Borrowing against the future: the response to the public consultation on the NHS bursary.

This paper discusses the UK Government's public consultation into the NHS bursary and the response from the Nursing and Midwifery Council. A public consultation stipulated that the current arrangements for funding, by the State, were not to be considered for discussion. Instead, the consultation only appraised views that would lead to the successful introduction of student finance loans for NHS professional education. Testimonies from nurses, midwives and nursing students expressed concern that the new funding arrangements were unaffordable, dis-incentivising and biased towards the marketisation of student loans in the UK, yet the changes went ahead. The changes to NHS bursary funding resulted from the UK Government's desire for growth in student numbers (and ostensibly not growth in financial figures), and the fact that nursing (and other healthcare) students will become more fiscally indebted, despite society's moral obligation to them.

Putting knowledge to work in clinical practice: Understanding experiences of preceptorship as outcomes of interconnected domains of learning.

AIMS AND OBJECTIVES: To explore how preceptor support can assist newly qualified nurses to put knowledge to work across interconnected forms of knowledge when delegating to healthcare assistants. BACKGROUND: Current literature on preceptorship in nursing has failed to explore how competence is underpinned by knowledge frameworks in clinical practice. DESIGN: An ethnographic case study in three hospital sites in England (2011-2014). METHODS: Data collection included participant observation, interviews with 33 newly qualified nurses, 10 healthcare assistants and 12 ward managers. Data were analysed using thematic analysis. A tool to assist newly qualified nurses to delegate and supervise newly qualified nurses during the preceptorship period was developed and piloted with thirteen newly qualified nurses in the same sites. A process evaluation was undertaken. FINDINGS: Focusing on a key task for newly qualified nurses, delegation to healthcare assistants, we argue that preceptorship can support newly qualified nurses as they put knowledge to work in the transition from qualifying student to newly qualified nurses. In supportive ward cultures, limited access to formal preceptorship can be bolstered by team support. newly qualified nurses in less supportive ward cultures may have both a greater need for preceptorship and fewer compensatory mechanisms available to them when formal preceptorship is not available. We argue that organisational learning contexts and individual learning styles (interconnected domains of learning) are key to understanding effective preceptorship. CONCLUSIONS: We suggest that putting knowledge to work early in their careers with preceptorship support may assist newly qualified nurses to develop confidence and competence in delegation and supervision of healthcare assistants. RELEVANCE TO CLINICAL PRACTICE: Our findings suggest that newly qualified nurses need to be supported by effective preceptorship in their learning as they transition from undergraduate to post graduate. Preceptorship programmes at ward and organisational level need to recognise the intensity of the learning required during this transition phase.

An analysis of delegation styles among newly qualified nurses.

Aim The aim of this research was to explore how newly qualified nurses learn to organise, delegate and supervise care in hospital wards when working with and supervising healthcare assistants. It was part of a wider UK research project to explore how newly qualified nurses recontextualise the knowledge they have gained during their pre-registration nurse education programmes for use in clinical practice. Method Ethnographic case studies were conducted in three hospital sites in England. Data collection methods included participant observations and semi-structured interviews with newly qualified nurses, healthcare assistants and ward managers. A thematic analysis was used to examine the data collected. Findings Five styles of how newly qualified nurses delegated care to healthcare assistants were identified: the do-it-all nurse, who completes most of the work themselves; the justifier, who over-explains the reasons for decisions and is sometimes defensive; the buddy, who wants to be everybody's friend and avoids assuming authority; the role model, who hopes that others will copy their best practice but has no way of ensuring how; and the inspector, who is acutely aware of their accountability and constantly checks the work of others. Conclusion Newly qualified nurses require educational and organisational support to develop safe and effective delegation skills, because suboptimal or no delegation can have negative effects on patient safety and care.

A critical commentary on management science in relation to reforms after institutional National Health Service failures.

AIM(S): A discussion paper on the United Kingdom (UK) National Health Service (NHS) market reforms. BACKGROUND: NHS market reforms reliance on management science methods introduced a fundamental shift in measuring care for commissioning. EVALUATION: A number of key reports are discussed in relation to NHS market reforms and management science. KEY ISSUES: NHS market reforms were influenced through a close alliance between policy makers, the department of health, free market think tanks and management consultancies. The timing of reforms coincided with reports on NHS failings and the evolution of measurement methods to focus on finance. CONCLUSIONS: The balance in favour of measurement practises is of concern. Management science methods are criticised in the Francis Report yet promoted as the solution to some of the key findings; why may be explained by the close alliance. IMPLICATIONS FOR NURSING MANAGEMENT: A return to principles of management involving consensus, trust and involvement to promote quality care and use management science methods to this end.

Delegation and supervision of healthcare assistants' work in the daily management of uncertainty and the unexpected in clinical practice: invisible learning among newly qualified nurses.

The invisibility of nursing work has been discussed in the international literature but not in relation to learning clinical skills. Evans and Guile's (Practice-based education: Perspectives and strategies, Rotterdam: Sense, 2012) theory of recontextualisation is used to explore the ways in which invisible or unplanned and unrecognised learning takes place as newly qualified nurses learn to delegate to and supervise the work of the healthcare assistant. In the British context, delegation and supervision are thought of as skills which are learnt "on the job." We suggest that learning "on-the-job" is the invisible construction of knowledge in clinical practice and that delegation is a particularly telling area of nursing practice which illustrates invisible learning. Using an ethnographic case study approach in three hospital sites in England from 2011 to 2014, we undertook participant observation, interviews with newly qualified nurses, ward managers and healthcare assistants. We discuss the invisible ways newly qualified nurses learn in the practice environment and present the invisible steps to learning which encompass the embodied, affective and social, as much as the cognitive components to learning. We argue that there is a need for greater understanding of the "invisible learning" which occurs as newly qualified nurses learn to delegate and supervise.

NHS market liberalisation and the TTIP agreement.

Governments over the past three decades have undermined the founding principles of the NHS through reforms and market liberalisation. With greater involvement of commercial interests in health care, the NHS will become less democratic and transparent. Recent reforms, which were intended to improve productivity, quality and cost efficiency, have left the NHS exposed to the unwieldy model of market liberalisation and the attrition of public health care. The role of community nurses has been particularly destabilised by commissioning, as their work is difficult to measure. The advent of the Transatlantic Trade and Investment Partnership could further undermine the NHS to the benefit of international commercial interests.

People, liminal spaces and experience: understanding recontextualisation of knowledge for newly qualified nurses.

BACKGROUND: Little is known about how newly qualified nurses delegate to health care assistants when delivering bedside care. AIM: To explore newly qualified nurses' experiences of delegating to, and supervising, health care assistants. DESIGN: Ethnographic case studies. SETTINGS: In-patient wards in three English National Health Service (NHS) acute hospitals. PARTICIPANTS: 33 newly qualified nurses were observed, 10 health care assistants and 12 ward managers. METHODS: Participant observation and in-depth interviews. FINDINGS: We suggest that newly qualified nurses learn to delegate to, and supervise, health care assistants through re-working (`recontextualising') knowledge; and that this process occurs within a transitional (`liminal') space. CONCLUSIONS: Conceptualising learning in this way allows an understanding of the shift from student to newly qualified nurse and the associated interaction of people, space and experience. Using ethnographic case studies allows the experiences of those undergoing these transitions to be vocalised by the key people involved.

'Doing the writing' and 'working in parallel': how 'distal nursing' affects delegation and supervision in the emerging role of the newly qualified nurse.

BACKGROUND: The role of the acute hospital nurse has moved away from the direct delivery of patient care and more towards the management of the delivery of bedside care by healthcare assistants. How newly qualified nurses delegate to and supervise healthcare assistants is important as failures can lead to care being missed, duplicated and/or incorrectly performed. OBJECTIVES: The data described here form part of a wider study which explored how newly qualified nurses recontextualise knowledge into practice, and develop and apply effective delegation and supervision skills. This article analyses team working between newly qualified nurses and healthcare assistants, and nurses' balancing of administrative tasks with bedside care. METHODS AND ANALYSIS: Ethnographic case studies were undertaken in three hospital sites in England, using a mixed methods approach involving: participant observations; interviews with 33 newly qualified nurses, 10 healthcare assistants and 12 ward managers. Data were analysed using thematic analysis, aided by the qualitative software NVivo. FINDINGS: Multiple demands upon the newly qualified nurses' time, particularly the pressures to maintain records, can influence how effectively they delegate to, and supervise, healthcare assistants. While some nurses and healthcare assistants work successfully together, others work 'in parallel' rather than as an efficient team. CONCLUSIONS: While some ward cultures and individual working styles promote effective team working, others lead to less efficient collaboration between newly qualified nurses and healthcare assistants. In particular the need for qualified nurses to maintain records can create a gap between them, and between nurses and patients. Newly qualified nurses require more assistance in managing their own time and developing successful working relationships with healthcare assistants.

Breastfeeding mothers' experiences: the ghost in the machine.

We critically review qualitative research studies conducted from 2000 to 2012 exploring Western mothers' breastfeeding experiences. We used the search criteria "breastfeeding," "qualitative," and "experiences" to retrieve 74 qualitative research studies, which were reduced to 28 when the terms "existential'' and "research'' were applied. We found that the impact of technology and the pervasive worldwide marketing of infant formula devalued breastfeeding mothers' narratives in a number of ways. Women's bodies were viewed as machine-like objects and the breast was seen as a disembodied object. Dominated by technological narrative, women's bodies were considered unpredictable and hormonal, needing to be managed by health care professionals. This means the disseminating breastfeeding discourse needs to be reinterpreted for practical use. We found that some of the researchers utilized narrative informed by phenomenological philosophy that appears to edge closer to understanding mothers' experiences in a more profound way than nonphenomenological research. However, we need to be mindful of the transparency of terms in replacing one form of technological narrative with another.

A social purpose model for nursing.

UNLABELLED: The very current international debate regarding the construction of professional role-identity in nursing involves analysis of context, competency, reflection, and theory. PROBLEM: What most of the literature shows is that nursing continues to struggle with inherited moral and behaviorist constructs in which essential is in opposition to essentialist caring values and remains part of a convoluted argument. Each of these two types of caring either figure or pre-figure in the "future of nursing," which, in the 21st century is contained within the market economy of healthcare reforms and international change. Therefore, how nursing's past is mapped is germane to any current or future understanding of nursing in a multidisciplinary workforce. METHODS: The paper takes a theoretical position employing a nursing model, newly constructed by the author, to examine 21st century nursing. The model seeks to gain an informed knowledge of practice to develop a means of evaluating nursing within its social context. The model is called a social purpose model. This article provides a historical mapping of the concept of new nursing from when it was utilized in another context nearly 18 years ago to now in the United Kingdom. This article includes a critical discussion of nursing's purposeful future to make the discussion more meaningful from an international perspective. Cartographically linking the past to the present is important, but if there is opportunity to define and identify the profession for a purposeful future, appropriate tools are needed to do so. FINDINGS: This article offers a social purpose model in which a subjective, objective, and contextual ideal of what nursing is today can be explored critically and applied both to the student and mentor's practice arena. CONCLUSION: To extend a definition of nursing for pragmatic purposes, nursing needs to be defined in relation to the social context within which it is practiced. Theory and experiential evaluation must inform action as a working adjunct to governmental documentation, taking 21st century nursing from the desktop to the bedside.

Plethora or paucity: a systematic search and bibliometric study of the application and design of qualitative methods in nursing research 2008-2010.

Qualitative methodology has increased in application and acceptability in all research disciplines. In nursing, it is appropriate that a plethora of qualitative methods can be found as nurses pose real-world questions to clinical, cultural and ethical issues of patient care (Johnson, 2007; Long and Johnson, 2007), yet the methods nurses readily use in pursuit of answers remains under intense scrutiny. One of the problems with qualitative methodology for nursing research is its place in the hierarchy of evidence (HOE); another is its comparison to the positivist constructs of what constitutes good research and the measurement of qualitative research against this. In order to position and strengthen its evidence base, nursing may well seek to distance itself from a qualitative perspective and utilise methods at the top of the HOE; yet given the relation of qualitative methods to nursing this would constrain rather than broaden the profession in search of answers and an evidence base. The comparison between qualitative and quantitative can be both mutually exclusive and rhetorical, by shifting the comparison this study takes a more reflexive position and critically appraises qualitative methods against the standards set by qualitative researchers. By comparing the design and application of qualitative methods in nursing over a two year period, the study examined how qualitative stands up to independent rather than comparative scrutiny. For the methods, a four-step mixed methods approach newly constructed by the first author was used to define the scope of the research question and develop inclusion criteria. 2. Synthesis tables were constructed to organise data, 3. Bibliometrics configured data. 4. Studies selected for inclusion in the review were critically appraised using a critical interpretive synthesis (Dixon-Woods et al., 2006). The paper outlines the research process as well as findings. Results showed of the 240 papers analysed, 27% used ad hoc or no references to qualitative; methodological terms such as thematic analysis or constant comparative methods were used inconsistently; qualitative was a catch-all panacea rather than a methodology with well-argued terms or contextual definition.

Liberating the NHS; commissioning, outsourcing and a new politics debate.

In the short months following the result of the UK 2010 General election, a new Government White Paper has been released entitled: Equity and Excellence: Liberating the NHS (Department of Health (DH), 2010a). It strives to distance itself from previous health-care proposals (DH, 2009), yet if the initiatives of this latest paper are combined against previous initiatives, also using high impact declarative terms, such as competition and choice, it is clear that little has changed and more important principles than saving money are at risk.

Annotation an effective device for student feedback: a critical review of the literature.

The paper examines hand-written annotation, its many features, difficulties and strengths as a feedback tool. It extends and clarifies what modest evidence is in the public domain and offers an evaluation of how to use annotation effectively in the support of student feedback [Marshall, C.M., 1998a. The Future of Annotation in a Digital (paper) World. Presented at the 35th Annual GLSLIS Clinic: Successes and Failures of Digital Libraries, June 20-24, University of Illinois at Urbana-Champaign, March 24, pp. 1-20; Marshall, C.M., 1998b. Toward an ecology of hypertext annotation. Hypertext. In: Proceedings of the Ninth ACM Conference on Hypertext and Hypermedia, June 20-24, Pittsburgh Pennsylvania, US, pp. 40-49; Wolfe, J.L., Nuewirth, C.M., 2001. From the margins to the centre: the future of annotation. Journal of Business and Technical Communication, 15(3), 333-371; Diyanni, R., 2002. One Hundred Great Essays. Addison-Wesley, New York; Wolfe, J.L., 2002. Marginal pedagogy: how annotated texts affect writing-from-source texts. Written Communication, 19(2), 297-333; Liu, K., 2006. Annotation as an index to critical writing. Urban Education, 41, 192-207; Feito, A., Donahue, P., 2008. Minding the gap annotation as preparation for discussion. Arts and Humanities in Higher Education, 7(3), 295-307; Ball, E., 2009. A participatory action research study on handwritten annotation feedback and its impact on staff and students. Systemic Practice and Action Research, 22(2), 111-124; Ball, E., Franks, H., McGrath, M., Leigh, J., 2009. Annotation is a valuable tool to enhance learning and assessment in student essays. Nurse Education Today, 29(3), 284-291]. Although a significant number of studies examine annotation, this is largely related to on-line tools and computer mediated communication and not hand-written annotation as comment, phrase or sign written on the student essay to provide critique. Little systematic research has been conducted to consider how this latter form of annotation influences student learning and assessment or, indeed, helps tutors to employ better annotative practices [Juwah, C., Macfarlane-Dick, D., Matthew, B., Nicol, D., Ross, D., Smith, B., 2004. Enhancing student learning through effective formative feedback. The Higher Education Academy, 1-40; Jewitt, C., Kress, G., 2005. English in classrooms: only write down what you need to know: annotation for what? English in Education, 39(1), 5-18]. There is little evidence on ways to heighten students' self-awareness when their essays are returned with annotated feedback [Storch, N., Tapper, J., 1997. Student annotations: what NNS and NS university students say about their own writing. Journal of Second Language Writing, 6(3), 245-265]. The literature review clarifies forms of annotation as feedback practice and offers a summary of the challenges and usefulness of annotation.

Annotation is a valuable tool to enhance learning and assessment in student essays.

UNLABELLED: As a United Kingdom (UK) wide organisation, the Quality Assurance Agencies ensure that best standards in higher education are reached. Following an institutional audit within a UK University, it was recommended that annotation be introduced to promote good practice in the management and implementation of giving feedback to students on assessed work. Annotation is a handwritten comment or mark written directly onto the page of the students' script. METHODS: A review of current literature, policy and practice in relation to annotation. Random sample of student scripts analysed for versions of annotation such as content, difference, length, approach and clarity. Questionnaires distributed to staff (n=74) and students n=249), analysed using SPSS and thematic analysis. OUTCOMES: For both staff and students, interpretations of annotation in terms of transparency of style and legibility were an issue. Both respondents agreed or strongly agreed that annotation enhances a student-centered approach to learning. For the student sample, there was an agreement or strong agreement that annotation helped inform the next assignment (82.2%). There was a recognition that annotation can convey a tone and the student survey indicated that the tone of some annotation undermines confidence. Findings show annotation is considered important by students but is different from other forms of feedback. Because annotation is written on the page it requires greater sensitivity towards students' work. Recommendations disseminate findings to develop health professional education. DISCUSSION: The annotator's presence can influence the student's interaction with their script causing them to evaluate their original writing differently. Ramage and Bean [Ramage, J.D., Bean, J.C., 1995. Writing Arguments, third ed. Allyn and Bacon, Needham Heights, MA.], use two different annotated versions of the same essay to model and contrast ''reading as a believer" and ''reading as a doubter" (cited in Wolfe [Wolfe, J.L., 2002. Marginal pedagogy: how annotated texts affects writing-from-source text. Written Communication 19 (2), 297-333.]). Multiple readings can be made of one text, but how the essay is read by the lecturer has the greater impact on the student. Annotation defies any stable definition precisely because it can be practiced in so many ways. It is vital that annotation is used and received appropriately so that negative effects of annotation are minimised and the positive effects emphasised. There are a number of ways of improving annotation, and good practice guidelines are offered in the conclusion to this paper.