lack of self worth (Miller

et al

. 1994).

Establishing a positive learning culture is both

complex and challenging, but Dixon (1999) and

Ward & McCormack (2000) suggest that it can be

created through the implementation of strategies

which develop challenge, openness, debate and a

more supportive environment.

Aim

The aim of this phase of the study was to gain an

in-depth understanding of how the implementation

of practice development strategies could enable

the creation of a culture of supportive learning in

practice.

Methodology

The methodological and philosophical structure

of the study was based on ePD. The ePD strategies

used are aimed at promoting the empowerment of

92 V. Wilson

et al.


nursing staff, utilizing staff knowledge and expertise

to identify the need for change, encouraging reflection

on and in practice, incorporating the views of

service users in the change process, and supporting

staff to challenge themselves and each other. This

work was supported by facilitators using systematic

and rigorous approaches to change (Garbett &

McCormack 2002). As the name ePD suggests, it

obviously focuses on the emancipatory intent of

developing clinical practice. It is not good enough

merely to impose a change on clinical practice;

the emancipatory function of ePD is linked to

transformative action and, in turn, to transforming

the culture in which practice takes place. This

approach is based on the theory of critical social

science, which is underpinned by the process of

enlightenment, empowerment and emancipation

(Fay 1987).

Principles of professional learning underpinned

the activities as this fitted with the philosophical and

methodological intent of the overall ePD study. The

adoption of these principles enabled participants

to choose from a ‘menu’ of learning activities that

constituted the ‘education intervention’. The menu

consisted of items such as action learning, high

challenge with high support, a variety of workshops,

teamwork development, journal club and one-to-

one clinical support. By offering a menu such as this,

the study worked with the principle of respecting

individual learning styles, whilst focusing the evalu-

ation on the effectiveness of the overarching educa-

tion intervention, as it was hypothesized (through

the stated aim) that the implementation of ePD

activities based on individual learning choices would

enable the development of a learning culture. Thus,

the effectiveness of the individual learning activities

was not the focus of the study (although information

about these has been collected).

Context

The study reported here was set in an SCN that

provided level two services for unwell newly born

infants and their families (referred to as ‘neonatal

nursing’). This was a funded study based on changing

nursing practice and therefore the key participants

were nurses, although other staff, such as doctors,

allied health and clerical staff, did participate in

some aspects of the study. Thirty nursing staff

participated in the study, the majority of whom were

both registered nurses and midwives. All staff were

women and the length of neonatal nursing experience

ranged from a few months (newly recruited experienced

nurses who had not worked with neonates before) to

> 25 years. The unit provided a 4-month placement for

one new graduate nurse and occasionally had either

an undergraduate or a postgraduate student. The

nurse unit manager started in her post 2 months

prior to the study, and one of her five associate unit

managers, or nurse leaders, was in charge of each

shift. Nurse educators worked with staff on the unit

for two half-days per week. The staff-patient ratio

was one to three.

The practitioner-researcher

McCormack & Garbett (2003) suggest that ‘credibility’

of practitioner-researchers is a key factor in the

success or otherwise of practice development projects.

The lead practitioner-researcher had not worked

with staff in the SCN before. However, as an

experienced childrens’ nurse and educator, the lead

practitioner-researcher had both ‘practice’ and

‘facilitation’ credibility amongst nursing staff. This

enabled engagement with staff whilst simultaneously

knowing the boundaries of such interactions in

research practice. The practitioner-researcher worked

with staff in the SCN for 1 day per week during the

lifetime of the study.

Participants

The study site self-selected for inclusion into the

study when a request for volunteers was circulated

within the healthcare organization. After the initial

agreement with the unit manager, information

sessions were held with nursing staff in order to

inform them about the study, clarify any queries

they had, outline the voluntary nature of the

study and to ensure they were happy to proceed.

The sample included all nursing staff. Process

consent was undertaken, whereby the practitioner-

researcher negotiated consent at each new stage

of the study (Dewing 2002). Ethical approval



was obtained from the local research ethics

committees of the healthcare organization and the

University.

Data collection and analysis

To evaluate, in a systematic manner, the processes

and outcomes of the study, several approaches to

data collection were undertaken, including:

• a nursing staff survey taken prior to implementa-

tion of ePD activities;

• participant observation (PO) pre- and post-

implementation of ePD activities;

• field notes taken during the practitioner-researcher’s

clinical time on the unit; and

• interviews with nursing staff pre- and post-

implementation of ePD activities.

This multimethod approach provided the

opportunity to use differing sources of evidence to

assist with creating a more meaningful and deeper

understanding of the changing context on the unit

from a variety of perspectives and enhanced the

credibility of the findings (Patton 1990). Cognitive

mapping was used to manage and analyse data, and

is defined by Eden

et al

. (1983, p. 39) as a ‘modelling

technique which intends to portray ideas, beliefs,

values and attitudes and their relationship to one

another in a form which is amenable to study and

analysis’. Thematic analysis was utilized in the process

of map formation and refinement (Boyatzis 1998).

An independent researcher examined the labels and

refinement of themes to enhance credibility.

Pre-intervention findings

Prior to implementing ePD activities in the study site,

an investigation of existing workplace culture was

undertaken. This work included three data-collection

strategies – staff survey, PO and in-depth interviews

(I) – and are outlined in Fig. 1 (phase one). The

findings of this work have been reported previously

(Wilson

et al

. 2005). However, the key themes from

the findings that relate directly to the ‘learning culture’

of the SCN (see Fig. 1) are summarized in order to

Fig. 1 The four phases of data collection and analysis.

94 V. Wilson

et al.


form the basis of this article. The term ‘staff ’ in this

article refers to nursing staff, unless otherwise stated.

Consistently, the findings uncovered contradictions

and tensions that were evident in everyday practice

and which created a distorted view of how learning

was being managed within the SCN. The survey

findings which related to learning (see Table 1)

suggested that the team believed that they were

highly skilled, had ample opportunity to learn and

were able to access information that would inform

their practice. However, this existed alongside other

opinions, which suggested that not all staff felt that

their learning requirements were being met.

This notion of tension was made more explicit in

the analysis of the observation data. Taking what

appeared to be differing views, these were explored

through individual interviews with staff members.

What emerged was a clearer picture of the tensions

that existed within individuals and the team in rela-

tion to learning in and from practice. Tensions were

both interpersonal and intrapersonal in nature and

this created confusion and inconsistency within the

learning environment. Three themes (partnership

vs. subservience, questioning vs. rituals, and team

vs. self-focused) were developed from the pre-

intervention data which illustrate the tensions that

existed for staff. An example of how these tensions

played out in practice can be found in Table 2 and

have been reported in greater detail previously

(Wilson

et al

. 2005).

Table 1 Survey results (learning subscale) pre-intervention

Learning in practice Mean Inference

1. Utilizing nursing skills effectively 3.37 1. Staff believe that they are highly skilled and use skills effectively

2. I regularly attend

in-service/short courses

3.16 2. Key elements of structural empowerment, such as access to

information, resources and support, as well as opportunities to learn

(Laschinger et al. 2001; Almost & Laschinger 2002) are evident

from the survey findings

3. Opportunity to attend courses regularly 3.16

4. Access to information

to inform practice

2.79 3. Less positive scores, with not all staff feeling that their learning

requirements are met within the existing culture

5. In-service meeting staff needs 2.53a

The survey was sent to all staff (n = 27). However, during the survey collection period, a number of staff were absent from the

unit and did not complete the survey on time. The survey return was 19/27–70%. Higher mean scores are indicative of greater

satisfaction; scores of > 3 indicate a positive response, and scores of < 3 contain a mixed result but tend towards more positive

responses.aThe score included ≈ 50% positive/50% negative responses.

Table 2 Overview of the pre-intervention findings

Partnership TENSIONS Subservience

I am now finding they (consultants)

are listening to me and asking for my input

Nurses are not valued for their input,

and have little involvement in the decision-making process

Questioning Rituals

I am trying to challenge practice, challenging

staff approaches to care in a non-threatening way

Keeping to the schedule, straight into tasks,

always done this way, do my chores

Team focused Self-focused

Sharing information and challenging

one another, that’s refreshing

Fear of new staff, disequilibrium,

having to begin a teaching role



The learning culture was underpinned by existing

tensions that restricted the effectiveness of work-

place learning and ensured that little sustainable

work was undertaken to change the workplace cul-

ture. Indeed, although there was significant evid-

ence of people engaging in learning activities, there

was little evidence to suggest that this learning was

shared with others or was impacting on the delivery

of care. There appeared to be an over-reliance on ritu-

alistic practice, with little evidence of nursing staff

challenging their own practice or indeed that of

members of the multidisciplinary team. Exploring

the learning culture enabled staff to identify what

was happening in practice and to develop a set of

values and beliefs related to what they believed

the learning culture should be. These were framed

around three central themes of the learning

environment, person-centred learning and the

process of learning.

Education intervention

With the initial data collection and analysis

complete, the intervention phase of the study began.

One strand of the overall ePD programme of work

was a specific project that focused on developing a

culture of learning in the SCN as a means of sustaining

long-term changes in practice. Elsewhere, it has been

argued that creating an effective learning culture is

crucial to the long-term sustainability of practice

changes (Manley & McCormack 2003). The ‘education

intervention’ was based on principles of professional

learning, which meant that a framework was presented

to staff that incorporated a ‘menu’ of learning

activities from which staff could choose, depending

on the individual learning style. The findings from

the pre-intervention phase were presented to staff

to enable them to make an informed choice about

the learning activity they wished to undertake (see

Fig. 2). Whilst these are represented in Fig. 2 as

individual activities, they form the overall education

intervention of the study, which was facilitated by

the practitioner-researcher over a 2-year timeframe.

The selected activities included the development

of an action learning set, where each participant

worked on a project/issue they identified as impor-

tant and which related to improving practice. Seven

nurses took part and the set was held for a half-day

Fig. 2 Overview of the emancipatory practice development (ePD) activities in the special care nursery (SCN).

96 V. Wilson

et al.


each month over 15 months. The practitioner-

researcher facilitated the set using the principles

outlined by McGill & Beaty (2001). Participants

were encouraged to involve other nurses in the work

they were undertaking. In addition, staff participated

in workshops held at various times throughout the

intervention period, which focused on factors such

as evidence-based practice and family-centred care.

All staff (including medical, nursing allied health

and clerical staff) participated in a values clarification

activity aimed at developing effective teamwork.

This was undertaken over a 2-month period at

the beginning of the study and included a series

of workshops, as well as individual work.

Another activity was the use of high challenge/

high support (hc/hs) where the practitioner-

researcher spent 1 day per week, for the duration

of the study, working alongside all nursing staff, chal-

lenging their everyday assumptions about practice

and supporting them to look at the effectiveness of

practice and the provision of family-centred care.

The model of hc/hs used in this study was adapted

from the clinical supervision strategies described

by Titchen & Binnie (1995), which are aimed at

helping nurses to think more deeply, enabling them

to share their experiences, as well as learning from

one another through working together. The

practitioner-researcher fosters a climate of critical

intent through reflective discussion and challenge to

increase nurses’ awareness about what is happening

around them and to question the subconscious acts

of everyday practice, in other words a process of

enlightenment (Grundy 1982). When this process

is focused on empowered practice, the resultant

heightened awareness enables the development of

expertise (Rolfe 1996). Learning about self through

enhanced self-awareness is an essential part of reflec-

tion (Atkins & Murphy 1993; Freshwater 1998) and

is probably one of the most challenging aspects of

this way of working. When processes to encourage

learning about self are used, the necessary high

challenge must be accompanied by high support

(Johns 1998). Working in this way enabled the

practitioner-researcher to establish credibility in a

much stronger and more personal way than could

be achieved by previous reputation. Further details

of each activity are presented in Table 3.

Findings postintervention

Acknowledging that tensions existed before any

practice development work commenced, the themes

identified in the pre-intervention phase (partner-

ship vs. subservience; questioning vs. rituals; team

focused vs. self-focused), as well as a new theme

(values and beliefs about learning), were used to

frame the outcomes arising from the education

intervention.

Partnership vs. subservience

Previously, some nursing staff working in the SCN

were striving for a partnership with medical staff,

especially senior medical staff. However, tensions

existed and some staff were happier for the status quo

to remain and to act in a subservient role to ensure

that they did not ‘rock the boat’. One of the greatest

challenges for nurses was their role during clinical

rounds. Previously, they had strived to be part of the

decision-making process, but often felt that their ideas

were not acknowledged or asked for. The culture had

begun to change during the ePD project as staff engaged

in activities such as high challenge-high support

and establishing effective teamwork. This resulted

in nurses learning to challenge doctors more often;

they were less willing to assume a subservient role

and were supported (by nurse leaders) to speak up

during clinical rounds. Doctors now actively

sought nurses’ input and considered what they said

as part of the decision-making process. The change

in how the clinical rounds were conducted illustrates

the development of nursing staff themselves and

the relationship that they had begun to foster with

medical staff:

I think there has been a significant change actually, rather than just being told … I think it is more of one where we are more in partnership and contributing more than we ever have.

The move was then one of prevailing over sub-

servience and developing partnerships.



Table 3

Post-intervention findings

ePD activity Involvement by staff Achievements Impact factor

Working in the unit: high

challenge/high support, one day

per week spent working alongside

nursing staff, challenging their

everyday assumptions about

practice and supporting them to

look at the effectiveness of practice

and the provision of family-

centred care

All nursing staff involved,

with a flow-on effect to

other staff within the SCN

(e.g. medical staff)

This was undertaken

during normal working

hours

Babies are recognized as

unique individuals

Development of a

supportive environment

Introduction of care that

is developmentally

appropriate

Increased awareness of

how language and

behaviour impacts on care

Increase in problem solving

and critical thinking

Family-centred care

drives nursing practice

Nursing staff now pro-

active in changes in the unit

Nurses participate in

decision making about care

Creation of an

environment that

supports the baby, the

family and staff

Emphasis on providing

developmental care

Families made to feel

welcome and encouraged

to participate in their

baby’s care

Nursing staff eager to

suggest potential changes

for improving practice

Nurses less subservient

and now act as advocates

Action learning set

Staff worked on issues related to

improving practice [see

Wilson

et al

. (2003) for details]

Seven nurses participated

half a day, meeting once a

month for 15 months.

Time funded by the unit

budget

Various achievements

based on the work of

participants, (e.g. change

from ritualistic nursing

handover to using a multi-

disciplinary database)

Multi-disciplinary

communication improved

in the unit.

Developed template for

changing practice

Workshops: evidence-based

practice 2 h over 4–5-week period

Around five staff

participated in the

workshops

Developed skills is

searching for evidence,

reviewing research

literature and using

evidence in practice

Use of evidence to inform

staff and to base practice

changes such as ‘reducing

noise levels in the nursery’

Workshop: family-centred care

Full day workshop

Seven staff participated in

the workshop

Staff clearer about the

barriers to FCC as well as

the difference between

what we say we do and

what we actually do in

practice

FCC becomes the

authentic philosophy that

drives care

Teamwork: values clarification

over a 2-month period.

Included workshops and

individual work

All staff (including

medical, nursing allied

health and clerical staff) in

the unit involved

Developed a shared vision

for teamwork. Worked

towards realizing vision

in practice.

See Wilson (2005b) for

further details

Improved teamwork, staff

morale, sense of

collegiality and

multidisciplinary

communication

One on one clinical support over

18 months

Limited use by a few

nursing staff

Staff feel challenged and

supported by the

facilitator

Individual staff take on

new challenges

Journal club Not established Nil Nil

ePD, emancipatory practice development; FCC, family-centred care; SCN, Special Care Nursery.

98 V. Wilson

et al.


Questioning vs. rituals

The tension that existed in the unit between ritual-

centred care and questioning practice resulted in

staff pulling in differing directions and care being

delivered in an inconsistent way. Nursing staff

worked hard on this as they undertook learning in

facilitated workshops, through hc/hs and teamwork

activities, as well as through the action learning

process. The dominant ritualistic approach to practice

changed as nurses reflected on their own practice

and questioned each other about the ways in which

they delivered care. This resulted in a heightened

awareness about everyday practice, a reduction of

rituals and an increased use of evidence, as most

staff moved towards a more patient-centred mode

of delivery. That being said, there were still a few

staff who remained loyal to inappropriate rituals

and were unable or unwilling to change their

practice. This, however, had little influence on the

dominant culture, where critical inquiry was not

only encouraged but expected, thereby reducing

rituals and increasing reflective questioning:

I think now with that challenge … people need to have a reasoning … with the challenge and thinking more about what we are doing, people will think ‘why did I do that?’ or ‘why am I doing this?

Team focused vs. self-focused

In the pre-intervention findings, learning was seen

as central to the evolving development of each staff

member and the unit as a whole. However, tensions

did exist between the needs of the individual learner

and the constant demand of teaching newly recruited

nursing and medical staff. This resulted in some staff

not engaging in learning at all, or learning only for

themselves where they were unwilling or unable to

take on a team learning role. Over the 2-year inter-

vention period, nursing and medical staff worked

more closely together (through team activities), which

ensured that the underlying tensions were reduced.

This resulted in them actively questioning one another

as they supported one another to learn. As they engaged

in more hands-on teaching (especially with new and

junior members of staff), they gained confidence in

their knowledge and skills, had greater questioning

ability and improved support and learning for all

staff within the SCN. This shifted the focus from

learning only for self onto working with one another:

… you feel that you have to know what you are doing and be confident with what you are doing … we have got junior nurses coming in to join the team, which is fantastic, I have to be there to be confident enough to support them, therefore they can trust me with what they are doing.

Table 4 Overview of the post-intervention findings

Prevailing over subservience TRANSITIONAL Developing partnerships

‘Learning now to challenge the doctors … we

have never done that before.

I’d have rolled out the red carpet, I would have

ages ago, not so much now’

I think there has been a significant change actually,

rather than just being told … we are more in partnership

and contributing more than we ever have

Reducing rituals Reflective questioning

There is still ‘a select few’ that are ‘ritualistic or

task orientated, not that they don’t listen … but

they don’t put it into practice’

A lot of the staff that were probably fixed at the start are

now questioning more what they are doing

Self-immersed Working with

There are some ho hum people that come to work,

do their work and go home

Everyone will work with you and help you … most

people are accessible … supported



For a few staff there still appeared to be a level of

disengagement as they kept to themselves. The

emphasis on being self-immersed was, however,

less evident with the strong move towards working

collaboratively.

In reviewing a summary of each aspect of these

findings (see Table 4), it can be seen that the unit

worked through a transitional phase whereby sig-

nificant changes occurred and development was an

ongoing process. These findings were greatly influ-

enced by the values and beliefs about learning held

by nurses.

Values and beliefs about learning

The theme of ‘values and beliefs about learning’

is articulated through the three subthemes of, ‘the

learning environment’, ‘learning about learning’

and ‘the responsible self ’. These themes were

explored and verified with staff at the completion

of the study. The practitioner-researcher worked

closely with the nurse manager and nurse educators

to develop their knowledge and skills about

practice development and to ensure that a con-

sistent approach to the education intervention was

adopted.

The learning environment

Whilst there have always been elements of the

requirements for structural empowerment (see Table 1)

within the SCN, such as access to education and

resources, these had not necessarily been utilized

effectively in the past. Staff could now be seen actively

to use educational opportunities and resources

to inform their learning, such as surfing the ‘net’,

engaging in clinical discussions and attending

tutorials. The unit had transformed into an active

learning environment:

… there is a lot of education which I think is really good. A lot more than I have had in any of the other wards.

Learning was seen as a fundamental component

of everyday work, and this was supported by en-

gagement in activities such as exploring the use of

evidence in practice.

The manager played a pivotal role in actively

supporting staff, ensuring that they had the oppor-

tunity and time to learn, which they were really

enthused by. This resulted in staff undertaking

specialist courses provided by another hospital:

It seemed that half the staff were there, which shows me that they want to learn more … it wasn’t just people who were new to the unit either.

Staff actively discussed their learning from courses

they attended and questioned one another in order

to deepen their learning. Supporting one another to

learn is an important aspect of the learning culture

and was conducive to positive learning experiences.

This was achieved in part by providing an environment

where learning was about challenge with support

and not about constructing negative judgements:

… a lot of them will ask questions they know they are not going to be put down if they don’t know something … I think that it is a fairly supportive environment for learning.

This level of support also ensured most people

enjoyed learning, it was ‘fun and enjoyable’ and

ensured staff connected with learning activities. The

learning environment was evolving and developing

and whilst progress had been made, staff indicated

the need for continuous improvement:

I think we have come a long way, it’s positive … there is still lots we need to do and there will always be lots we need to do.

Learning about learning

In exploring their values and beliefs about learning,

staff in phase one were able to identify processes

that may enable them to learn within the context of

the SCN. Over the 2-year intervention period, they

were able to adopt some of these activities, such as

100 V. Wilson

et al.


up-skilling programs, benchmarking and problem-

based learning packages, as they engaged in active

learning. Staff recognized and utilized different ways

of learning, which ranged from reading articles to

reflection on learning, as well as learning through

observation:

I am learning by observation and after I maybe read something … it is good to do both theory and practice together.

It was also important to utilize learning opportu-

nities when they arose, even though these might

be in a stressful situation with a very sick baby. Staff

were still able, ‘to learn, to observe, to listen’.

The staff in the unit themselves were a very

important component of the learning experience

and individuals were identified as preceptors, role

models and mentors. They provided appropriate

information in a systematic way, facilitated learning

experiences and modelled practice behaviours:

I try to copy them … I sort of go to them, and at a distance observing them.

The unit manager again played a pivotal role in

learning. She was a respected team leader and was

perceived to be a role model and mentor because of

her expertise and knowledge.

One area that was identified as not being used

effectively was giving and receiving feedback, which

staff found difficult and suggested that it was

probably one of the areas of which people were most

afraid. This was compounded when feedback was

not well received. This not only presented additional

challenges for effective workplace learning, but also

created personal challenge for the individual:

… some people will be able to give feedback quite easily because the person will accept that and maybe appreciate that, but the person who takes it the wrong way or is quite difficult … probably need it the most and that’s the people that don’t get it.

Staff, however, did recognize this and were trying

to improve this aspect of the learning culture to

ensure that feedback was viewed as non-threatening

and became part of everyday practice.

The responsible self

For a few staff a tension remained in the unit

between learning for self and feeling obliged to

‘keep up to date’. Whilst they were encouraged to

participate in choices about their own learning,

some staff did not want to take ownership and

responsibility for this and thought it was ‘their

given right that someone do it for them’. This

proved to be an ongoing challenge for education

and, in particular, the practitioner-researcher and

educators in the unit who tried to engage all staff

in active learning. The majority of staff however,

did take on responsibility for their own learning,

were open to suggestions for self development and

actively engaged in learning activities they chose to

suit their needs:

I enjoy the learning I choose, I don’t just go and do something because I feel I have to … we have all got different expertise or a different interest.

The notion of ‘knowing self ’ was reflected in

those staff (the majority) who developed an

understanding of their limitations and wanted to

further develop themselves. Others (the minority)

had little insight or were afraid to admit their

limitations, which resulted in them defending their

practice expertise to ensure that they were not

thought to be lacking in skills or knowledge. This

was considered to be unsafe practice and was

being increasingly challenged in the unit. Never-

theless, it was encouraging to note that in general,

staff were willing to be more honest in their

approach to knowing self, to admit when they

didn’t know something and to use opportunities to

think things through, develop knowledge and skills,

build their confidence and gain understanding.

They were able to use this sense of knowing to teach

others:



I can teach them, give them knowledge of what I have gained. It was also the acknowledgement that the importance of learning was something that needed to be prioritized and not lost in the rush of everyday practice: I suppose for me it’s not forgetting that I need to … keep on learning and developing.

Learning did indeed become integral to everyday

practice and was used as a basis to improve care.

Learning was continuous and improved staff

satisfaction with work and with self. Whilst learning

could be seen as a challenge, it was the individuals’

commitment to lifelong learning that created the

greatest influence to the learning culture of the unit

and ensured that for the majority of staff learning

became part of the

responsible self

:

I always feel I’m going to be challenged intellectually because there is no way I would ever say I know everything in this place you are going to learn something new everyday, every baby is different … If you said you knew everything you are going to have to quit your job.

Outcomes

The nature of ePD work and the fact that a number

of activities were used in the unit simultaneously

impacts on the ability to attribute outcomes to

specific activities. Indeed, outcomes are strengthened

by the cumulative nature of the work undertaken and

the interactions between activities. However, Table 3

illustrates each ePD activity, the involvement of staff,

and the potential links between the achievements

to date and the related impact of the initiatives.

Evidence for these achievements have been sourced

from the data collected in the overall study, including

participant observation, action learning data, focus

group and individual interviews. A discussion of each

of these findings is beyond the scope of this article,

but they are discussed in detail in Wilson (2005a).

The postintervention findings relate to the overall

outcomes for the SCN and within that contain the

experiences of the individual. In order to illustrate

how this is manifested for the individual, Fig. 3

highlights an example from the journey of one nurse

as she engaged in one of the education mechanisms

adopted in the unit. Within this journey, Jane moves

through the stages of enlightenment as she becomes

aware of ‘self ’ within the practice context and how

this impacts upon the delivery of care. Jane then acts

as a positive role model within the SCN as she is

empowered to adopt new behaviours. The final

stage of emancipation occurs as Jane challenges

others (using the hc/hs intervention) to look at their

practice, and she, in turn, develops new initiatives,

which support her new way of working.

Discussion

There was little evidence in this study of the

underlying assumptions associated with an adult

learning approach, such as being self-directed; a

readiness to learn, using accumulated experience

as a resource for learning; and adopting a problem-

centred approach to learning (Knowles 1977).

Clinicians seemed to be switched off from adult

learning principles and were reliant instead on

education being available for consumption, if and

when they desired it, rather than something in

which they actively engaged or necessarily wanted.

This may have been influenced by their previous

experience as learners, which embraced a more

pedagogical approach and a teacher-centred model

of education, whereby they expected, and at times

demanded, that others take responsibility for their

learning. This is consistent with other studies, such

as those of Platzer

et al

. (2000), who identified the

challenges associated with engendering a sense of

self-responsibility for learning amongst adult learners.

With this challenge in mind, the findings from this

study would suggest that re-engaging clinicians with

the concepts of an andragogical approach, such as

uncovering their internal desire to learn, and

creating learning opportunities that were relevant

to everyday practice, are important mechanisms in

enabling the discovery of self within the learning

context (Knowles, Holton & Swanson 1998). Context

is increasingly seen as the key factor in influencing

the development of practice (Rycroft-Malone 2004).

102 V. Wilson

et al.


The work of Freire (1972) has been influential

in developing the understanding of the impact of

context on the empowerment of the individual and

there was evidence of this within this study. Freire

(1972) argues that context has the ability to oppress

individuals and their ability to learn through experi-

ence and further argued that active learning is the

key to reducing oppression. Whilst others argue that

Freire is idealistic (Weiler 1996), a growing body of

evidence in practice development (Manley 2004) and

in action research (Winter & Munn-Giddings 2001)

shows that workplace culture also significantly impacts

on an individuals’ ability to learn in and from their

own practice (Bierema & Eraut 2004). The data from

this study sheds more light on understanding the

connections between workplace culture and indi-

vidual learning. The practice development strategies

implemented in the SCN enabled staff to engage in

learning that was meaningful to them, and this ulti-

mately led to the development of a positive learning

culture. Eraut

et al

. (2004) suggest that it is the rela-

tionships developed within the team, as well as the

acceptance of appropriate learning mechanisms,

that ultimately result in the occurrence of learning.

Eraut

et al

. (1998, 2004) indicates that there are

four types of learning, occurring within the work

environment, which may result in learning. There is

evidence in this study (see Table 3) of each type of

activity being implemented in practice. First, there

is evidence of participation in group activities (see

teamwork), which was aimed at achieving a com-

mon goal. Second, Eraut

et al

. (2002, 2004) suggested

working alongside others as a means of learning

through observation and increased awareness of

how others work, this can be evidenced through

the hc/hs work undertaken in the SCN. Third, he

suggests that engaging in challenging tasks, such as

action learning in this study, results in on-the-job

learning and increases both motivation and con-

fidence in the individual. Finally, working directly

with clients enhances learning. This was a key

emphasis in the study and resulted in the develop-

ment of a family-centred philosophy of care that

enabled collaboration between clinicians and

families in order to provide care for the patients.

Eraut

et al

. (2000) highlight the significance in the

relationship among challenge, support and confidence.

Through the intervention of ePD activities in the

Fig. 3 Jane’s learning journey.



SCN and, in particular, the hc/hs approach, it can

be seen that an increased level of challenge enabled

clinicians to engage in learning. With this came an

increase in motivation to learn and the development

of the responsible self, where practitioners not only

understood learning but were active in seeking out

learning opportunities and sharing their learning

with one another. It is suggested that supporting

grassroots learning is important in creating a learn-

ing climate (Eraut

et al

. 1998). In order to support

this kind of learning, the role of the manager is

pivotal, yet managers themselves are given little

training in how to facilitate this kind of workplace

learning (Eraut

et al

. 2002). In this study, the role of

the manager was indeed pivotal in the engagement

of staff in learning and the overall outcomes for the

SCN. The manager herself engaged in most of the

learning strategies and adopted the techniques as

she became a positive role model and a facilitator of

practice development, which ensured that others

were motivated to participate.

Through the adoption of practice development

strategies that supported professional learning

principles (Knowles 1990; Ward & McCormack

2000), nurses who were actively engaged in learning

about learning were able to understand and chal-

lenge the role of self within the learning culture as

they moved from dependent to independent learner

and took on the role of responsible self, as depicted

in Fig. 4.

Figure 4 illustrates the strong links of the environ-

ment, learning about learning and the responsible

learner, as well as the influence that each aspect has

on one another. Nurses re-generated their perception

of self within the learning culture as they embraced

the notion of responsible self and reconnected with

enthusiasm and excitement to learning. They were

able to empower themselves (Gibson 1991) and

develop lifelong learning skills based on their own

vision for learning (Senge 1990), which held per-

sonal meaning for self: ‘learning is something I want

to do more, so that I can do the best job that I can do’

(Rogers 1969). This resulted in those who had pre-

viously dominated with negative attitudes toward

learning, having a reduced impact on the overall

learning culture, and those staff who had been

passive, developed greater autonomy as they were

supported through the changing context. This was

of utmost importance in building a sustainable

culture where challenge became part of everyday

practice.

Practice development is concerned with creating

a culture that is not only sustainable, but where

developing practice is not dependent on any one

individual (Garbett & McCormack 2004). It would

therefore be a failure if the practice development

work ground to a halt once the practitioner-researcher

had left the unit, as the emphasis is on developing

practitioners who carry on the work long after the

intervention is completed. One-year postintervention,

one-third of the staff have now undertaken formal

education in their speciality. They continue to

implement new initiatives, including ideas such

as the ‘hug a bub program’, where volunteers work

alongside staff to reduce the distress of babies

withdrawing for narcotic addiction, and the ‘babies

like books too’ initiative, which introduces reading

to babies from birth. These projects have enabled

staff to put into action the skills they developed

during the study as they strive to improve care:

I think we have come a long way, it’s positive … there is still lots we need to do and there will always be lots we need to do.

Fig. 4 Re-generating the ‘self ’ in learning.

104 V. Wilson

et al.


Conclusion

It can be seen, from this study, that the learning

culture has a significant impact on how nurses go

about their everyday practice. Cultural shift can be

achieved through the intervention of ePD activities.

In this study, the learning culture of the unit was

shaped by a series of tensions where staff were, at

times, working against one another. When these

tensions were revealed it enabled them to look at

their existing practice and to move forward with the

help of the practitioner-researcher. In doing this

they were able to turn the tensions around and work

towards a more effective learning culture. This was

achieved by freeing the oppressive elements of the

tension-laden culture as they worked towards being

an effective team. A supportive learning culture was

created that was embedded within the environment,

where learning about learning was seen as an important

part of the context that enabled the development of

the responsible self.

References

Almost J. & Laschinger H. (2002) Workplace

empowerment, collaborative work relationships, and

job strain in nurse practitioners.

Journal of American

Academy of Nurse Practitioners

14

, 408–420.

Atkins S. & Murphy K. (1993) Reflection; a review of

the literature.

Journal of Advanced Nursing

18

,

1188–1192.

Bierema L. & Eraut M. (2004) Workplace-focused

learning: perspectives on continuing professional

education and human resource development.

Advances

in Developing Human Resources

6

, 52–68.

Boyatzis R. (1998)

Transforming Qualitative Information

.

Sage, Thousand Oaks.

Clark P. (2001) What residents are not learning.

Observations in an NICU.

Academic Medicine

76

,

419–424.

Dewing J. (2002) From ritual to relationship: a

person-centred approach to consent in qualitative

research with older people who have dementia.

Dementia

2

, 157–171.

Dixon D. (1999) Achieving results through

transformational leadership.

Journal of Nursing

Administration

12

, 17–21.

Eden C., Jones S. & Sims D. (1983)

Messing About in

Problems

. Pergamon, Oxford.

Eraut M., Alderton J., Cole G. & Senker P. (1998)

Learning from other people at work. In:

Supporting

Lifelong Learning

(eds R. Harrison

et al

.), pp. 127–145.

Routledge, London.

Eraut M., Alderton J., Cole G. & Senker P. (2000)

Development of knowledge and skills at work.

In:

Differing Visions of a Learning Society

, Vol. 1.

(ed. F. Coffield), pp. 231–262. The Policy Press, Bristol.

Eraut M., Alderton J., Cole G. & Senker P. (2002) The

impact of the manager on learning in the workplace.

In:

Supporting Lifelong Learning, Volume 2, Organising

Learning

(eds F. Reeve

et al.

), pp. 91–108. Routledge,

London.

Eraut M., Maillardet F., Miller C., Steadman S., Ali A.,

Blackman C. & Furner J. (2004)

Learning in the

Professional Workplace: Relationships between Learning

Factors and Contextual Factors

. AERA Conference

Paper, San Diego.

Fay B. (1987)

Critical Social Science

. Polity Press, Cambridge.

Freire P. (1972)

Pedagogy of the Oppressed

. Herder &

Herder, New York.

Freshwater D. (1998)

Transformatory learning in nurse

education. PhD Thesis. University of Nottingham,

Nottingham.

Garbett R. & McCormack B. (2002) The qualities

and skills of practice developers. Nursing Standard 16,

33–36.

Garbett R. & McCormack B. (2004) A concept analysis

of practice development. In: Practice Development in

Nursing (eds B. McCormack, K. Manley & R. Garbett),

pp. 10–32. Blackwell Publishing, Oxford.

Gibson G. (1991) A concept analysis of empowerment.

Journal of Advanced Nursing 16, 354–361.

Grundy S. (1982) Three modes of action research.

Curriculum Perspectives 2, 23–34.

Hoff T., Pohl H. & Bartfield J. (2004) Creating a learning

environment to produce competent residents: the

roles of culture and context. Academic Medicine 6,

532–540.

Johns C. (1994) Guided reflection. In: Reflective Practice in

Nursing (eds A. Palmer, S. Burns & C. Bulman),

pp. 110–130. Blackwell Science, Oxford.

Johns C. (1998) Opening the doors of reflection. In:

Transforming Nursing Through Reflective Practice (eds

C. Johns & D. Freshwater), pp. 1–20. Blackwell Science,

Oxford.

Kaye B. & Jordan-Evans S. (2000) Retention: Tag you’re it!

Training and Development 54, 29–33.

Knapper C. & Croppley A. (1999) Lifelong Learning and

Higher Education, 3rd edn. RoutledgeFalmer,

London.



Knowles M. (1977) The Adult Education Movement in the

United States, 2nd edn. Krieger Publishing Co, New

York.

Knowles M. (1990) The Adult Learner: a Neglected Species,

4th edn. Gulf Publishing Co., Texas.

Knowles M., Holton E. & Swanson R. (1998) The

definitive classic in adult education and human

resource development. In: The Adult Learner, 5th edn.

Chapter 11, pp. 198–201. Gulf Publishing Co., Texas.

Laschinger H., Finegan J., Shamian J. & Almost J. (2001)

Testing Karasek’s demands-control model in

restructured healthcare settings: effects of job strain on

staff nurses’ quality of work life. The Journal on Nursing

Administration 31, 233–243.

Manley K. (2004) Workplace culture: is your workplace

effective? How would you know? Nursing in Critical

Care 9, 1–3.

Manley K. & McCormack B. (2003) Practice development:

purpose, methodology, facilitation and evaluation.

Nursing in Critical Care 8, 22–29.

McCormack B. & Garbett R. (2003) The characteristics,

qualities and skills of practice developers. Journal of

Clinical Nursing 12, 317–325.

McGill I. & Beaty L. (2001) Action Learning: A Guide for

Professional, Management and Educational

Development, 2nd edn. Kogan Page Ltd, London.

Melia K. (1987) Learning and Working: the Occupational

Socialization of Nurses. Tavistock Publication Ltd,

London.

Miller C., Tomlinson A. & Jones M. (1994) Researching

Professional Education: Learning Styles and Facilitating

Reflection. English National Board of Nursing,

Midwifery and Health Visiting, London.

Nolan C. (1998) Learning on clinical placement: the

experience of six Australian student nurses. Nurse

Education Today 18, 622–629.

Patton M. (1990) Qualitative Evaluation and Research

Methods, 2nd edn. Sage, California.

Platzer H., Blake D. & Ashford D. (2000) Barriers

to learning from reflection: a study of the use of

groupwork with post-registration nurses. Journal

of Advanced Nursing 5, 1001–1008.

Rogers C. (1969) Freedom to Learn. Charles E. Merrill,

Ohio.

Rolfe G. (1996) Closing the Theory Practice Gap: a New

Paradigm for Nursing. Butterworth Heinmann,

Oxford.

Rycroft-Malone J. (2004) The PARIHS Framework – a

framework for guiding the implementation of

evidenced-based practice. Journal of Nursing Care

Quality 19, 297–304.

Senge P. (1990) The Fifth Discipline: The Art and Practice of

the Learning Organization. Doubleday Currency, New

York.

Titchen A. & Binnie A. (1995) The art of clinical

supervision. Journal of Clinical Nursing 4, 327–334.

Wade R. (1994) Teacher education students’ views on class

discussion: implications for fostering critical reflection.

Teaching and Teacher Education 10, 231–243.

Ward C. & McCormack B. (2000) Creating an adult

learning culture through practice development. Nurse

Education Today 20, 259–266.

Weiler K. (1996) Myths of Paulo Freire. Harvard

Educational Review 66, 353–371.

Wilson V. (2005a) Developing a culture of family-centred

care: an emancipatory practice development approach.

PhD Thesis, Monash University, Melbourne.

Wilson V. (2005b) Developing a vision for teamwork.

Practice Development in Health Care 4, 40–48.

Wilson V., Keachie P. & Engelsmann M. (2003) Putting the

Action into Learning: the experience of an action

learning set. Collegian 10, 22–26.

Wilson V., McCormack B. & Ives G. (2005) Understanding

the workplace culture of a special care nursery. Journal

of Advanced Nursing 50, 27–38.

Winter R. & Munn-Giddings C. (2001) A Handbook for

Action Research in Health and Social Care. Routledge,

London.

Re-generating the ‘self’ in learning: developing a culture of supportive learning in practice

Documents

Transcript of Re-generating the ‘self’ in learning: developing a culture of supportive learning in practice