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.

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.

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.