Nursing Praxis March 2016 Vol 32 No 1

IN NEW ZEALAND Journal of Professional Nursing

INSIDE THIS ISSUE...

Looking back and looking forward Factors that influence new graduates’ preferences for speciality areas Oral health experiences of Maori with dementia and whanau perspectives oranga waha mo nga iwi katoa A “toolkit” for clinical educators to foster learners’ clinical reasoning and skills acquisition

Volume 32. No. 1

MARCH 2016

Praxis: “The action and reflection of people upon their world in order to transform it.”

(FREIRE, 1972)

E D IT OR IAL BOAR D EDITORS-IN-CHIEF: Jean Gilmour Jill Wilkinson

RN, PhD, MCNA (NZ) RN, PhD, MCNA (NZ)

EDITORS: Norma Chick Mandie Foster Willem Fourie Michelle Honey Kathy Nelson Tineke Water

PE, RN, RM, PhD RN, PhD RN, PhD, FCNA (NZ) RN, PhD, FCNA (NZ) RN, MA, VUW, PhD RN, PhD

COVER: Crimson was deliberately chosen by the Editorial Group as the colour for this journal as it represents, for us, imagination, intuition, potentiality, struggle and transformation.

KORU: Designed for this journal by artist, Sam Rolleston: The central Koru indicates growth, activity and action. The mirrored lateral Koru branches indicate reflection.

Transformation is shown by the change of the initial plain Koru design to a more elaborate one.

PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org

W www.nursingpraxis.org

ISSN 2423-012X HANNAH & YOUNG PRINTERS

CO NTE NTS PEER REVIEWERS:............................................................................................................................... 4 EDITORIAL: Looking back and looking forward

Dr Louise Rummel......................................................................................................................... 5

ARTICLES: Factors that influence new graduates’ preferences for speciality areas

Jill Wilkinson, Stephen Neville, Annette Huntington, Paul Watson................................................. 8

Oral Health experiences of Māori with dementia and whānau perspectives - oranga waha mō ngā iwi katoa

Jean Gilmour, Annette Huntington, Bridget Robson.................................................................... 20

A “toolkit“ for clinical educators to foster learners’ clinical reasoning and skills acquisition

Catherine Cook ......................................................................................................................... 28

NOTES FOR CONTRIBUTORS.............................................................................................................. 38

Page 3

Vol. 31 No. 3 2015 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

THANK YOU TO OUR PEER REVIEWERS FOR 2015 On behalf of the Nursing Praxis in New Zealand Editorial Board and our Administrator we would like to thank the reviewers of the manuscripts submitted for publication. The expertise and constructive feedback provided improves the quality and standard of the journal. We thank you for the significant contribution you make to Nursing Praxis in New Zealand.

Dr Jean Gilmour and Dr Jill Wilkinson Co-Editors-in-Chief

Sue Adams

Kay Laracy

Elaine Papps

Margaret Adamson

Anecita Gigi Lim

Sandra Richardson

Cheryl Atherfold

Jacquie Kidd

Dianne Roy

Jill Clendon

Marianne Mackenzie

Barbara Docherty

Sylvia Meijers

Judy Honeyfield

Kathy Nelson

Isabel Jamieson

Anthony O’Brien

Wendy Scott Stacey Wilson Judy Yarwood Kim Van Wissen Denise Wilson

Please visit our website www.nursingpraxis.org if you would like to become a reviewer or update your details.

Page 4

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand EDITORIAL LOOKING BACK AND LOOKING FORWARD Emeritus Professor Dr Norma Chick PE RGON RM PhD,

also exciting. Through the paper on Nursing Knowledge

FCNA, has been a member of the Editorial Group of Nursing

Norma introduced me and hundreds of other nurses to

Praxis in New Zealand from the inception of “Nursing

nursing theory and research. She can be credited with

Praxis” in 1985 to the present day (2016). One can only

influencing the mind-set of a whole generation of nurses

marvel at this length of service of a great, disciplined

from thinking of nursing as only a practical occupation

and logical mind, and her determination to advance

supported by procedural knowledge to one that is

the profession of nursing as a discipline in its own right.

scientifically based on sound evidence to provide a clear

Reflecting on the early issues of Nursing Praxis in New

rationale for nursing judgements and actions.

Zealand my mind goes back to my early associations with Norma.

From the outset, Norma introduced students to the importance of building a distinctive body of knowledge

Alongside Dr Nan Kinross, Norma began the first post-

that would establish nursing as a discipline in its own

registration, advanced education for registered nurses

right. Discipline was defined as “a unique perspective, a

in New Zealand at Massey University, Palmerston North.

distinct way of viewing all phenomena which ultimately

In their co-authored book Chalk & Cheese (2006) both

defines the limits and nature of its inquiry” (Donaldson

wrote of the struggles they experienced to establish

& Crowley, 1978, p.113). Norma taught that received

nursing in the university environment. Starting in 1973

knowledge while it supported a vocational perception

as a small unit within the Department of Psychology with

of nursing, was inadequate to provide the foundation

three students nursing grew quickly, helped by the strong

for a scientific discipline. Thus began our journey of

interest shown by New Zealand nurses in furthering their

discovery – introduction to philosophy, logic, and exposure

education, and Massey University’s mandate to provide

to conceptual frameworks and to theories of nursing,

extramural studies throughout the country.

mainly those developed by American nurse scholars such as Henderson, Orem, Roy, Rogers, and others, and most

The entry requirement for university nursing studies

importantly our own search for a definition of nursing.

in the 1970s was a nursing registration. Local students could study “internally”, attending weekly classes, but

Norma was also a superb research supervisor as early

the majority of students, myself included, had to take

students moved on to graduate studies and began

the extramural option. Our studies were undertaken by

conducting clinical research in nursing. Her capacity to

mail, with study guides and set readings arriving at regular

challenge students to think critically, to write incisively,

intervals. The study guide content was comprehensive

and to defend their views by references to research

and it spelt out step by step what was required of the

evidence and careful reasoning was legendary. It is these

student. They were the forerunners to other types of

qualities that she also brought to her editorial board work

study at a distance, forecasting contemporary forms

for Nursing Praxis.

such as e-learning. Each “paper” included compulsory on-campus courses of intensive lectures, tutorials, group projects and tests. On-campus courses were gruelling but

Page 5

Rummel, L. (2016).Editorial: Looking back and looking forward. Nursing Praxis in New Zealand, 32(1) 5-7.

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Under Norma’s instruction, nurses developed an ability

“trailblazers” laid down a generation ago and sustained

to think critically about their practice and to consider the

through contributions such as Norma’s work on Nursing

importance of theory development and research. These

Praxis journal.

two activities were essential if nursing was to rise as a discipline in its own right. The latter did not just happen;

Norma was never one to “rest on her laurels”; always

nurses had to be taught to think differently.

looking to what needed to be done next. We should learn from her. The work of nursing scholarship and

I recall the struggle in Norma’s paper Nursing Knowledge

development of the discipline is not done! As Dr. Stephen

reading and trying to understand conceptual and

Neville, in a 2013 Nursing Praxis editorial reminded its

theoretical frameworks as a way to view person , health,

readers, too many nurses are failing to take the final step

nurse, and environment; the four key conceptual areas

in the research process - that of publication. Too few

viewed as the means to “organise facts, principles and

nurses are adding to the repository of nursing knowledge

theories” (Doheny, Cook, & Stopper, 1997, p. 7) for the

by publishing the outcomes of their research. Published

delivery of nursing care. Moreover the importance of

research is vital to the development of the profession and

research as a means of analysis and resolution of nursing

to nursing practice. Nursing as a profession cannot develop

care problems and a way to discover new knowledge or

if our research and scholarly work remain unpublished,

to validate what is already known. However, in Norma’s

unavailable to others, and not open to critique and testing

mind “theory and research were inextricably connected

in clinical practice.

and it was difficult to think one without the other” (Chick, & Kinross, 2006, p. 130).

In an early Nursing Praxis editorial, Dr Norma Chick issued a challenge: “Advanced education in nursing promises

If the fortitude and persistence of both Norma and Nan

to play a transforming role in bringing about the full

in those early days of developing nursing as a scientific

integration of nursing into health care planning. Let us

and clinical discipline in the New Zealand context of

make it happen” (Chick, 1989, p. 4). Has it happened? The

advanced education had not continued, nursing in New

same challenge is important in 2016 if the people of New

Zealand would not be where it is today. Their self-belief

Zealand are to benefit from the advancement of nursing

and persistence in the face of many challenges has served

knowledge and its full contribution to the planning, design

the profession of nursing admirably. The status of nursing

and delivery of health care.

in New Zealand today is a testimony to the early work of Norma as one of its academic pioneers.

Dr Louise Rummel RN PhD with input from Dr Irena Madjar, RN PhD.

Today, a bachelor’s degree is the entry qualification

Senior Lecturer Faculty of Nursing and Health Studies, Manukau Institute of Technology

for nursing practice in New Zealand, and reading and understanding research and the research process is part of every nurse’s undergraduate nursing education.

Research and theory development (usually in the form of grounded theory) is undertaken at the Masters and Doctoral Degree level by increasing numbers of nurses completing postgraduate degrees. Much of what we in nursing education today take for granted must be credited to the foundational work that Norma and other Page 6

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand References Chick, N. (1989). Editorial. Nursing Praxis in New Zealand, 4(2), 2-4.

Chick, N., & Kinross, N. (2006). Chalk & cheese: Trail-blazing in NZ nursing: A story told through memoir. Christchurch, Xpress

Printing House.

Doheny, O.M., Cook, B.C., Stopper M.C. (1997). The discipline of nursing: An introduction (4th ed.). Connecticut, USA: Appleton &

Lange.

Donaldson S.K. & Crowley D.M. (1978) The discipline of nursing. Nursing Outlook 26(2), 113-120.

Neville, S. (2013). Editorial. Nursing Praxis in New Zealand, 29(1), 2-3.

Page 7

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand FACTORS THAT INFLUENCE NEW GRADUATES’ PREFERENCES FOR SPECIALITY AREAS Jill Wilkinson, RN, PhD, Senior Lecturer, School of Nursing, Massey University, Wellington, NZ Stephen Neville, RN, PhD, Associate Professor & Head of Department (Nursing), Auckland University of Technology, Auckland, NZ Annette Huntington, RN, PhD, Professor & Head of School of Nursing, Massey University, Wellington, NZ Paul Watson, RN, PhD, Principal advisor – Nursing, Office of the Chief Nurse, Ministry of Health, Wellington, NZ

Abstract In 2012 all District Health Boards in New Zealand participated in a national pilot of the Advanced Choice of Employment system to recruit graduating and newly graduated registered nurses into two supported first year of practice programmes, namely the ‘Nurse Entry to Practice’ and ‘Nurse Entry to Specialty (mental health)’ programmes. The system requires applicants to choose in order of preference up to four District Health Boards and three clinical areas where they would like to work. This paper reports a survey of nurses who had registered with the Nursing Council of New Zealand in 2012 and explored factors that influenced their preference for three government priority specialty areas: primary health care, mental health and aged-related residential care. A self-reported survey and a non-probability sample of new graduate nurses was used. The response rate was 34% (n=287). Data were analysed descriptively. The results indicate that new graduate nurses prefer to work in surgical or medical areas to consolidate their technical skills. These experiences are thought to provide a good foundation for future career development. Clinical placement experiences have an important influence on choice of practice setting. Preference for an area is linked to positive experiences as a student. The government priority areas were seen as complex areas and a new graduate needs appropriate support to work there.

Supported first year of practice programmes are more available in hospital settings than primary care or aged residential care and therefore influence where nurses choose to work. Finally, nurses who are educated for the profession are disinclined to fill workforce gaps, but desperation for a job often drives them into areas where they have little interest.

Key words New graduate nurse; baccalaureate nurse; career choice; first year of practice; survey

Introduction In 2012 all District Health Boards (DHBs) in New

DHBs and by some private providers. The online ACE

Zealand participated in a national pilot of the online

system requires the graduating or newly graduated

Advanced Choice of Employment (ACE) system to recruit

nurse to choose in order of preference up to four DHBs

graduating and newly graduated registered nurses.

and three clinical areas where they would like to work.

These nurses enter one of two supported first year

Nurse Entry to Practice Programmes were first established

of practice programmes: the ‘Nurse Entry to Practice’ (NETP) programme or the ‘Nurse Entry to Specialist Practice (mental health)’ (NESP) programme offered in

Page 8

Wilkinson, J., Neville, S., Huntington, A., & Watson, P. (2016).

Factors that influence new graduates’ preferences for specialty areas. Nursing Praxis in New Zealand, 32(1), 8-19.

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand in 2005 when the then Minister of Health announced new

less ‘dynamic’ areas (Leh, 2011). These preferences have

funding to ensure DHBs provided a supported first year

changed very little over the last 20 years at least (see

of practice for newly registered nurses (Nursing Council

Happell, 1999; Stevens & Dulhunty, 1997). Nonetheless,

of New Zealand, n.d.). In 2007 this scheme was extended

workforce shortages in three government priority

from acute areas to cover newly registered nurses in age-

areas (mental health [MH], age related residential care

related residential care and primary health care. Many

[ARRC] and primary health care [PHC]) suggests there

of the DHBs offering NETP programmes also require the

is need to better understand the factors that influence

nurses to complete a postgraduate paper offered by a

graduating nurses’ choice of clinical practice setting in

Nursing Council approved tertiary education provider.

New Zealand (Ministry of Health, 2015). This paper reports

The NESP programme is specifically for those newly

on a national survey of recently graduated registered

registered nurses working in mental health and addiction

nurses and explored the factors that influenced their

services. The NESP varies slightly from NETP in that NESP

preference for employment with particular reference

requires the nurses to complete a postgraduate certificate

to the three government priority specialty areas.

as part of their supported programme (Te Pou, 2015).

Review of the Literature Background

Studies were identified for this review through searching

The research literature is replete with surveys of final

PubMed and the EBSCO platform databases, which

year student nurses who have been asked to rank their

included Medline, CINAHL Plus, Academic search premier

preference to work in a range of clinical practice areas

and Health source (Nursing/Academic edition, Education

as registered nurses (Birks, Al-Motlaq, & Mills, 2010;

source and PsychINFO). The key words and MeSH terms

Ganz & Kahana, 2006; Halcomb, Salamonson, Raymond,

used in the search were ‘students, nursing’, ‘specialties,

& Knox, 2012; Koskinen, Hupli, Katajisto, & Salminen,

nursing’, ‘choice’, ‘career choice’, ‘education, nursing’,

2012; Larsen, Reif, & Frauendienst, 2012; McCann, Clark,

‘baccalaureate’ and ‘new graduate nurse’. The search was

& Lu, 2010; Shen & Xiao, 2012; Stevens, 2011; Stevens

limited to quantitative and qualitative studies published

& Crouch, 1998). The relative popularity of some clinical

from 2006 onwards unless key earlier studies warranted

practice areas over others is therefore well known.

inclusion. In addition, the choice of area of practice in

The most common methods of data collection are by

the first year following graduation had to feature in the

survey using forced choice and free-text responses,

research findings for the study to be included in the

and interviews or focus groups. Invariably the findings

review. A total of 15 studies were chosen to review. There

are that the desirability of cardiac care, intensive care,

was no New Zealand research published on the topic.

emergency department, and acute medical/surgical settings is high. These clinical practice areas are viewed

A critical thread throughout the literature concerns the

as ‘high-tech’, dynamic and life-saving. Conversely, aged

disproportionate emphasis placed by undergraduate

care and mental health settings are viewed as ‘low-tech’

teaching staff on acute care environments and

areas, are considered boring and unfulfilling, and are

development of the associated technical skills (McCann

consistently the least desirable areas to work as a newly

et al., 2010). Indeed some curriculum contain little or

registered nurse. Community health (the term used in

variable gerontology content (Prentice, 2012). Despite

the literature to describe all nurses who work outside

the fact that most acute care is provided to those who

of hospitals or long-term care) features less often, but

are over 65 years, invariably, the emphasis in the curricula

where it is included, it ranks with the other low-tech

on acute care is at the expense of more ‘basic’ subjects

Page 9

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand such as long-term care contexts for older people (Stevens

more prestigious and attractive that environment

& Crouch, 1998). The attitude of teaching staff towards

becomes to newly registered nurses. Furthermore,

age care settings is noted by students (Abbey et al., 2006)

the status accorded to various high-tech and low-tech

and although not overtly negative, the higher value and

environments is reinforced by society (Gouthro, 2009;

importance of high-tech environments is made clear

Stevens, 2011), and by gender stereotypes where some

when juxtaposed against the low-tech or basic nursing

clinical practice areas are considered to be inherently

environments typical of aged care settings (Stevens &

more suitable for females than males. For example,

Crouch, 1998). These authors also noted the qualifications

woman are thought to be more suited to school nursing,

of those academics who design and deliver the majority

paediatrics, and home health areas, whereas mental

of the curriculum and found few qualifications amongst

health, critical care and emergency departments are

staff in non-acute areas of nursing. There is an argument

perceived as more suitable for men (Roth & Coleman,

that supports the transferability of acute care skills to

2008). Indeed, more men than women want to work

non-acute environments, but this may not always be

in critical care areas (Halcomb et al., 2012), and more

apparent to students.

women than men in public health (Larsen et al., 2012).

Stevens (2011) acknowledges the influence of the

Community health settings are viewed by some final

curriculum on choice of specialty area for a graduating

year students as lacking in prestige due to their low-

nurse, but suggests that clinical placement experiences

tech nature and lack of rigour compared to hospital

may have a more profound influence. In the context

placements. Students worry that their education and

of aged care, Brown, Nolan, Davies, Nolan and Keady

high-tech skills will be under-utilised and ultimately

(2008) report negative experiences of some students in

lost in a community health environment, or that a

‘impoverished’ environments where standards of care are

background in medical/surgical nursing is necessary

poor due in part to resource related factors. Impoverished

first (Leh, 2011). Similarly, the intention to work in

environments are described as having inadequate physical

public health more than one year after graduation was

surroundings, insufficient resources and equipment,

found by Larsen et al. (2012) to be twice as high as that

and little investment in staff training, little opportunity

at graduation. These authors suggest that recruitment

for advancement, poor pay, and poor staffing levels.

strategies should be focussed on more experienced nurses.

More time spent in these environments as students, or employment as health care assistants, correlates to

Gouthro (2009) reports that student nurses’ perception

decreased preference for aged care as a career destination

of mental health nursing is similar to that of aged care

(Stevens, 2011). Conversely, some aged care environments

and community health with respect to its second class

described as ‘enriched’, were inspiring and staffed by

status, its absence of technological tools, and lack of

skilled, knowledgeable and approachable staff who

focus on curing illness. Again, the quality and diversity

provided excellent care to patients and mentorship to

of clinical placement experiences significantly impact on

students. Placement experiences such as these had an

these attitudes and is reflected in mental health being

important impact on choice to work with older people as

consistently ranked low as a desirable career option (Ganz

registered nurses (Abbey et al., 2006; Brown et al., 2008).

& Kahana, 2006; Happell & Gaskin, 2013; McCann et al., 2010). A systematic review of 21 studies about student

Stevens and Crouch (1998) suggest that where nurses’

nurses attitudes towards mental health nursing found

work resembles the curative work of medicine, the

that while theoretical preparation and longer clinical

Page 10

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand placement improves overall attitude, there is no evidence

Ethical considerations

that these factors result in more graduates beginning

The ethical aspects of the study were evaluated by peer

careers in mental health (Happell & Gaskin, 2013).

review, judged to be low risk and therefore formal ethical approval was via notification to the relevant University

The discussion thus far has concerned intrinsic motivation

Human Ethics Committee.

variables that are related to career intentions. Extrinsic motivation variables too have a bearing, and may override personal preferences for a particular specialty area due to the practicalities associated with accepting a position.

Examples are the geographical location, salary, hours of work, opportunity for professional development and advancement, and fees rebate incentive schemes (Birks, AlMotlaq, & Mills, 2010; Larsen et al., 2012; Lea et al., 2008).

Views about where to work may also be influenced by other people such as family members, recently graduated nurses especially if they are from the same programme, and the immediate peer group (McCann

Sample The total number of new graduate nurses in 2012 was 1620. Of these, 839 had agreed to receive emails and survey invitations for research purposes from the NCNZ. An invitation to participate in the survey and a hyperlink to the online survey (hosted by the Survey Monkey platform) was emailed to these nurses by Nursing Council administration staff in July 2013. A reminder email was sent out two weeks later. Two-hundred and eighty-seven nurses responded to the survey giving a response rate of 34%.

et al., 2010). A decision to work in one area may also

Survey tool

be a strategic decision to gain clinical experience that

The literature about the preferences for clinical

will contribute to a nurse’s long-term career plans.

practice area of newly graduated nurses informed

In sum, and as Prentice (2012) points out, it is not

the development of the electronic survey questions.

one factor, but a combination of clinical experiences,

Questions were grouped into three main categories

theory, personal characteristics and practicalities that

about the undergraduate curricula, clinical placement

determine where a new graduate will choose to work.

experiences, and personal circumstances that have a bearing on choice, as well as the inclusion of demographic

Method

questions. The survey questions were a mix of forced choice and short answer which allowed for further

Aim

comment to expand on or clarify forced choice responses.

Review by senior nursing academics and staff of the

The aim of the study was to explore the factors that

Office of the Chief Nurse confirmed the questions

influence new graduate preferences for a particular

were appropriate for meeting the aim of the research.

clinical setting in New Zealand.

Data analysis Design

The data were exported from Survey Monkey into an Excel

The study was a descriptive cross-sectional electronic

spreadsheet, and then imported into SPSS version 20 (IBM

survey using a non-probability sample of nurses who

SPSS Inc, 2014) for analysis. The data were checked for

had registered with the Nursing Council of New Zealand

errors following the method described by Pallant (2013),

(NCNZ) in 2012.

then analysed using fundamental descriptive techniques.

Most of the variables are categorical, but where variables

Page 11

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand are continuous, measures of central tendency are

ACE portal they were required to nominate up to three

reported. Figures were produced using Microsoft Excel.

preferred clinical practice areas. Figure 1 shows the choices

Thomas’ (2006) general inductive approach was utilised

made (n=284). The areas are ranked according to first

to analyse the written or text responses provided by

choice. The first nine areas are almost identical to the

participants. This data analytic method is commonly

rankings published in the Ministry of Health document

used to reduce, sort, organise and make sense of

The recruitment of new graduate nurses in New Zealand

qualitative data “… without the constraints imposed

which used the entire ACE cohort and is 4.5 times larger.

by structured methodologies” (p.238). The written

With regard to the three government priority areas of PHC,

responses were read and key categories formulated in

ARRC and MH, chi-square goodness-of-fit tests123 indicate

relation to the focus of each of the short answer questions.

there were no significant differences in the proportion of respondent’s preferences in this survey to those reported

Results Factors that influence new graduates’ preferences for specialty areas The median age of new graduate respondents was 27

in the Ministry of Health data (Ministry of Health, 2015).

Respondents were invited to comment on what had

to expand on or clarify forced choice responses. Review by senior nursing academics and staff of the

attracted them to their top three choices. Typical words (range 20Chief to 56 years), withthe a mode ofwere 22 years thatfor is mee@ng the aim of the Office of =the Nurse confirmed ques@ons appropriate associated with these choices were positive: enjoy, research. commensurate with a new graduate cohort. Similar to passion, fast paced, high acuity, challenge, variety, Data wider analysis nursing workforce, 95% (n=272) are female. the satisfaction, rewarding, and solid experience. Many cited The data were exported from Survey Monkey into graduates an Excel spreadsheet, and then imported into SPSS Although there were responses from of all the positive version 20 (IBM SPSS Inc, 2014) for analysis. The data were checked for errors following the method clinical placement experiences in these areas. education institutions that provided BN programmes, the described by Pallant (2013), then analysed using fundamental descrip@ve techniques. Most of the

sample was not distributed in proportion to the graduating variables are categorical, but where variables are con@nuous, measures of central tendency are Factors influencing choice of clinical practice area population each institution = 5 to 30). reported. Figures from were produced using Microso] E(range xcel.

Factors that influence new graduates’ preferences for specialty areas

The factors that influence preference for clinical practice Thomas’ (2006) general induc@ve approach was u@lised to analyse the wri^en or text responses provided by par@cipants. This data analy@c method is commonly used to reduce, sort, organise and area are

Choice of clinical practice area

shown in figure 2 and are ranked according

make sense of qualita@ve data “… without the constraints imposed by structured methodologies” (p.

to influence. The need to consolidate nursing skills in When graduates applied position usingin the 238). The new wri^en responses were read and for key caategories formulated rela@on to the focus of each a hospital environment is the most important factor of the short answer ques@ons.

Results The median age of new graduate respondents was 27 (range = 20 to 56 years), with a mode of 22 years that is commensurate with a new graduate cohort. Similar to the wider nursing workforce, 95% (n=272) are female. Although there were responses from graduates of all the educa@on ins@tu@ons that provided BN programmes, the sample was not distributed in propor@on to the gradua@ng popula@on from each ins@tu@on (range = 5 to 30).

Choice of clinical pracRce area When new graduates applied for a posi@on using the ACE portal they were required to nominate up to three preferred clinical prac@ce areas. Figure 1 shows the choices made (n=284). The areas are ranked according to first choice. The first nine areas are almost iden@cal to the rankings published in the Ministry of Health document ‘The recruitment of new graduate nurses in New Zealand’ which used the en@re ACE cohort and is 4.5 @mes larger. With regard to the three government priority areas of PHC, ARRC and MH, chi-­‐square goodness-­‐of-­‐fit tests123 indicate there were no significant differences in the propor@on of respondent’s preferences in this survey to those reported in the Ministry of Health data (Ministry of Health, 2015). c

Figure Choice ofhere] clinical practice area [Insert fi1: gure 1 about

Figure 1: Choice of clinical pracGce area

1

primary care, X2(2, n=271) = .919, p < .63

2

aged care, X2(2, n=271) = 4.25, p < .11

3 mental health X2(2, n=271) = .343, p < .84

c 6

Page 12

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand (58%, n=167), followed by long term career plans and

Advanced nursing practice roles and expectations of

the availability of a NETP or NESP programme. A chi

postgraduate study featured prominently in the short

square analysis shows a highly significant relationship

answer responses:

between the importance of consolidating nursing skills

Currently I am working in an inpatient unit to further

in the hospital and a later question that asked if they

my clinical skills within the mental health sector with

were concerned about losing skills outside the hospital,

a view to possibly transition into community mental

X2(6, n=237) = .52.584, p=.000. These findings indicate

health nursing (with further study prospects), then

there is a perception amongst graduate nurses that they

work towards working as a DAO [Duly authorised

should consolidate their nursing skills in the hospital

officer] in the Psychiatric Assessment Triage Team

environment before embarking on employment outside

(Crisis Team). Hopefully later there will be a position

the hospital. Short answer responses were consistent

within primary/rural health further up the coast

with this finding: “Felt med-surg nursing would be the

for me to work with Māori whanau/hapu and iwi.

best area to work to give me that base knowledge”.

Availability of NETP or NESP programmes

Career plans

A total of 78% (n=223) of respondents identified that the

Choice of clinical area was related to the respondents

availability of NETP and NESP programmes influenced

career plans or trajectory for 78% (n=209) of respondents

their choice of clinical setting. Successfully securing a

who answered this question (n=269). There were many

place on a NETP or NESP programme meant that some

short answer responses about participants’ career

graduates made a conscious decision to work in an

plans, indicating that respondents had carefully

area of practice they were not necessarily interested in.

considered their nursing future. For example, Continue gaining experience within the hospital

I am currently on the NESP programme as I was not

setting, do some post graduate study then maybe

given a position on the NETP. Due to this set back I

branch out into primary health care during which

now no longer know how I can continue along my

I hopefully will have found my niche in nursing.

Factors that influence new graduates’ preferences for specialty areas

o

Figure 2: Factors influencing preference of clinical practice area

Figure 2: Factors influencing preference of clinical pracGce area

Page 13

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand previous career plan as the only experience I have is in

Attractors to government priority areas

mental health which is a field I do not want to work in.

Respondents were asked to identify the things that would have attracted them as new graduates to the government

Those who were not successful in securing a NETP

priority areas of ARRC, MH and Primary Health Care.

placement through the ACE system made contact with other DHBs who still had vacancies, as well as making

Age Related Residential Care:

sure NETP programme coordinators were aware that

A number of respondents said there was nothing that

as a new graduate they were prepared to wait until

would attract them to working in ARRC with comments

a vacant position in a future intake became available.

like “Only if I had to”. Others identified financial rewards

I arranged to meet with the NETP programme

or incentives, for example “… better incentives such

co-ordinator and gave her my CV. I went through

as higher pay or money towards paying of student

an interview as a position became available and I

loans and education opportunities”. Occasional

was offered a NETP position to start in Jan 2013.

references were made related to the level of skill needed to work in the sector: I probably would’ve preferred to work in aged care rather than theatre

Geographical area

because of the clinical skills I could have gained.

Sixty-two percent (n=178) of respondents agreed it was important they stay in the same geographical area after

Other respondents suggested they would be attracted

degree completion. Reasons for wanting to stay are shown

to working in ARRC if more support was provided to

in figure 3. Staying close to friends and family and family

new graduates:

responsibilities such as older parents or having children

More peer support for new grads - at the

at school were ranked as having the ‘most important’ and

moment new grads are often left working in

‘important’ influences, followed by partner’s employment.

charge of night shifts/admin of meds/supervising

Another influence on wanting to stay in the same

unregistered staff with no peer support at

geographical area was because “I know the area

all - making it unsafe for those new to nursing. andFactors the culture of the DHB through placements”. that influence new graduates’ preferences for specialty areas

o

Figure 3: Influences to stay in same geographical area

Figure 3: Influences to stay in same geographical area

Page 14

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Mental Health:

in the acute care environment was important and they

Some respondents identified that there were no

would work in PHC later in their careers. For example,

incentives that would entice them to work in MH. As

“I would consider primary health later after a few years

identified above, several participants said financial

in acute care nursing” and “I was told that it would

incentives would influence them to work there:

help if I had a good clinical foundation [working in the

“ridiculously good pay” and “if I knew I could swap

acute care setting] before going into primary care”.

easily to other areas of nursing without much difficulty”.

The idea of working in MH was not ruled out for some

Others felt there were not enough jobs in PHC:

respondents as identified by comments such as “I enjoyed

I would have liked to work in primary care but just felt

this in training however wanted to have a solid understanding

there were not the jobs available in this area. One of

of medical and surgical nursing at the beginning of my

my classmates who did her last clinical placement in

career and might pursue this area in the future”; and,

primary care still does not have a job. Also this area

“Not ready yet. Don’t have enough life experience”.

has a reputation for potentially being very unsupported especially if you are in a small practice and the other

Primary Health Care:

nurse doesn’t agree with you being there or doesn’t like

As with ARRC and MH, some were not interested at all

you. This could be an issue in an aged care facility too.

in PHC. Other common factors that would entice new graduates to work in the PHC setting included money and

Clinical placement experiences

greater levels of support. For example, “I love primary

Clinical placement experiences in ARRC, PHC and MH were

health but I have a very big student loan and I decided

a strong influence on choice of practice area as a new

it was not paying enough to cover my loan as compared

graduate (figure 4). Short answer responses elaborated

to shift work”; and, “I feel in primary care I need to

on the influence of student placement experiences and

have the confidence of working without much support”.

choice of clinical area. These were loosely categorised as positive and negative responses with examples provided

Consistent with earlier comments about the need to

in table 1.

consolidate nursing skills in the hospital environment, several respondents commented that initially working

Discussion

Factors tthat hat influence influence nnew ew ggraduates’ raduates’ ppreferences references ffor or sspecialty pecialty aareas reas Factors

The purpose of this research was to explore factors that influence new graduate preferences for a particular clinical setting. Consistent with findings in the published research, the need to consolidate nursing skills in a hospital environment was ranked as the ‘most important’ or ‘important influence’ in choosing this setting. Working outside the hospital was perceived to lead to a loss of nursing skills (Leh, 2011; Shen & Xiao, 2012). Technical nursing skills are perceived by graduates to be consolidated

oo

n=254 n=254

Figure 44: : IInfluence nfluence oof f cclinical linical pplacements lacements oon n cchoice hoice oof f cclinical linical aarea rea Figure

Figure 4: Influence of clinical placements on choice of clinical

area

Page 15

in secondary and tertiary level hospitals and this may

account for new graduate nurses preferring employment in surgical and medical areas (Brown et al., 2008; Halcomb

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Factors that influence new graduates’ preferences for specialty areas Table 1: Examples of clinical experiences during the BN that influenced choice of clinical area

Table 1: Examples of clinical experiences during the BN that influenced choice of clinical area POSITIVE COMMENTS

NEGATIVE COMMENTS

“Mental health placement was very good -­‐ it gave me insight into what the work involved -­‐ and from this placement I knew that it wasn't up my alley. Primary Health Care: I specifically asked to have my placement at [name of primary care service] as I knew they had an amazing philosophy and support in place -­‐ this largely influenced my desire to work in an organisa@on that has a philosophy congruent with theirs. Aged care: My placement here was in first year -­‐ I found it wasn't really my type of nursing -­‐ and from working as a Caregiver prior to entering nursing, I was not exactly 'taken' by the RN's role in this area”.

“Mental health was not a placement I enjoyed. I learnt what I needed to be able to know how to work with mental health paGents in a hospital seOng, however, from my placement I knew I wasn't suited to be a mental health nurse so I was not interested in applying for the mental health nursing new graduate programme”.

“Aged care was our first clinical, generally in rest homes. The main focus was consolida@ng pa@ent care principles and the beginning of pa@ent assessment … I had very good experiences in my mental health clinical. I very much considered this as an op@on for my new graduate year but I did not choose it because I and I did not I would like to spend @me in a general aslso e[ng also and want to become specialised in mental health so early did not want to become specialised in mental health in m y career.” so early in my career.”

“I think the style of nursing in mental health was not really my style, I'm more a task orientated person. And my 3rd year placements in Mental health and PHC were not very encouraging, and somewhat lacking for me, so I did not choose this area”.

“It intrigued me regarding mental health although I felt that my level of knowledge and assessment skills would need to increase prior to going into those environments, although I wouldn't rule this out in the future. I felt primary health nurses were very knowledgeable and I felt I couldn't do my pa@ents jus@ce if I went straight into one of these environments. I also feel as a new grad that the support was perhaps not up to standard and the poten@al for becoming isolated probable. I felt I could definitely work in aged care, however felt that lack of support and isola@on were very prominent. And also a lack of variety was another large factor in my choice away from aged care.”

“Experience in in aged showed that Experience aged care care showed that there there w as a

l ow n urse t o p aGent r aGo w ith was a low nurse to paGent raGo with the the majority of care provided by health majority of care provided by health care care assistants. I found this to be negaGve assistants. I found this to be negaGve as a as a of care the provided care provided was a not a lot of lot the was not level level required to provide excellent or even required to provide excellent or even adequate care a majority of the Gme. I will not work in this area unless a major shif in the way these services are provided, meaning a higher nurse to paGent raGo plus higher skilled health care assistants.

Primary health care would need a relevant NETP program to support new entrant nurses as many community faciliGes were not keen to provide or link in with the rogram”.

NETP program.

Page 16

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

c 19

Nursing Praxis in New Zealand et al., 2012). These experiences are thought to provide

was also made about the professional isolation of

a good foundation for future career development.

these areas. Career plans indicated that nurses may want to work in these areas in the future when they

Similar to findings by Leh (2011), a range of influences were

had a broader range of experience and expertise to

identified which varied widely according to the career plans

bring to their practice. There were many positive

of nurses, the availability of a NETP or NESP programme,

views expressed about eventually working in each of

and the influence of clinical experiences offered by the

the government priority areas, particularly in ARRC.

various education institutions. The personal circumstances of individual nurses may override all these factors and

Limitations to this study include a non-probability

the opportunity to work in a preferred area appears to

sample, a response rate of 34% and the potential for

be carefully weighed against the need to stay in the same

non-response bias. Response bias refers to potential

geographical area due to the needs of family, and the often

differences in view and experience between those

urgent need to be in paid employment (Prentice, 2012).

who chose to respond to the survey and those who did not respond (Polit & Beck, 2008). The findings are not

The career plans of new graduates were ranked as

generalisable due to the non-probability sample and the

the second most important influence on choice of

reasonably low response rate. However, the choice of

clinical practice area. Detailed plans were provided

clinical practice areas the findings in this study report

by respondents demonstrating considerable thought

are representative in relation to previously published

had gone into a planned career trajectory that often

Ministry of Health data (Ministry of Health, 2015).

included clear expectations of postgraduate study and advanced practice roles (Ganz & Kahana, 2006; Happell & Gaskin, 2013; McCann et al., 2010). New graduates educated for the profession were disinclined to fill workforce gaps, but desperation for a job drives

Conclusion Clearly evident in the data was the preference to work in an acute hospital environment as opposed to ARRC,

them into areas where they have little interest.

PHC or MH. This is unsurprising as for many years newly

The third most important factor influencing preference

There is a consistent sense of newly registered nurses

for clinical practice area, and a problem that is unique to New Zealand, was the availability of a NETP or NESP programme. The NETP programme is not universally available in primary care or aged related residential care, and NESP has limited placements. Given the importance placed on getting into a structured and supported first year of practice programme, and the encouragement to consolidate nursing skills in a hospital (medical/surgical) setting, new graduates nurse

registered nurses have preferred to work in acute settings. feeling they should consolidate their learning by working in the hospital setting before moving to what they consider to be more challenging and less supportive contexts.

Managing this preference requires a range of strategies if the goal is to have more newly registered nurses working in areas such as PHC and MH. Understanding their preference and working, with some urgency, to improve the strategies in PHC, MH and ARRC to support new graduate nurses seems important. Furthermore, the

chose settings where these programmes were offered.

tertiary education sector needs to be aware of the impact

The three government priority areas of PHC, MH and

have on the choices students make regarding place of

ARRC were recognised by students as complex areas that need good support to work in safely. Comment

Page 17

and influence attitudes expressed by nurse educators employment post registration. Therefore, the findings from this study can inform future workforce planning in relation to clinical area of choice for new graduates.

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Acknowledgement Funding for this research was received from the Ministry of Health.

Jill Wilkinson as author and Nursing Praxis in New Zealand Co-Chief Editor has excluded herself from all review, editorial and publication decisions for the article consistent with journal policy.

References Abbey, J., Abbey, B., Bridges, P., Elder, R., Lemcke, P., Liddle, J., & Thornton, R. (2006). Clinical placements in residential aged care facilities: The impact on nursing students’ perception of aged care and the effect on career plans. Australian Journal of Advanced Nursing, 23(4), 14-19.

Birks, M., Al-Motlaq, M., & Mills, J. (2010). Pre-registration nursing degree students in rural Victoria: Characteristics and career aspirations. Collegian, 17(1), 23-29.

Brown, J., Nolan, M., Davies, S., Nolan, J., & Keady, J. (2008). Transforming students’ views of gerontological nursing: Realising the potential of ‘enriched’ environments of learning and care: A multi-method longitudinal study. International Journal of Nursing Studies, 45(8), 1214-1232. doi: 10.1016/j.ijnurstu.2007.07.002 Ganz, F. D., & Kahana, S. (2006). Perceptions of Israeli student nurses regarding clinical specialties and factors that influence these perceptions. Journal of Advanced Nursing, 56(1), 88-98. doi: 10.1111/j.1365-2648.2006.03983.x Gouthro, T. J. (2009). Recognizing and addressing the stigma associated with mental health nursing: A critical perspective. Issues in Mental Health Nursing, 30(11), 669-676. doi: 10.1080/01612840903040274 Halcomb, E. J., Salamonson, Y., Raymond, D., & Knox, N. (2012). Graduating nursing students’ perceived preparedness for working in critical care areas. Journal of Advanced Nursing, 68(10), 2229-2236. doi: 10.1111/j.1365-2648.2011.05911.x Happell, B. (1999). When I grow up I want to be a…? Where undergraduate student nurses want to work after graduation. Journal of Advanced Nursing, 29(2), 499-505. doi: 10.1046/j.1365-2648.1999.00913.x Happell, B., & Gaskin, C. J. (2013). The attitudes of undergraduate nursing students towards mental health nursing: A systematic review. Journal of Clinical Nursing, 22(1/2), 148-158. doi: 10.1111/jocn.12022 IBM SPSS Inc. (2014). Statistical Package for the Social Sciences (Version 22) [Software]. Retrieved from http://www-01.ibm. com/software/analytics/spss/ Koskinen, S., Hupli, M., Katajisto, J., & Salminen, L. (2012). Graduating Finnish nurse students’ interest in gerontological nursing-a survey study. Nurse Education Today, 32(4), 356-360. doi: 10.1016/j.nedt.2011.05.015 Larsen, R., Reif, L., & Frauendienst, R. (2012). Baccalaureate nursing students’ intention to choose a public health career. Public Health Nursing, 29(5), 424-432. doi: 10.1111/j.1525-1446.2012.01031.x Leh, S. K. (2011). Nursing students’ preconceptions of the community health clinical experience: Implications for nursing education.

Journal of Nursing Education, 50(11), 620-627. doi: 10.3928/01484834-20110729-01 McCann, T. V., Clark, E., & Lu, S. (2010). Bachelor of Nursing students career choices: A three-year longitudinal study. Nurse Education Today, 30(1), 31-36. doi: 10.1016/j.nedt.2009.05.014

Page 18

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Ministry of Health. (2015). The recruitment of new graduate nurses in New Zealand. Retrieved from http://www.health.govt.nz/our work/nursing/developments-nursing/recruitment-new-graduate-registered-nurses Nursing Council of New Zealand. (n.d.). Entering the workforce: Nurse entry to practice programmes. Retrieved from http://www nursingcouncil.org.nz/Education/Registered-nurse Pallant, J. (2013). SPSS survival manual: A step by step guide to data analysis using IBM SPSS (version 20) (5th ed.). Crow’s Nest, NSW: Allen & Unwin.

Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). London: Lippincott Williams & Wilkins.

Prentice, D. (2012). Pursuing a career in gerontological nursing: The influence of educational experiences on new RNs career choice.

Perspectives: The Journal of the Gerontological Nursing Association, 35(2), 5-11.

Roth, J. E., & Coleman, C. L. (2008). Perceived and real barriers for men entering nursing: Implications for gender diversity. Journal of Cultural Diversity, 15(3), 148-152.

Shen, J., & Xiao, L. D. (2012). Factors affecting nursing students’ intention to work with older people in China. Nurse Education Today, 32(3), 219-223. doi: 10.1016/j.nedt.2011.03.016 Stevens, J. A. (2011). Student nurses’ career preferences for working with older people: A replicated longitudinal survey. International Journal of Nursing Studies, 48(8), 944-951. doi: 10.1016/j.ijnurstu.2011.01.004 Stevens, J. A., & Crouch, M. (1998). Frankenstein’s nurse! What are schools of nursing creating? Collegian, 5(1), 10-15. doi: 10.1016 S1322-7696(08)60265-6 Stevens, J. A., & Dulhunty, G. M. (1997). A career with mentally ill people: An unlikely destination for graduates of pre-registration nursing programs. Australian Electronic Journal of Nursing Education, 13(1), Retrieved from: http://www.scu.edu.au/schools/ nhcp/aejne/archive/vol3-1/acareer.htm.

Te Pou. (2015). New entry to specialist practice: Mental health and addiction nursing. Retrieved from http://www.tepou.co.nz initiatives/new-entry-to-specialist-practice-mental-health-and-addiction-nursing/47 Thomas, D. (2006). A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation, 27, 237 246. doi: 10.1177/1098214005283748

Page 19

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand ORAL HEALTH EXPERIENCES OF MĀORI WITH DEMENTIA AND WHĀNAU PERSPECTIVES - ORANGA WAHA MŌ NGĀ IWI KATOA Jean Gilmour, RN, PhD, Associate Professor, School of Nursing, Massey University, Wellington, NZ Annette Huntington, RN, PhD, Professor, School of Nursing, Massey University, Wellington, NZ Bridget Robson, BA, DPH, Director Te Rōpū Rangahau Hauora a Eru Pōmare, University of Otago, Wellington, NZ

Abstract This paper reports a study of the oral health experiences and needs of Māori with dementia and their whānau. Age-related change is associated with oral health issues such as gum recession, risk of caries and issues with previous dental work. A diagnosis of dementia is an added factor due to care provision difficulties. A descriptive qualitative research design was used to develop an in-depth understanding of oral health issues from the perspective of the people being interviewed.

Seventeen whānau members were interviewed and the data analysed thematically. Four themes were identified; a whānau concern reflecting childhood and whānau oral health experiences and care; oral health issues which identified current concerns and difficulties; enabling oral health care covering participants’ strategies to manage oral health in the context of dementia, and finally improving future prospects where whānau made suggestions to improve oral health services. The impact of dementia on oral health is compounded by barriers to dental care because of ability to cope with dental visits, the high cost of dental services, and competing demands influencing caregiver priorities. Suggested service improvements include provision of oral health information for whānau, affordable community based services able to address the oral health requirements of people with dementia, and service provider education about dementia. Nurses in a variety of health care contexts can contribute to the direct provision of skilled routine oral health care, oral health education for whānau members and support staff, and education of health professionals about appropriate care for people with dementia.

Keywords Māori; whānau / family; dementia; nursing; oral health

Introduction Good oral health enables full interaction with the social

caused by illnesses such as Alzheimer’s disease, vascular

and material world; to have good kai, to speak clearly,

dementia and Lewy body dementia (Prince, Albanese,

to hongi, kiss, smile and laugh, without discomfort or

Guerchet, & Prina, 2014). The purpose of this study

embarrassment. It is also to be free from active disease

was to explore the oral health experiences of Māori

in the mouth that affects overall health and wellbeing

with dementia and their whānau. In 2008 there was

(Robson et al., 2011, p.9). Dementia is associated with

estimated to be at least 1483 Māori with dementia

poor oral health status (Chalmers, Carter, & Spencer,

in New Zealand, 3.6% of a total population of 40,746

2003; Philip, Rogers, Kruger, & Tennant, 2012; Rejnefelt,

New Zealanders with dementia (Access Economics,

Andersson, & Renvert, 2006). The term dementia encompasses symptoms such as progressive memory loss, disorientation and problems with cognitive functioning Page 20

Gilmour, J., Huntington, A., & Robson, B. (2016). Oral health experiences of Māori with dementia and whānau perspectives - oranga waha mō ngā iwi katoa. Nursing Praxis in New Zealand, 32(1), 20-27.

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand 2008). These numbers are predicted to increase to

Specific oral health issues centre on the gradual loss

4,338 or 5.8% of the total population with dementia

of ability to carry out oral self-care, communicate

in 2026. There appears to be no research published

symptoms such as pain, and to consent to and tolerate

focusing on Māori with dementia and oral health.

dental treatments (Ettinger, 2000). Medications for managing behaviour, depression and other conditions

This research was carried out as a partnership between

contribute to hyposalivation or xerostomia which

Te Rōpū Rangahau Hauora a Eru Pōmare and Alzheimers

increases plaque accumulation and dental caries

New Zealand with an overall goal of raising awareness of

growth (Friedlander, Norman, Mahler, Norman, &

oral health issues for Māori with dementia. It was part of a

Yagiela, 2006; Lam, Kiyak, Gossett, & McCormick,

larger study funded by the Health Research Council of New

2009). Sugar based medication may also increase

Zealand and the Ministry of Health. The study was tasked

the potential for tooth decay (Dougall & Fiske, 2008).

with the identification of oral health research priorities for three specific groups: low income Māori adults; older

Contemporary approaches to caring for people with

Māori adults; and Māori with special needs, disabilities, or

dementia provide guidance on enabling oral health

who are medically compromised. The full study is reported

care with the focus on respectful relationships with the

in Robson et al. (2011). This paper reports in detail the

person and whānau. The term person-centred care is

findings from the project on oral health experiences

used to highlight the need to acknowledge and respect

and needs of Māori with dementia and their whānau.

personhood and relationships (Frenkel 2004; Kitwood 1997), and the family/whānau-centred care concept

Background

highlights the role of whānau in supporting people with

Research in a range of settings identified people with

dementia (New Zealand Council of Christian Social Services,

dementia as having poorer oral health status than

2009). Supporting oral health for people with dementia

those without dementia. In residential care people with

is an intimate activity requiring sensitivity, good timing

dementia have a higher incidence of caries, reduced saliva

and a manner that is respectful of the person’s identity

flow and poorer oral hygiene (Rejnefelt, Andersson, &

and enhances opportunities for choice and autonomy.

Renvert, 2006; Philip et al., 2012; Willumsen, Karlsen, Næss, & Bjørntvedt, 2012). An American study of

Family education about oral care includes: regular oral

21 nursing home residents found significant under-

care as part of the daily routine, providing explanations

detection and under-treatment of pain and dental

through the process, providing the care in small steps,

problems in people with dementia (Cohen-Mansfield &

having visible cues in the bathroom such as a list of

Lipson, 2002). In community settings an Australian study

steps and labelled equipment, and oral care reminders

found dentate people with dementia, as compared to a

(Henry & Smith 2004). The best practice guidelines

similar group without dementia, had significantly more

for supporting the oral health needs of people with

oral diseases, decreased denture use over one year,

dementia in residential care promote regular dental

increased denture related ulcers, increased plaque and

and nursing assessment, provision of oral health

increased caries (Chalmers, Carter, & Spencer, 2003).

care, and caregiver education; guidelines which are

The need for assistance with teeth cleaning increased

also applicable at home (Pearson & Chalmers 2004).

from the baseline 24% to 58.2% at one year. People with dementia were significantly less likely to see the dentist.

Page 21

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Method

provided reflective commentary on the interview process.

The aim of this research was to explore the oral health

Five interviews were carried out with people with

experiences of both Māori with dementia and their

dementia and whānau, the other interviews were with

whānau. A qualitative research design was used in

whānau members only. There were 13 interviews in total.

order to describe and interpret everyday experiences

Data analysis was by a thematic analysis approach.

within the context of the meaning of these phenomena

Initially immersion in the data is required by reading and

conveyed by the research participants. A descriptive

re-reading the interview transcripts and notes, followed

approach was used to allow the interview information to

by identification of key statements, the development

be presented in every day language so as to stay close to

of codes to encompass the statements, and finally

the words of the people interviewed (Sandelowski, 2000).

development of themes (Braun & Clarke, 2006). The analysis was shaped by the topics covered in the semi-

The research participants were five people with dementia

structured interviews with the exception of the first

and twelve whānau members receiving services from

theme - a whānau concern - as participants reflected on

two Alzheimers organisations providing services in

their oral health within their family and life experiences.

provincial regions. Two community workers advertised the study and conducted the interviews. The inclusion

The coding and thematic development was carried out by

criterion for participants was identification as Māori.

two of the authors in order to validate the interpretations

People with dementia needed the ability to consent,

of the data. Verbatim quotes are presented in the

to verbally communicate their experience and to

findings to support the analysis and the credibility of the

indicate that they understood the purpose of the study.

researchers’ interpretation. The credibility of the findings

The criterion for inclusion of whānau members was

is strengthened with the congruency evident between this

involvement in caring for a Māori whānau member

study in relation to the financial and availability barriers

with a diagnosis of dementia. Participants received

to dental care and the findings of the larger study of low

information about the study and consented to be

income Māori adults; older Māori adults; and Māori

interviewed. They received a koha to acknowledge

with special needs/disabilities (Robson et al., 2011).

their contribution along with oral health information developed for the study and oral care supplies. The use

Results

of pseudonyms and removal of identifying information

Four themes emerged from the research data: a whānau

commenced from the outset of data collection. The study

concern; oral health issues; enabling oral health care;

was approved by the Multi-region Ethics Committee.

and improving prospects for a better future. These themes reflect the influence of the history of the person

The data collection method was semi-structured interviews

with dementia and their whānau, the current reality

which allowed interviewers to respond to issues raised by

for the person with dementia, and what the whānau

the participants. Interviews were either digitally recorded

feel would be helpful and would like in the future.

and transcribed or recorded in written form. The interview questions were in sections focused on (i) the experience

A whānau concern:

of oral health problems, (ii) access to oral health services,

“Oral health is very important to my whanau”

(iii) everyday practices aimed at maintaining and improving

Some whānau members situated their discussion about

oral health, and (iv) participants’ ideas about dental

oral health within a family and personal history context

care service improvements. The community workers

as a daughter explained:

Page 22

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Oral health is very important to my whānau because

(interviewed or being cared for) did not have their own

if you have a good set of teeth, whether it’s your own

teeth or dentures. The cost of dental care was considered

teeth or whether it is a set of dentures, the physical

prohibitive, an issue raised by people with dementia and

appearance can be aesthetically pleasing. (10 [number

by whānau members. As one person with dementia stated:

of interview])

The biggest problem is especially for families and … not only for Māori but even Pākehā, it doesn’t matter, it’s

Oral health care was talked about as practices that were

getting well out of hand, so out of hand that the people

passed down through generations, a collective as well

can’t afford to go to the dentist to get their teeth done. (2)

as individual concern. Having a positive attitude to oral hygiene within the whānau was the experience of a

There were various issues in relation to denture

number of participants and reflected in comments such

management. Visiting the dentist could be difficult

as, it is very important to the whānau … good habits,

as a daughter explained, giving her reasons for

have always done it, right from grandparents down

not being able to get dentures for her mother

… you learn from the parents and the school dentists

who was in poor health and with no transport:

(11/Wife). A number of the participants in the study had recollections of dental care provided when they were young, mainly from the school dental services.

No, would have been years ago when we were going to go and take her to the dentist to get her some teeth but because she is so fragile, well, we just

We couldn’t afford it but we did have that once

didn’t want to do anything to get her some teeth

a year check, they came through and that ’s

really.... that would have been a big ordeal for her. (4)

when they did our teeth when the dentist came … a trained dentist … I think they came from the

Travel distances in some instances were long, one family

health department. (3/Person with dementia)

travelled over 100 kilometres to a dental technician and then endured a long wait with some stressful behaviours

Missing teeth were a continual reminder of the

needing to be managed. There are now issues with loose

importance of oral care over a life time, I think well

dentures but the family felt the person with dementia could

my teeth didn’t last me my natural life. Every time

no longer cope with treatment. Not having teeth was not

I smile I’ve got a big hole in my face (2/Person with

always seen as negative, one person with dementia stated

dementia). Participants commented positively on younger generations’ commitment to oral health; I know a lot of Māori families you know that they make the children go to the dentist, even if they’re frightened of the dentist they make them go (2/Person with dementia).

Oral health issues: “ That would have been a big ordeal for her ” A notable finding was the lack of professional dental care with one person going to the dentist occasionally, one when it was an emergency and teeth needed to be pulled out and the rest did not have a dentist and had not had a check for many years. Many of the people with dementia

Page 23

well what do I want to go to a dentist for … I can eat as well as I am with my gums but the diet was limited. Oh well some food I don’t like, I don’t like boiled up meat...fish fingers, I like that and again I have potatoes, when she bakes (6).

In instances where the person with dementia had usable dentures there were some problems managing their use and care. One daughter explained her mother had false teeth but at the moment she doesn’t use them because she’ll spit them out and I’ll have to find them (1). Another daughter talked about problems caused by bottom dentures because of her teeth just Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand rubbing up against her gums because of food being

more community based dental services outside of main

underneath her dentures not being cleaned (5). When

centres. The cost of services was another barrier and

the person with dementia could technically still clean

there were suggestions that dental services should

their teeth there were also concerns about the impact

be subsidised or free. A carer made the point that if

of memory loss; he has the memory of thinking he has

you’ve got to choose between getting your teeth done

but in actual fact he hasn’t ...you can actually smell his

and putting food on the table you’re definitely going

breath and yes it hasn’t been cared for (10/Daughter).

to go for food on the table aren’t you (2/Wife). There were also comments that dentists should be available

Enabling oral care: “I found a way around it”

on the same cost basis as a general practitioner, we

Some people with dementia had established oral care

should have a dentist...I suppose working like doctors...

routines that worked for them. The key strategy discussed

readily available like a doctor (3/Person with dementia).

was having the tooth brush and tooth paste in view in the bathroom as a reminder; I found out if you do it like

Reducing the stress associated with dental care for

a habit ...you do it straight away…or else you forget it,

the person with dementia was another important

well it’s too late, you are walking down the street. Well

area. Sug gestions included arranging timely

you can use an apple anyway (12/Person with dementia).

appointments in the morning before the person

Whānau also had developed oral care techniques:

became tired, keeping waiting times short, and

Now with mum having dementia was quite hard to

having appropriately educated practitioners.

ask her for her dentures, like it’s hard to get them out

There is other things that could be sort of, could

of her mouth, but once I got them out of her mouth

cause stress for those that may have dementia and

it was a bit of a job trying to get them back into her

have to wait, wait in a reception room you know to

mouth. But I found a way around it...I said to mum

get that service, to get dental care., Maybe another

got a lolly for you so yes it worked. (3/Daughter)

suggestion is for specialists to gain training in those elderly people who may have dementia. (10/Daughter)

Dentures were also mentioned as making oral care more straightforward as they could be cleaned easily.

The need for health professionals to be knowledgeable

The differences in ability to manage oral hygiene

about dementia was promoted by a number of caregiver

may well reflect the overall cognitive abilities of

participants. As one caregiver stated, you can’t just say

the person with dementia; however, it appears that

oh we’ll get a specialist in, try and find someone who

routines can assist the person and their caregivers to

does it and who is willing to help them [people with

manage teeth cleaning and denture management.

dementia], to do things like that for them (1/Daughter).

Improving future prospects:

Education and information about oral health was also

“Information would be useful”

mentioned as a strategy useful to whānau/families, I

Most study participants were clear that overall oral health

think probably information would be useful, providing

is important but that there were barriers to dental care,

information about the care and, oh well dental care,

also the accessibility, obtaining denture care or oral

dental health care, that would be useful (10/daughter).

care is not necessarily accessible (10/Daughter). The

Training for caregivers was also seen as important

participants lived in rural areas with limited access to

by the wife caring for her husband with dementia,

a range of services and identified the need to develop

her involvement in this research prompting

Page 24

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand her to talk to his caregiver about his oral care.

I’m going to have a talk to her about whether she is actually going to look after his oral hygiene or whether I’m going to have to do that. But I think because she is a lovely lady she will do it for me. (11/Wife)

Discussion The whānau members interviewed for this project appreciated the importance of having a healthy mouth, and many had developed useful strategies to care for their own oral health or that of their family member. But no-one could deny the challenges involved in daily oral health care and support was scarce in obtaining safe, accessible and affordable care for a loved one with dementia.

Despite the evidence for the poorer oral health status of people with dementia, the whānau interviewed for this study had not been alerted to the oral health needs of people with dementia nor received education and support in this area from primary health providers.

A concurrent survey of Alzheimers community staff supported these findings with the majority of staff reporting that they did not provide oral health information to whānau (Robson et al., 2011). Reasons for not providing education included a lack of oral health information resources and the need for oral health education of staff.

The literature stresses the need for forward planning for oral health care in the context of a progressive cognitive disability such as dementia. Oral health treatment plans can be developed (Ettinger, 2000), and including a dentist in multidisciplinary care planning is suggested to preempt the need for crisis management (Dougall & Fiske, 2008). Education around oral health maintenance such as the availability of saliva substitutes and stimulants if necessary, topical fluoride, good oral hygiene and regular dental visits are also important to avoid excess disability from dental complications (Ghezzi & Ship, 2000; Little, 2005). Consequently, an information sheet has been developed as an outcome of this study as a resource

Page 25

for whanāu and health professionals by the research team and published as a bilingual resource through Alzheimers New Zealand (http://www.alzheimers. org.nz/about-dementia/booklets-and-fact-sheets) along with a background evidence fact sheet for staff.

Along with whānau and staff education about oral health support, this study also highlights the need for nurses and other health professionals to receive education about dementia so as to provide a safe and accessible service for people with dementia. It is important to be flexible and adapt treatment approaches according to the needs of the person. General guidelines include making sure noise and activity is kept to a minimum, that communication is clear and simple, and that there is a continuity of health professionals (Little, 2005; Friedlander et al., 2006; Sacco & Frost, 2006).

Participants suggested that dental care should be accessed in a similar way as primary health care services. Only some people with dementia will choose to be involved with their local Alzheimers Society or have regular dental treatment but all will have contact with a primary care provider. Integrating oral health services with primary care services would ensure broader coverage for high risk people with disabilities such as dementia who are not currently accessing dental services. The Māori health provider model of integrated primary health and dental services as demonstrated by Ora Toa Health Services (www.oratoa.co.nz) or the Tipu Ora Charitable Trust (www.tipuora.org.nz) provides a best practice model that could usefully be adopted by other providers.

Some participants in this study argued for subsidised or free dental care for elderly people, a finding in common with an English study of older people from a socially deprived area, where publicly available dental care was seen as a right of citizenship and the privatisation of dental care as age related discrimination (Borreani, Jones, Scambler, & Gallagher, 2010). Integrated and subsidised dental coverage would also work towards addressing oral health inequities. Māori participants Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand in our study found the cost of dental visit care an

in maintaining a healthy mouth, and difficulties obtaining

insurmountable barrier to oral health care. This finding

dental treatment and denture repairs, especially when

was echoed in the overall study of low income Māori

whānau resources are stretched. Access to excellent

adults; older Māori adults; and Māori with special needs

dental care earlier in life improves the chances of having

where consistently participants (148 interviewed in

a healthy mouth in later years. With a rapidly growing

focus groups; 126 surveyed) noted financial cost as a

older Māori population, it is time to focus on increasing

critical barrier to dental care access (Robson et al., 2011).

the availability of accessible, affordable, and culturally acceptable dental care for Māori with dementia, and

The small number of participants is a limitation of this

indeed for all older Māori. Special measures are required

study along with the recruitment locations. Many of the

to ensure the progressive realisation of the right to good

participants lived in rural settings and the issues around

oral health for all, for life - oranga waha mō ngā iwi katoa.

access to dental treatment may be different in urban centres. Additionally, while the challenges presented by the

Acknowledgements

symptoms of dementia to good oral health may be generic,

We thank the people interviewed for making this research

the support and education available may vary widely

possible, Valerie Broadbent and Paea Paki for their support

across regions and population groups. More research

with data collection and Alzheimers New Zealand as our

is required to underpin effective interventions aimed

research partners. We acknowledge Te Kete Hauora,

at improving the oral health of people with dementia.

Ministry of Health, and the Health Research Council for funding the research, and the researchers and partner

Conclusion

organisations involved in the wider Oranga Waha project.

Good oral health supports nutrition, speech, general physical health, emotional wellbeing, dignity, and freedom

Jean Gilmour as author and Nursing Praxis in New

from dental pain (New Zealand Dental Association,

Zealand Co-Chief Editor has excluded herself from all

2010). People with dementia face particular challenges

review, editorial and publication decisions for the article consistent with journal policy.

References Access Economics. (2008). Dementia economic impact report 2008: Report for Alzheimers New Zealand.

Canberra,Australia: Alzheimers New Zealand.

Borreani, E., Jones, K., Scambler, S., & Gallagher, J.E. (2010). Informing the debate on oral health care for older people: A qualitative study of older people’s views on oral health and oral health care. Gerodontology, 27(1),11-8. doi:10.1111/j.17412358.2009.00274.x.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. doi:10.1191/1478088706qp063oa Chalmers, J.M., Carter, K.D., & Spencer, A.J. (2003). Oral diseases and conditions in community-living older adults with and without dementia. Special Care in Dentistry, 23(1), 7-17. doi:10.1111/j.1754-4505.2003.tb00283.x Cohen-Mansfield. J., & Lipson, S. (2002). The underdetection of pain of dental etiology in persons with dementia. American Journal of Alzheimer’s Disease and Other Dementias, 17(4), 249-53. doi: 10.1177/153331750201700404 Dougall. A., & Fiske, J. (2008). Access to special care dentistry, part 9: Special care dentistry services for older people. British Dental Journal, 205, 421-34. doi:10.1038/sj.bdj.2008.891.

Ettinger, R.L. (2000). Dental management of patients with Alzheimer’s disease and other dementias. Gerodontology, 17(1), 8-16. doi:10.1111/j.1741-2358.2000.00008.x Page 26

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Frenkel, H. (2004). Alzheimer’s disease and oral care. Dental Update, 31(5), 273-4, 276-8. doi: 10.1177/153331750201700404 Friedlander, A.H., Norman, D.C., Mahler, M.E., Norman, K.M., & Yagiela, J.A. (2006). Alzheimer’s disease: Psychopathology, medical management and dental implications. Journal of American Dental Association, 137(9), 1240-51. doi: 10.14219/jada. archive.2006.0381 Ghezzi, E.M., & Ship, J.A. (2000). Dementia and oral health. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics, 89(1), 2-5. doi:10.1016/S1079-2104(00)80003-7 Henry, R., & Smith, B. (2004). Treating the Alzheimer’s patient: A guide for dental professionals. Journal of the Michigan Dental Association, 86(10), 32-36, 38-40.

Kitwood, T. (1997). Dementia reconsidered: The person comes first. Buckingham, England: Open University Press.

Lam, A., Kiyak, A., Gossett, A.M., & McCormick, L. (2009). Assessment of the use of xerogenic medications for chronic medical and dental conditions among adult day health participants. The Consultant Pharmacist, 24(10), 755-64. doi: 10.4140/ TCP.n.2009.755 Little, J.W. (2005). Dental management of patients with Alzheimer’s disease. General Dentistry, 53(4), 289-96.

New Zealand Council of Christian Social Services. (2009). Working together we can respond to dementia. Wellington, New Zealand: New Zealand Council of Christian Social Services. Retrieved from http://www.nzccss.org.nz/uploads/publications/ NZCCSSdementiareportFINAL29Sep09.pdf New Zealand Dental Association. (2010). Healthy mouth, healthy ageing: Oral health guide for caregivers of older people. Auckland, New Zealand: New Zealand Dental Association. Retrieved from http://www.healthysmiles.org.nz/assets/pdf/ HealthyMouth,HealthyAgeing.pdf Pearson, A., & Chalmers, J. (2004). Oral hygiene care for adults with dementia in residential aged care facilities. Joanna Briggs Institute Reports, 2, 65-113. doi:10.1111/j.1479-6988.2004.00009.x Philip, P., Rogers, C., Kruger, E., & Tennant, M. (2012). Oral hygiene care status of elderly with dementia and in residential aged care facilities. Gerodontology, 29(2), 306-311. doi:10.1111/j.1741-2358.2011.00472.

Prince, M., Albanese, E., Guerchet, M., & Prina, M. (2014). World Alzheimer report 2014. Dementia and risk reduction. An analysis of protective and modifiable factors. London, England: Alzheimer’s Disease International. Retrieved from http://www.alz. co.uk/research/world-report-2014 Rejnefelt, I., Andersson, P., & Renvert, S. (2006). Oral health status in individuals with dementia living in special facilities.

International Journal of Dental Hygiene, 4(2), 67-71. doi : 10.1111/j.1601-5037.2006.00157.x Robson, B., Koopu, P., Gilmour, J., Rameka, R., Stuart, K., Simmonds, S., Purdie, G., Davies, C., & Paine, S-J. (2011). Oranga Waha Oral health research priorities for Māori: Low income adults, kaumātua, and Māori with disabilities, special needs, or chronic health conditions. Wellington, New Zealand: Te Rōpū Rangahau Hauora a Eru Pōmare. Retrieved from http://www.otago. ac.nz/wellington/otago019612.pdf Sacco, D., & Frost, D.E. (2006). Dental management of patients with stroke or Alzheimer’s disease. Dental Clinics of North America, 50(4), 625-33. doi: 10.1016/j.cden.2006.08.001 Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing and Health, 23(4), 334-40. doi: 10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G Willumsen, T., Karlsen, L., Næss, R., & Bjørntvedt, S. (2012). Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Gerodontology, 29 (2), 1741-2358. doi: 0.1111/j.1741-2358.2011.00554.x

Page 27

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand A ‘TOOLKIT’ FOR CLINICAL EDUCATORS TO FOSTER LEARNERS’ CLINICAL REASONING AND SKILLS ACQUISITION Catherine Cook, RN, PhD, Senior Lecturer, School of Nursing, Massey University, Auckland, NZ

Abstract Teaching clinical skills continues to be a mainstay in assisting novice practitioners towards competence and expertise, whether at a patient’s bedside or in simulated settings. Despite this vital role, those tasked with these responsibilities such as nurse educators, preceptors or clinical teaching associates, draw primarily from their own tacit knowledge of how to pass on their practice wisdom about skills mastery. There is often scant educational preparation for nurses involved in clinical teaching. Therefore learners’ skills acquisition may be ad hoc, rather than an efficient process designed to develop novice nurses. The ‘intuitive’ teaching of clinical skills risks learners gaining technical competence but not being able to articulate a critical analysis of whether and why a technique is best practice, nor how they ensured holistic care throughout a procedure. Clinical reasoning may lag far behind technical know-how.

Although Patricia Benner identified that novices learn best by following rules and frameworks, little subsequent research about the novice to expert continuum has been applied to the development of novice educators. This article is a synthesis of three teaching and learning models: the Model of Practical Skill Performance; the 4A Model; and Five Minute Preceptor; and three specific skills: ‘think aloud’; questioning; and feedback. These models and skills bring together a readily accessible ‘toolkit’ of micro-skills teaching to assist educators in planning learners’ skills acquisition, maximising efficiency and satisfaction for educators and learners. The toolkit also provides educators with ‘scaffolding’ frameworks to support their own progress towards becoming expert educators.

Key words Novice to expert; clinical teaching; teaching models; clinical reasoning

Introduction Teaching clinical skills, whether at a patient’s bedside

from their own tacit knowledge of how to transmit their

or in simulated settings, continues to be a mainstay of

practice wisdom about skills mastery (Kinchin, Cabot,

assisting novice practitioners towards competence and

& Hay, 2009). The ‘intuitive’ teaching of clinical skills

expertise. Quality preceptorship is vital for the retention

reflects the persistence of a traditional apprenticeship

of new graduates and preceptors’ satisfaction (Broadbent,

model, whereby learners develop technical competence

Moxham, Sander, Walker, & Dwyer, 2014; Haggerty,

but might not be able to articulate a critical analysis of

Holloway, & Wilson, 2013; Smedley, Morey, & Race,

whether and why a technique is best practice. Clinical

2010). The shift of nursing education from hospitals to

reasoning may lag far behind technical know-how.

tertiary settings emphasises theory informing practice (praxis). However, there has not been a matched rigour to

The focus of this article is the micro-skills of clinical

ensure that clinical educators engage in sound educational

teaching, to make tacit knowledge accessible. There is

practices when teaching ‘hands on’ clinical skills. Instead, those undertaking clinical roles such as nurse educators, preceptors or clinical teaching associates, draw primarily Page 28

Cook, C. (2016). A ‘toolkit’ for clinical educators to foster learners’ clinical reasoning and skills acquisition. Nursing Praxis in New Zealand, 32(1), 28-37.

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand scant literature that brings together these micro-skills

practical know-how is for the most part acquired tacitly.

in a way that is readily accessible to nurse educators.

What follows is a synthesis of three models and three

In a recent study, Benner, Sutphen, Leonard, and Day’s

specific skills, underpinned by theory. Together, these

(2010) overview of clinical teaching addresses contextual

provide a ‘toolkit’ of teaching approaches, enabling

factors related to learning skills, rather than explicitly

those providing clinical education to plan learners’

concentrating on stages or frameworks for the acquisition

skills acquisition, maximising efficiency and satisfaction

process per se. Benner et al. identify that professional

on the part of the educator and the learner. Effective

practice excellence develops out of a synthesis of three

clinical teaching is, of course, also shaped by ‘bigger

‘apprenticeships’; intellectual, practical and ethical. These

picture’ contexts, such as collaboration between

apprenticeships draw attention to the importance of

clinical institutions and tertiary providers to ensure

the following components: pre-reflection in preparation

undergraduate nursing students have optimal learning

for clinical experiences; the importance of educators’

experiences (see for example Bourgeois, Drayton, &

use of questioning; educators’ elicitation of clinical

Brown, 2011; Edgecombe & Bowden, 2009). Other

reasoning; coaching students’ priority setting skills;

important institutional components shape educators’

and creating learning situations whereby students

role development. These include an organisational

undertake clinical ‘detective work’, in order to answer

commitment to professional development, mentoring and

puzzling questions. Simmons (2010, p. 1155) defines

adequate staffing. Gaberson, Oermann and Shellenbarger

clinical reasoning as “a complex cognitive process

(2015) and Rose and Best (2005) usefully provide in-

that uses formal and informal thinking strategies to

depth analyses of the foundations of clinical teaching.

gather and analyse patient information, evaluate the significance of this information and weigh alternative

Background

actions.” Clinical reasoning entails thinking (cognition) and

The classic work of Patricia Benner, From novice to expert

reflecting (metacognition), as well as discipline-specific

(1984), drew from the work of Dreyfus and Dreyfus

knowledge. Benner et al.’s notion of three apprenticeships

(1986) in explaining the progression of novice nurses

provides a useful ‘umbrella’ for focusing clinical teaching.

to becoming expert practitioners. Benner emphasised the importance of novices learning alongside experts.

The argument proposed in this article is that

Despite the considerable influence of her research,

expert nurses who are novice teachers have some

which shapes the Nursing Council of New Zealand

characteristics of Benner’s description of novice

Competencies for Registered Nurses (2012), her early

nurses; therefore novice educators also benefit from

work pays limited attention to the details of how experts

being taught general ‘rules’ to guide planning and

transmit knowledge of clinical skills and enable learners to

performance (Benner, 1984; Grassley & Lambe, 2015).

blend holistically psychomotor skills, human interactions

Benner (1984) identified that novices learn best by

and adaptation to the instability of patients’ needs and

following rules and frameworks, but little subsequent

wishes. Significantly, Benner proposed that expert nurses’

research has focused on novice clinical educators’

work is fluid and becomes ordinary to these practitioners

development. One of the exceptions is a study by Cangelosi,

to the extent that they are not consciously aware of what

Crocker, and Sorrell (2009), which highlights that expert

makes up their craft. Field (2004) provides a valuable

clinical nurses may experience confusion and distress when

critique of Benner’s work. She contends that greater

they take on a clinical educative role without educational

efficiency in the shift from novice to expert is facilitated by

preparation. Manning and Neville’s (2009) study also

educational support of mentors, rather than accepting that

indicates that without formal preparation and structure,

Page 29

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand the transition of senior nurses to clinical educational roles

acquisition. When learners have the opportunity to

is fraught with avoidable levels of stress and uncertainty.

reflect on experiences with an educator, assumptions and thought patterns become accessible, providing another

Although Benner et al. (2010) do not provide an in-depth

avenue for scaffolding learning (Benner et al., 2010). Skills

analysis of how to teach psychomotor clinical skills, they

acquisition involves cognition, psychomotor skills and

advocate for constructivist, learner-centred approaches.

affect; additionally a supportive learning environment for

They draw attention to the limitations of behaviourist

adult learners optimally nurtures a climate in which nurses

learning. The latter approach was the basis of the

will develop intrinsic motivation to learn (Huckabay, 2009).

traditional apprenticeship model of nursing training, whereby education focused on students uncritically

Model of Practical Skill Performance

learning to undertake tasks, not on fostering their ability

Although there is substantial literature on how to assess

to apply clinical reasoning. Benner et al.’s argument,

nurses’ clinical skills there is limited research about

supported by Handwerker (2012), is that behaviourist

how best to systematically teach these same skills. One

approaches that include mastery of considerable content

Scandinavian tool, the Model of Practical Skill Performance

have dominated nursing education, and in the process

(MPSP) (Bjørk & Kirkevold, 2000; Nielsen, Sommer, Larsen,

educators have sacrificed the development of rich

& Bjørk, 2013; Reierson, Hvidsten, Wighus, Brungot,

learning experiences for decontextualized, content

& Bjørk, 2013), provides a research-based in-depth

heavy programmes focused on outcome measurements.

framework to enable educators and learners to identify the discrete components of skills acquisition that require

By contrast, constructivist approaches address the

mastery for clinical competence. The model identifies

ways people make sense of what they learn, shaped

the developmental component of skills acquisition, and

by previous experiences. A constructivist concept, the

the situated learning aspect; that technical and manual

‘zone of proximal development’ (ZPD), developed by the

skills need to be adapted uniquely to the contexts

Russian psychologist, Lev Vygotsky (1978), continues

of patients, undertaken in ways that convey caring.

to be a useful construct, pertinent to nurse educators.

The ZPD is the zone in which guided learning takes

The MPSP is depicted as five concentric circles. According

place, enabling the learner to extend from current

to Bjørk and Kirkevold’s (2000) model, central to learning

limited independent ability to that which is achievable

is comprehension of the substance of the task at hand;

with collaboration and expert guidance. The concept

content knowledge is necessary to underpin clinical

of scaffolding is a later refinement of Vygotsky’s ZPD,

skills. Substance and sequence, and accuracy are the

and refers to the guide or teacher skilfully withdrawing

next levels of practice focus; developing a logical order

incremental levels of assistance as the learner gains

to the activity and maintaining precision for safety and

independence. The educator’s ability to assess this process

efficiency. Fluency will only develop with practice and

of fading support allows for the learner’s maturation and

integration also comes with repetition. Integration

self-reliance (Kneebone, Scott, Darzi, & Horrocks, 2004).

occurs when the learner becomes holistically attentive to the patient as well as focusing on the specific task

Many learners will know the frustrations of micro-

at hand. Educators strive to enable learners to infuse

management where this assessment of ZPD has not taken

all levels of skill acquisition with caring comportment.

place and learners are excessively supervised (Beckman & Lee, 2009). Reflective practice, also a constructivist

The MPSP is most useful when the model is used explicitly

approach, is an important component of clinical skill

by educators and learners. Reierson et al. (2013) describe

Page 30

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand how an action research process with nurse educators

Anchoring practices include questions such as, “Have

was undertaken as part of educators adopting the MPSP

you undertaken this procedure before?” “Tell me what

to ensure curriculum consistency and transparency in

you already know about…” “What went well and what

clinical teaching and learning processes. Both students

was challenging last time you…?” Answers provide the

and educators reported that using the model provided

educator with additional information in order to scaffold

transparency to the often invisible aspects of skills

learning in ways that draw attention to learners’ current

acquisition. Novices, who focus primarily on concrete

abilities, skills and knowledge gaps. These anchoring

learning and rules (Benner, 1984), more readily pay

practices equate with attention to the substance (MPSP)

attention to substance, sequence and accuracy, and

at the core of a clinical skill and the importance of pre-

fluency. Deepening awareness of integration and

reflection on clinical learning. Vella’s (2008) step of

caring comportment are accessed through reflective

adding can be related to the concept of priming; the

practice subsequent to completion of the task. Caring

educator, when priming, draws the learner’s attention

comportment is best learnt from nurse educators who

to key points to watch out for, prior to the educator

are consciously aware that they are role models and

modelling a specific skill. Novices otherwise may not be

value this responsibility (Perry, 2009). Nielsen et al.

able to identify the discrete elements that contribute to

report that clinical supervisors in their study considered

a clinically accomplished encounter. Through priming,

that educators’ clear, consistent use of the MPSP

the learner is a much more active learner than when

supported timely development towards competence.

‘shadowing’ an expert. The latter involves learning through observation alone (Weitzel, Walters, & Taylor, 2012). Bjørk

4A Model A clinical adaptation of Vella’s (2008) 4A model of small group classroom learning captures some of the key components of the MPSP (Bjørk & Kirkevold, 2000). The simplicity of a four-step model means that educators can readily remember and incorporate the steps, even into brief bedside teaching moments. Vella’s model focuses on the educator anchoring the learner in their current knowledge level; the educator adding additional information, such as a demonstration of a skill; then the learner applying the skill; finishing with the educator facilitating reflection on what the learner will take away from the experience, in order facilitate the student generalising the learning. When the author taught this model to nurse educators on the post-graduate clinical

and Kirkevold’s MPSP (2000) sequence and accuracy can be related to Vella’s steps of adding and applying; a back-andforth process. Weitzel et al. advise that educators need to move seamlessly between modelling and coaching; adding further demonstration of a component of a skill and guiding the learner’s application of skills through specific instructions, encouraging phrases and reminders.

Integration and caring comportment (MPSP) are further cultivated in Vella’s away phase. Vella contends that these four steps ensure that learners “…move…ineluctably toward authentic ownership of the content, whether that content is a new set of skills or challenging concepts or behaviors manifesting in attitudes” (2008, p. 65).

Five Minute Preceptor

teaching paper, they reflected that it was the away

A third model for clinical teaching is the Five Minute

component that they routinely overlooked. In their

Preceptor (5MP) (Bott, Mohide, & Lawlor, 2011), a five-step

subsequent assignments they reported the successful

nursing adaptation of the medical One Minute Preceptor

application of the model, incorporating attention to the

(Neher & Stevens, 2003). The 5MP model is based on

final integrative away component of reflection to help

Kolb’s (1984) theory of experiential learning; learning

sustain the learning beyond the specific experience.

takes place not through experience alone, but through

Page 31

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand reflective observation, abstract conceptualisation and

the 5MP (Bott et al., 2011) is where educators correct

active experimentation. Step one is to get the student

errors and misinterpretations. Learners’ development

to ‘take a stand’. A broad request can be used, such as,

is enhanced when they receive constructive feedback

“tell me about your patient and what stage you’re up to

detailed enough for them to comprehend what they

inAyour work with her today”.

Step twoto involves need to do to improve.

The 5MP steps four and five link ‘toolkit’ for clinical educators fosterprobing learners’ clinical reasoning and skills acquisition for evidence: “tell me more about…” “What else might

well to the away stage of Vella’s (2008) 4A model. To

you take into account?” These are anchoring practices

undertake steps four and five of 5MP, educators need

(4A model), and also link to the substance (MPSP) of

skills to provide feedback; a point addressed below.

Table 1: 4A Model (Vella, 2008).

Step 1) Anchor 2) Add 3) Apply Blend 1, 2, & 3 4) Away

Action Educator connects learner to current knowledge level Educator provides additional information and models correct skill performance Learner applies skill and may need educator’s coaching Steps 1-3 are blended throughout the learning experience as the educator continues to checks current knowledge, model and coach Educator facilitates reflective process to ensure learner generalises learning to future imagined experiences

Table 1: 4A Model (Vella, 2008).

the task at hand. These steps enable the educator to

The three approaches to clinical skills teaching described

assess rapidly the learner’s current knowledge and

above; the MPSP (Bjørk & Kirkevold, 2000); the 4A model

skills, and where there are gaps. Step three involves the

(Vella, 2008); and the 5MP model (Bott, Mohide, & Lawlor,

educator sharing general rules. Bott et al. recommend

2011), can be blended to ensure the incorporation of

sharing a maximum of three ‘pearls’. These points may

clinical reasoning with the development of psychomotor

include expert nurses sharing skilled know-how; tips

skills (Borneuf & Haigh, 2010). What follows is an

gleaned from years of experience (Morrison & Symes,

exploration of three specific skills: think aloud, questioning,

2011). This step is an opportunity for educators to guide

and giving feedback during clinical teaching. These three

learners in increased mastery of sequence and accuracy

communication strategies can be used effectively at every

(MPSP). Step three of the 5MP is linked to the 4A model

stage of the clinical teaching models discussed above.

steps of the educator adding and the learner applying the newly-acquired knowledge and skill (Vella, 2008).

Think Aloud

Step four of 5MP is to reinforce the positives. Ideally,

The think aloud (TA) process is ideal in order for learners

learners clearly understand where they are performing

to extract the most from educators’ demonstrations, and

well, as perceptions of competence foster confidence.

for educators to assess learners’ depth and accuracy of learning. Students’ adequate task completion is not an

Feedback is discussed more fully below. In brief, providing

indicator of the learner being able to think critically about

‘applause’, such as “you were such a star, you did a

what they are doing and why (Banning, 2008; Gardin,

great job,” is unhelpful for learners as it is non-specific,

2010). Studies demonstrate that the problem-solving

whereas feedback such as, “I noticed your thorough

of experts differs from that of novices, and surface skill

assessment of the patient’s pain and the many steps

mastery without the learner’s commentary may mask

you took to ensure his comfort”, allows the learner to

gaps in knowledge. This difference was highlighted in a

identify where they were performing well. Step five of Page 32

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand study of home-care nurses. Azzarello (2003) identified that

et al.’s (2015) research using TA in simulated situations,

expert nurses were able to recognise interconnections

they noted that students most skilful in concurrent

in their assessment processes; they noticed meaningful

TA were able to maintain a patient-centred approach,

patterns and avoided being distracted by insignificant

using touch, eye contact and language modification.

details. Their extensive home-care practice enabled

In order for TA to be used as an effective strategy,

them to see situations as wholes; for example the ways

learners need opportunities to familiarise themselves

people’s co-morbidities were shaped by social and

and gain comfort with the process. Role plays and

environmental influences. By contrast, although novice

simulation serve as helpful precursors to using TA in the

home-care nurses typically had good content knowledge

presence of patients. Banning (2008) highlights that nurse

of topics, they did not discern the interrelated aspects of

educators using TA need content knowledge, excellent

problems and therefore had incomplete understanding

communication skills and mastery of TA facilitation.

of issues. Expert nurses do not automatically notice the ingredients of their clinical decision making; decisions

Questioning

simply ‘appear’ (Lyneham, Parkinson, & Denholm, 2008).

Busy preceptors may unwittingly foster a less-than-ideal

In order to pass on advanced practice wisdom, TA is

learning environment by giving information rather than

beneficial. Think aloud is either a process undertaken

asking questions. Although apparently time-saving, this

concurrently with an activity, or occurs retrospectively.

shortcut does not stimulate critical thinking that will lead more swiftly to independent practice. Nickitas (2012)

Think aloud makes accessible clinical reflection in

acknowledges that it is an acquired skill to ask empowering

action (simultaneous with practice) and on action

questions to guide practice. She advises educators to

(retrospective reflection); practices identified by Schön

foster a climate of questioning by role-modelling that all

(1987; 1992). Schön (1992) proposed that for competent

questions are welcomed and inquisitiveness is valued as

practitioners, reflection in action is part of the artistry of

an essential ingredient of clinical reasoning. Weitzel et

their practice. He used the analogy of jazz improvisation

al. (2012) caution preceptors to avoid using questions

to illustrate the on-the-spot decision making of skilled

in ways that provoke shame and embarrassment. For

practice. Learners will not gain optimum benefit through

example, when questions are not well scaffolded and are

merely watching a skilled performance. Educators miss

instead persistently used to show learner’s knowledge

valuable opportunities if they focus solely on reflection-

deficits, questions become impediments to learning.

on-action; nuances will be missed in retrospective

Educators’ questioning of learners at the patient’s bedside

reflection. Concurrent TA occurs on a continuum of

must be sensitive to the level of interactional tension

complexities, from simple descriptive verbalisations of

and modified to ensure the needs of patients are not

reasons for actions, to exposing a depth of explanation

overlooked and the morale of learners is maintained

of planning and anticipation (Burbach, Barnason, &

(Rizan, Elsey, Lemon, Grant, & Monrouxe, 2014). Weitzel

Thompson, 2015; Ericsson & Simon, 1998). Think aloud

et al. also advocate waiting for answers; often educators

is therefore not merely the narration of one’s actions,

become uncomfortable with a gap of even a few seconds

but is rather a description of clinical reasoning (Burbach

and do not give learners the thinking time they need.

et al., 2015). A point of complication in the TA process

Empowering questions are those that assist in developing

is that in the presence of patients and their families,

problem-solving in the present and in future similar

decisions need to be made about the extent to which

situations. Nickitas (2012) recommends that educators

TA is used, and the modification of language required

consider asking questions to explore the following

in order to maintain caring comportment. In Burbach Page 33

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand six areas: clarifying questions, “can you tell me more

can be primed to expect regular feedback. The educator

about this condition?”; analytical questions, “what

ideally normalises both motivational and developmental

will be the consequences of opting for this choice?”;

feedback; the former highlights what is going well, and

questions that inspire reflection in unpredictable

the latter details areas for further learning: “How have

ways, “ why was the outcome beneficial?”; questions

you found feedback in the past? What is helpful and

that support breakthrough thinking, “is there another

unhelpful?” “Once the procedure is finished, away from

approach that could be just as successful?”; questions

the patient, I’ll be asking you to tell me what you thought

that challenge assumptions, “what do you think are

went well and where your skills and knowledge are still

the benefits of going with the patient’s preference

developing”; “I’ll be giving you feedback about what’s

rather than your own?”; and questions that encourage

going well and where I notice further knowledge and

learners to create ownership for solutions, “From your

clinical tips are needed.” The educator can also alert

learning, what do you recommend is needed here?”

the learner that they too appreciate feedback as part of their ongoing refinement of their role: “Once we’ve

Additionally, Benner et al. (2010) draw attention to the

completed the procedure, I’d like to hear from you what

value of ‘what if’ questions. These questions allow the

was useful in terms of the guidance I provided, and what

educator to keep making adaptations to a situation to

you needed more or less of” (Cleary, Happell, Lau, &

elicit the learner’s depth and flexibility of thinking in

Mackey, 2013). Educators ideally ensure that learners

responding to a clinical situation, so that maximum

are clear about goals of the clinical teaching session,

learning is taken from the current learning situation

and that feedback will therefore be anticipated: “During

and extended into future, imagined scenarios. For

the process of you doing this procedure I’ll be paying

example, for the away segment of the 4A model (Vella,

particular attention to how you monitor and respond to

2008), educators can ask, “what if this patient with

the patient’s emotional and physical comfort.” Preparation

pneumonia also had asthma?” “What if the laboratory

for feedback optimises the likelihood that the learner

result showed sepsis?” “What if the oxygen saturation

will be actively engaged (Ramani & Krackov, 2012).

dropped further?” “what if this patient was eighty-five instead of twenty-five?” “What if the patient developed

Educators need to be discerning about what feedback is

confusion?” “What if the patient was allergic to the

given in front of the patient and when privacy is needed.

recommended medication?” “What if the family wanted

Feedback is preferably given based on the educator’s direct

the patient to be discharged?” “What if the treatment plan

observation, rather than on second-hand information.

was not compatible with the patient’s cultural beliefs?”

Learners are more likely to discount feedback if it is not

Nickitas (2012) argues that educators’ commitment

based on the educator’s first-hand observation (Bing-You,

to asking questions is pivotal to clinical advancement.

Paterson, & Levine, 1997). A study by Telio, Ajjawi, and Regehr (2015) identified that feedback had the greatest

Feedback

impact when the receiver perceived the educator’s

Feedback is a vital component at all stages of clinical

beneficent motivation. Therefore, a climate of trust and

teaching. When well planned and implemented, feedback

respect enhances feedback being adopted. This point

supports learners to self-assess, noticing their own

was highlighted in Vallant and Neville’s (2006) study of

abilities, challenges and uncertainties. Patients’ safety

student nurses’ experiences of preceptorship, in which one

depends on nurses’ competence in self-assessment

participant commented, “[n]urturing, they acknowledge

(Weitzel et al., 2012). Using Vella’s (2008) anchoring phase

where your fears are, and your weaknesses are but they

of preparation for a clinical learning experience, learners

won’t let you stop there, they push you, they push you to

Page 34

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand get over this and then take on the next bit” (p. 28). Specific

and the intellectual, practical and ethical competence

behavioural examples are valued, not educated guesses

of learners when pedagogically sound approaches

at underlying motivations: “When you interrupted the

are consistently used. Novice educators will be able

patient for the third time and tried to impress on her the

to provide optimum clinical teaching when they have

evidence base for taking the medication, I noticed that

incorporate educational rules and frameworks. Clinical

she appeared increasingly agitated, raising her voice and

reasoning is a vital component of care delivery as task

avoiding eye contact.” It is important that the feedback

mastery alone does not ensure that nurses are able to

is not too detailed or overwhelming; up to three key

think critically, thereby adapting skills to optimise patient

points of developmental feedback, with a specific plan

safety and wellbeing. Three models; the MPSP (Bjørk

to improve in these areas is advisable (Weinstein, 2015).

& Kirkevold, 2000), the 4A model (Vella, 2008) and the 5MP (Bott, Mohide, & Lawlor, 2011); and the skills of

Conclusion

think aloud, questioning, and giving feedback, provide

The tacit knowledge of expert nurses is not an adequate

educators with scaffolding frameworks to support their

foundation for clinical teaching. Nurses involved in clinical

own progress towards becoming expert educators.

education enhance their own professional satisfaction

References Azzarello, J. (2003). Knowledge structures and problem representations: How do novice and expert home care nurses compare?

Southern Online Journal of Nursing Research, 4(2), 1-26.

Banning, M. (2008). The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. Nurse Education Today, 28(1), 8-14. doi:10.1016/j.nedt.2007.02.001 Beckman T., & Lee, M. (2009). Proposal for a collaborative approach to clinical teaching. Mayo Clinic Proceedings, 84(4), 339-344. doi:10.4065/84.4.339 Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: JosseyBass.

Bing-You, R. G., Paterson, J., & Levine, M. A. (1997). Feedback falling on deaf ears: Residents receptivity to feedback tempered by sender credibility. Medical Teacher, 19(1), 40-44. doi:10.3109/01421599709019346 Bjørk, I.T., & Kirkevold, M. (2000). From simplicity to complexity: Developing a model of practical skill performance in nursing. Journal of Clinical Nursing 9(4), 620-631. doi: 10.1046/j.1365-2702.2000.00328.x Bott, G., Mohide, E. A., & Lawlor, Y. (2011). A clinical teaching technique for nurse preceptors: The five minute preceptor. Journal of Professional Nursing, 27(1):35-42.doi:10.1016/j.profnurs.2010.09.009 Borneuf. A., & Haigh, C. (2010). The who and where of clinical skills teaching: A review from the UK perspective. Nurse Education Today, 30(2), 197–201. doi:10.1016/j.nedt.2009.07.012 Bourgeois, S., Drayton, N., & Brown, A. (2011). An innovative model of supportive clinical teaching and learning for undergraduate nursing students: The cluster model. Nurse Education in Practice, 11(2), 114-118. doi:10.1016/j.nepr.2010.11.005

Page 35

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Broadbent, M., Moxham, L., Sander, T., Walker, S., & Dwyer, T. (2014). Supporting bachelor of nursing students within the clinical environment: Perspectives of preceptors. Nurse Education in Practice, 14(4), 403-409. doi:10.1016/j.nepr.2013.12.003 Burbach,B., Barnason, B., & Thompson, S. (2015). Using “think aloud” to capture clinical reasoning during patient simulation.

International Journal of Nursing Education Scholarship, 12(1), 1-7. doi: 10.1515/ijnes-2014-0044.Cangelosi, P. R., Crocker, S., & Sorrell, J. M. (2009). Expert to novice: Clinicians learning new roles as clinical nurse educators. Nursing Education Perspectives, 30(6). 367-71.

Cleary, M., Happell, B., Lau, S.,Mackey, S. (2013). Student feedback on teaching: Some issues for consideration for nurse educators.

International Journal of Nursing Practice, 18, S62-66. doi: 10.1111/ijn.1201 Dreyfus, H. L. & Dreyfus, S. E. (1986). Mind over machine. New York, NY: The Free Press.

Edgecombe, K., & Bowden, M. (2009). The ongoing search for best practice in clinical teaching and learning: A model of nursing students’ evolution to proficient novice registered nurses. Nurse Education in Practice, 9(2), 91-101. doi:10.1016/j.nepr.2008.10.006 Ericsson, K., & Simon, H. (1998). How to study thinking in everyday life: Contrasting think-aloud protocols with descriptions and explanations of thinking. Mind, Culture, and Activity, 5(3), 178–186.

Field, D. E. (2004). Moving from novice to expert – the value of learning in clinical practice: A literature review. Nurse Education Today, 24(7), 560-565. doi:10.1016/j.nedt.2004.07.009 Gaberson, K., Oermann, M., & Shellenbarger, T. (2015). Clinical teaching strategies in nursing (4th ed.). New York, NY: Springer.

Gardin, F. A. (2010). The “think aloud” method to promote student modeling of expert thinking. Athletic Therapy Today, 15(4), 18-21.

Grassley, J., & Lambe, A. (2015). Easing the transition from clinician to nurse educator: An integrative literature review. Journal of Nursing Education, 54(7), 361-366. doi:10.3928/01484834-20150617-01 Haggerty, C., Holloway, K., & Wilson, D. (2013). How to grow our own: An evaluation of preceptorship in New Zealand graduate programmes. Contemporary Nurse, 43(2), 162-171. doi:10.5172/conu.2013.43.2.162 Handwerker, S. M. (2012). Transforming nursing education: A review of current curricular practices in relation to Benner’s latest work.

International Journal of Nursing Education Scholarship, 9(1), 1-16. doi:10.1515/1548-923X.2510 Huckabay, L. M. (2009). The effect of creating a mental set on cognitive learning and affective behaviors of nursing students. Nursing Forum 44(4), 222-234. doi:10.1111/j.1744-6198.2009.00148.x Kinchin, I. M., Cabot, L. B., & Hay, D. B. (2009). Using concept mapping to locate the tacit dimension of clinical expertise: Towards a theoretical framework to support critical reflection on teaching. Learning in Health & Social Care, 7(2), 93-104. doi:10.1111/j.14736861.2008.00174.x Kneebone, R. L., Scott, W., Darzi, A., & Horrocks, M. (2004). Simulation and clinical practice: Strengthening the relationship. Medical Education, 38(10), 1095-1102. doi: 10.1111/j.1365-2929.2004.01959.x Kolb, D. (1984). Experiential learning: Experience the source of learning and development. Englewood Cliff, NJ: Prentice Hall.

Lyneham, J., Parkinson, C., & Denholm, C. (2008). Explicating Benner’s concept of expert practice: Intuition in the emergency room.

Journal of Advanced Nursing, 64(4), 380-387. doi:10.1111/j.1365-2648.2008.04799.x Manning, L., & Neville, S. (2009). Work-role transition: From staff nurse to clinical nurse educator. Nursing Praxis in New Zealand, 25(2), 41-53.

Morrison, S. M., & Symes, L. (2011). An integrative review of expert nursing practice. Journal of Nursing Scholarship, 43(2), 163-170. doi:10.1111/j.1547-5069.2011.01398.x Neher, J. O., & Stevens, N. (2003). The one minute preceptor: Shaping the teaching conversation. Family Medicine, 35(6), 391-393.

Page 36

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Nickitas, D. (2012). Asking questions and appreciating inquiry: A winning strategy for the nurse educator and professional nurse learner. Journal of Continuing Education in Nursing, 43(3), 106-110. doi:10.3928/00220124-20111201-01 Nielsen, C., Sommer, I.,Larsen, K., & Bjørk, I. (2013). Model of practical skill performance as an instrument for supervision and formative assessment. Nurse Education in Practice, 13(3),176-180. doi:10.1016/j.nepr.2012.08.014 Nursing Council of New Zealand. (2012). Competencies for Registered Nurses. Wellington, New Zealand: Author.

Perry, B. (2009). Role modeling excellence in clinical nursing practice. Nurse Education in Practice, 9(1), 36–44. doi:10.1016/j. nepr.2008.05.001 Ramani, S., & Krackov, S. (2012). Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher, 34(10), 787791. doi:10.3109/0142159X.2012.684916 Reierson, I., Hvidsten, A., Wighus, M., Brungot, S., & Bjørk, I. (2013). Key issues and challenges in developing a pedagogical intervention in the simulation skills center - An action research study. Nurse Education in Practice, 13(4), 294-300. doi:10.1016/j.nepr.2013.04.004 Rizan, C., Elsey, C., Lemon, T., Grant, A., & Monrouxe, L. (2014). Feedback in action within bedside teaching encounters: A video ethnographic study. Medical Education,48(9), 902-920. doi:10.1111/medu.12498 Rose, M., & Best, D. (Eds.). (2005). Transforming practice through clinical education, professional supervision and mentoring.

Edinburgh, United Kingdom: Churchill Livingstone.

Schön, D. A. (1987). Educating the reflective practitioner. San Francisco, CA: Jossey-Bass.

Schön, D. A. (1992). The theory of inquiry: Dewey’s legacy to education. Curriculum Inquiry, 22(2), 119-139. doi: 10.2307/1180029 Simmons B. (2010). Clinical reasoning: Concept analysis. Journal of Advanced Nursing 66(5), 1151–1158. doi:10.1111/j.13652648.2010.05262.x Smedley, A., Morey, P., & Race, P. (2010). Enhancing the knowledge, attitudes, and skills of preceptors: An Australian perspective. The Journal of Continuing Education in Nursing, 41(10), 451-461. doi:10.3928/00220124-20100601-08 Telio, S., Ajjawi, R., Regehr, G. (2015). The “educational alliance” as a framework for reconceptualizing feedback in medical education.

Academic Medicine, 90(5), 609–614. doi:10.1097/ACM.0000000000000560 Vallant, S., & Neville, S. (2006). The relationship between student nurse and nurse clinician: Impact on student learning. Nursing Praxis in New Zealand, 22(3), 23-33.

Vella, J. (2008). On teaching and learning: Putting the principles and practice of dialogue education into action. San Francisco, CA: Jossey-Bass.

Vygotsky, L. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.

Weitzel, K., Walters, E., & Taylor, J. (2012). Teaching clinical problem solving: A preceptor’s guide. American Journal of Health-System Pharmacy, 69(18), 1588-1599. doi:10.2146/ajhp110521 Weinstein, D. (2015). Feedback in clinical education: Untying the Gordian Knot. Academic Medicine, 90(5),559–561. doi:10.1097/ ACM.0000000000000559

Page 37

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand NOTES FOR CONTRIBUTORS The initial and continuing vision for Nursing Praxis in New Zealand is that, within the overall aim of fostering publication as a medium for the development of research and scholarship, the Journal should: â&#x20AC;˘ Inform and stimulate New Zealand nurses. â&#x20AC;˘ Encourage them to reflect critically upon their practice, and engage in debate and dialogue on issues important to their profession.

Nursing Praxis in New Zealand publishes material that is relevant to all aspects of nursing practice in New Zealand and internationally. The Journal has a particular interest in research-based practice oriented articles. Articles are usually required to have a nurse or midwife as the sole or principal author. There is no monetary payment to contributors, but the author will receive a complimentary copy of the Journal in PDF format. The ideas and opinions expressed in the Journal do not necessarily reflect those of the Editorial Board.

Nursing Praxis in New Zealand publishes original research, discursive papers (including conceptual, critical review and position papers that do not contain empirical data), methodological manuscripts, commentaries, research briefs, book reviews, and practice issues and innovations. Contributions are also accepted for Our Stories, which are short pieces profiling historical and contemporary stories, which reveal the contributions of individual nurses to our profession.

Further details are available on the Nursing Praxis in New Zealand website - www.nursingpraxis.org

Page 38

Vol. 32 No. 1 2016 - Nursing Praxis in New Zealand

OUR W E B SIT E OF FERS • Easy search of our database for past abstracts and articles online • Subscribers may view complete articles and read full issues online • Sign up for email or RSS updates from Nursing Praxis • Subscribe to online access of all current and past issues of the journal • View all information for contributors and reviewers

www.nursingpraxis.or g

PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org W www.nursingpraxis.org