Section Three — Findings and Discussion for the Nurse Rotation Scheme Study
3.1 Introduction
As previously mentioned (1.1), the reasons for addressing many of the topics that were selected was to elicit data that could help in the search for common or individual factors that might influence the level of success of the nurse scheme in general
In this type of research, it is important that the voices of the participants are heard as well as the voice of the researcher (Lather 1991) so, here, the comments of rotation scheme nurses will be used to illustrate and validate the findings. Some voices will be heard more than others. There are two reasons for this. First, some speakers sum up succinctly what others are taking longer to say. Second, some quotes could not be used because the speaker could be clearly recognised. However, where a useful quote is available but would be likely to identify the speaker the words are paraphrased to uphold confidentiality. Similarly, there are places where just one or two words would reveal the speakers identity so these are replaced with four dots. Three dots are used where, for the sake of brevity, words that do not contribute to the meaning of the quote have been omitted.
Thus, much of what follows is from extracts from the transcripts of the interviews and consists of quotes from the experienced nurse participants on the scheme. However, also included are some of my own comments relating to those quotes but only where it is relevant to the context or when some explanation for conflicting views is required.
To provide an easier flow to the reading of this section on the findings of the study, my main comments have been reserved for the concluding section where various arguments and explanations are developed. In consequence, should the reader come across quotes that surprise them but which appear not to have raised comment, he or she is requested to note them in anticipation of what may be encountered in the concluding section.
3.2 Reasons for joining the rotation scheme
As discussed in section 1.1, this was the fourth cohort of nurses who had joined the D/E Nurse Job Rotation Scheme. However, since an aim of this report is to help to convince stakeholders of the value of such a scheme and the desirability of a continuation or restart, it was judged that asking the practitioners about their reasons for joining the scheme could provide information to assist in the identification of possible future cohorts.
A strength of unstructured interviews is that they lead to a diversity of responses. This is reflected in what follows and, indeed, with all the topic areas discussed in this section. The comment fall into three groups.
3.2.1 Opportunity to learn more through varied experiences
Some rotation scheme nurses claimed that it was a chance for varied experiences that drew them to the scheme. John, Ellie and Holly are good examples of this group. John, who had worked for a time as a nurse post qualification, said,
“I just thought it would be a good way of getting experiences; a way of getting off the wards and working somewhere else. It’s a good way of getting those experiences without having to apply for the job and go through the personnel department which is a bit of a pain to deal with.”
Ellie argued,
“It seemed like a good idea at the time because I didn’t really know what area I wanted to work in or what to expect. So it seemed promising that I’d have three placements in different areas and then, after that I figured that I’d know exactly where I wanted to work.”
Holly said,
“Well, I saw it advertised! I think it was on the Nursing Times website and I was just flicking through. And I thought it would be a good idea to give me experience in a few different areas because I was unsure about where I wanted to work and I just thought it would be quite a valuable thing to do.”
Finally, Tony said,
“Having moved down to London, and not knowing London very well, and having not had a particularly good experience where I was it seemed to be a very good opportunity to actually get a feel for different areas whilst being employed.”
3.2.2 Attraction of the educational aspects of the scheme
Holly and Tony also commented on the attraction of the educational aspect of the scheme. Holly remarked,
“And obviously, the idea of doing the degree with it, I thought that would be a good idea seeing as the Trust pays for you to do that”,
whilst Tony commented,
“There’s all the different very positive things about the education and about the option to move around and the nurse rotation facilitated this move.”
Kim and Clive also remarked on the educational aspect of the scheme. Kim, going into rather more detail than the others, said,
“I think it was professional development and the structure of the course and how it was advertised. It was exactly what I wanted. With it being work based learning, I knew straight away that it would actually improve my practice when dealing with the patients and with an update on all policies. I knew it would enhance my work. I’d know exactly what I’m supposed to do with all my clients. On other degree programmes you will not be sure whether it will be applicable with your client group or how you use it after the programme. This one, the way it is and the way it was advertised, it empowers you as you go along.”
Clive said,
“I found it attractive; the fact that your diploma would be upgraded to a degree level, plus the opportunity of working as well as the study. I found that quite attractive.”
Asked about the rotation part of the scheme, Clive responded,
“The rotation part was attractive because as a student you do some placements and the placements on the rotation scheme are for about eight months so I would gain a lot of knowledge and skills in different settings for eight months.”
3.2.3 Other reasons for joining the scheme
3.2.3.1 Fees paid
Caroline’s response for this topic was rather vague. She merely claimed that,
“The attraction was the free programme that led to something.”
3.2.3.2 Preventing stagnation
Michael wanted to keep abreast of his work. He commented,
“I wanted to work for a year or two and then carry on with my studies with further education. I didn’t want to stagnate. They say that nurses, once they’ve got the qualification, once they’ve gone into a job, they don’t want to move and I didn’t want something like that for me. And then I found out the opportunity was good because I was working at the same time and studying and I was updating. I hate to stay stagnant and not update with things.”
3.2.3.3 Consolidation
Anne was quite specific, saying,
“I wanted to consolidate my training. You see, I was on an elderly ward and I was always fascinated with acute. I felt I needed some acute experience and then the rotation offered different placements where you could go and experience different types of nursing, you know, be in different wards, different types of mental health wards. So that’s what’s held my interest as well. So that’s why I decided to go on it.”
3.2.3.4 Developing nurse leaders
Finally, Sarah said,
“I finished my training in January 2002. I saw an advert for the nurse rotation in Ealing and I thought it was interesting. It looked quite attractive from the job advert. I think it was that that attracted me and I applied for it and had an interview. And, from what they described of it, it was really attractive. From what they said, it was going to be a management kind of thing. They were looking for nurse leaders and I think the rotation was a way of working round a career move and it was quite an ambitious kind of project. I thought that was in line with my career objectives. I want to see myself progressing as fast as possible.”
It must be remembered that one-off interviews provide a snapshot in time. On another occasion, participants might have said something slightly different or even made claims used here by others. Indeed, the next section demonstrates that even within an interview views can be expanded and take a slightly different direction.
However, reflecting on the explanations provided for joining the scheme, whilst there were points such as free education and a more rapid progression, it does appear that the educational aspect of the scheme and the opportunity to gain substantial experience via rotation were the main attractions.
At first glance, education seems to be given more attention but when one considers that a number of comments were indirectly related to rotating this tends to balance things. Examples of comments indirectly related to rotating are Michael not wanting to stagnate, Anne’s consolidation of her learning and Sarah’s career objectives. Unfortunately, as can be seen in 3.4, for a variety of reasons, the opportunities offered by rotation did not always materialise whilst the educational aspect of the scheme would appear to have transcended expectations (see 3.6).
3.3 Degree versus Rotation
Although the specific topic area provided was, ‘Your reason(s) for joining the rotations scheme’, there were a considerable number of comments made, or responses provided to my further probes, which provided further insights as to why the educational or the rotation aspects of the scheme were or were not more attractive to some of the nurses who joined. Some relevant comments were made at other points in the interviews. This was because of the nature of unstructured interviewing where topic areas are offered, the only direct questions are follow up questions, and there is no specific order to the responses,. These comments are also included at this point.
Here, the rotation scheme nurses demonstrated very individual perspectives although it was possible to place them into four groups, those for whom the rotation was most important, those for whom getting the degree was most important, those who considered both to be equally important and one person, Kim for whom the main attraction was work based learning. The groupings have been used for clarity.
3.3.1 The rotation was more important.
3.3.1.1 Short term aims
Ellie had said earlier that she joined the scheme because of the rotation. I asked if the qualification had any importance. She replied,
“It was a little bit of both but more the rotation because I didn’t really know where I wanted to work so the scheme seemed like a good idea. I would experience three different places and then I’d have an opportunity to decide exactly where I wanted to go, what area I wanted to work in but the qualification was also an attraction.”
3.3.1.2 Medium and long term aims
It is interesting to note that whilst Ellie was hoping to experience different possibilities her response suggests that she may not yet have realised the career implications of doing so. That is, she did not mention that such a move could help her to develop a CV that would facilitate any changes she might wish to make later on in her career.
3.3.1.3 Choice
Talking about why he joined the scheme, David had said,
“And then I saw an advert for the rotation. I actually wanted to move and then, when I saw this advert, what really fascinated me was how it was advertised, that you rotate from various areas and I would have a choice. And the choices that were there, about six or more choices. So I decided to join the rotation because of that.”
3.3.1.4 Desire to identify a client group with whom to work
Then, considering the topic of whether it was mainly the degree or the rotation that had drawn him to the scheme, David indicated that he was now ready to make a long-term commitment to a clinic area or client group, and wanted experiences that would help him to make that choice. He commented,
“It was mainly the rotation because I’ve got to a point in my life where I’m actually looking for a place where I feel that this is my job and I’m staying here. I decided that, before I did that, I’d love to have experience in other areas rather than go from acute to straight to where I want to go. That is why I turned down the (hospital name omitted). I thought that I really needed to have this experience. The other reason is because I’m doing a psychology degree therefore, to me, it meant a lot to do the rotation and see other areas. I was hoping for forensic or rehab and community, so I was hoping that the scheme would give me quite a good experience.”
3.3.2 The degree was more important
Caroline’s response was very much to the point. She argued,
“Getting the qualification was the first priority. The rotation was part of it but getting the degree, the qualification, was my main priority.”
3.3.2.1 Opportunity to facilitate on going study
Michael argued that the degree was the most important for him. He said,
“It’s very important because it’s giving me a leeway to carry on with studies really and not staying just with work. I’ve always had the sort of people who said, ‘Get a job and it’s for life. Get a job and stop there. You don’t want to move on’. But life is not only for that.”
3.3.2.2 Gaining qualifications in a low paid job
Tony not only explained that the qualification was a more important consideration than the rotation; he also made it clear that the fact that the scheme was being financed by the Trust was very important. He remarked,
“Well, I did my diploma in higher education for my nursing because that was the way I could survive. If I’d gone and done a degree it would have been very difficult but I had always had it in my mind that I wanted to top up to degree when I actually started working. So, in regards to having a job and being funded and getting a degree out of that over a two year period, I thought it was quite a good deal.”
I asked if funding was quite important and Tony replied,
“Yes, very much so, yes.”
Sarah had actually changed her mind about what was most important and she also pointed out the importance of getting funding. It should be noted that this does not necessarily mean that the other participants did not find funding important. It merely demonstrates that there were other factors that were more salient at that point.
3.3.2.3 The dynamic of motivation/ placement/ education and satisfaction
Sarah reflected,
“When I first started, I think the rotations were slightly more important than the degree because it was about gaining the experience. Unfortunately, I haven’t had the most pleasant of experiences so that has probably changed. Now I’m focussing more on the degree part because it’s more interesting. It’s something that motivates me and I can see possible changes that can be made. The degree was always important because it’s continuing education. I do not have a degree and I thought that sooner or later it would be essential. It was attractive because it’s something I would have wanted to achieve in the long run if I was going to pay for myself or I would do it otherwise. So the scheme, because it offered this degree programme without any extra cost, it was quite attractive.”
Sarah added,
“And the time to do it was provided as well, so that was really an attractive option.”
3.3.3 Both the degree and the rotation were equally important
3.3.3.1 Gaining a degree
Robert’s reasons for seeing both as equally important were quite pragmatic. He explained,
“What attracted me to the rotation scheme was the education programme attached to it. I was really attempting to do my degree before I moved out of (country of origin) but when the opportunity came it actually worked out that I was assessed within the interview and the whole programme was set rolling. I therefore decided that I would at least have my degree as part of my educational development and thereafter. I don’t mind being on short courses but I wish to have a degree. Having a degree is a thing that I have an ambition for in life so that is why I decided to join the scheme.”
3.3.3.2 Career potential/ employability
Robert added,
“Universally, any job you apply to or any line in which you find yourself, a degree is usually a very basic qualification. There are some other qualifications that can be used, standard qualifications for most of the jobs you may be doing in any part of the world.”
These combined comments could be seen as ambiguous. On the one hand they could be interpreted as Robert’s desire to have a qualification that furthered his educational development whilst on the other hand they could be taken to indicate his awareness that such a qualification could ensure that he would be short listed for future posts thus maximising his employability, locally, nationally and internationally.
Ambiguity is one of the dilemmas of research carried out using unstructured interviews. Unfortunately, it is not always noted at time, but when it is, it can be overcome by notes made at the time about the context of an interview or, as in this case, by further probing.
3.3.3.3 Evidence of equal opportunity for immigrants
To clarify, I asked,
“So, when you came to the scheme that was more important for you than the rotation was it?”
Robert replied,
“The rotation is equally important. I find the rotation quite important as well in the sense that I know definitely that even if at the end of the rotation and at the end of the two years I have to apply for a job elsewhere, or if I decide to deflect at the end of the two years, at least the CV will be quite good. Whichever line I want to go to within psychiatry… maybe I decide to go into community or I decide to go into acute or elderly or rehabilitation or whichever, that experience that I already had in the past, coupled with the experience I have had in this country, the CV will look definitely adequate.”
John had said that he had joined the scheme because,
“I just thought it would be a good way of getting experiences, be a way off getting of the wards and working somewhere else”, so I enquired about the degree aspect. He responded, “That was good as well. That was also part of the attraction; that you get the chance to have that education.”
To clarify, I asked,
“Which of those two would you say was the main one”? John replied, “Both as much as each other.”
Holly’s and Clive’s responses were both brief. Holly argued,
“Both were important to me although I must say I was a bit unsure about doing the degree so soon after qualifying” whilst Clive said, “I would say the degree was the most attractive but the rotation was attractive too because as well as doing the degree I felt that you would be working in different settings which would improve your confidence.”
3.3.4 The importance of work based learning
Only four of the participants made any reference to the fact that they were studying for a work based learning degree.
Kim remarked,
“The course is designed in such a way that it can help you whatever client group you are working with because it is work based.”
This suggested that the course was both general enough to be useful in every setting, and specific enough to be useful in any setting
Her response led me to enquire as to whether the main attraction had been the work based learning rather than the degree. She replied,
“Yes, that was the main attraction rather than the degree. The degree I was planning to do at a later stage, eventually, but I chose the work based learning.”
I then asked Kim if the rotation had attracted her and her reply suggested that she found the opportunity to learn highly attractive. She answered,
“In a way it did but not as much as the work based learning. But my initial impression was, if you are going to rotate in three different disciplines, then basically you are learning about three different disciplines. So then, that was something that really attracted me.”
3.3.5. Employability
Initially, Ruth’s comments appeared to indicate that she had become career minded. She had previously said that she joined the rotation because
“I thought it would be something good, to move around and not get myself bored.” Now she commented, “Initially, the education came second but now it is good, particularly since you need to get qualifications if you are to go anywhere.”
However, this was not totally clear so I asked if that meant that having a qualification was, for her, just a way towards a better job. She replied,
“The qualification in itself is meaningful because for me, I find that if I’m not doing something that I enjoy and I find meaningful, I would just probably cut it off as soon as possible which hasn’t been the case with the course. I looked at it and I thought, ‘What a good way to move around as well as learning new things. Work based learning that’s applicable to work would be good’. It would be an excellent opportunity really. So the learning’s the best bit and the degree just happens to come with it.”
It is interesting to note that Ruth’s arguments about the need for work based learning are very similar to those made by the original course organisers but come from a quite different perspective. She appeared to be looking at things from the perspective of personal enjoyment whilst the course organisers were concerned that the education provided would help clients to get a better service and ensure that the organisation met its own objectives.
Unlike Kim, Ruth was not focused mainly on work based learning. Indeed her comments showed that she found all aspects of the scheme equally attractive as her next comment shows.
At this point I was still unsure as to Ruth’s meaning so I asked whether moving around or the educational aspect provided the main attraction. Ruth answered,
“At the time I decided to apply it was the moving around. I didn’t want to get stuck on one ward but I think education became a close second as well, because you need to get degrees and stuff like that if you want to develop yourself. I wanted to go up so education became a close second. At the time that I decided I wanted to move on I was on a ward that was not particularly stimulating or anything like that.”
Ellie’s response showed that the idea of work based learning is still very new to some, perhaps many, people. I had asked her if the fact that it was a work based learning degree had been an attraction and she answered,
“I didn’t really think of it. I just saw it as being a degree so I didn’t really think about the differences and I don’t think the job advert said that it was work based. I think it just said a degree so only when I started going for academic classes did I understand what it was going to be like but now I think it’s a good idea.”
When I discussed this topic with Robert, I had probed further and asked him what was attractive about this particular degree. I asked if it was that the degree involved work based learning as opposed to the learning in a degree that’s more traditional. His response indicated a utilitarian approach that did not differentiate between approaches to learning. He said,
“It doesn’t matter to me. Whether it’s work based or traditional, once you have a degree there is this recognition that you are able to deliver the goods in whatever sphere of human endeavour you find yourself.”
3.4 Placements
On the whole, respondents did seem to enjoy and gain substantially from their placements. Problems are given prominence here in order that they can be discussed later and, hopefully, addressed in any future rotation schemes.
3.4.1 Satisfaction and dissatisfaction; negotiating different perspectives
The opportunities offered by rotation did not always materialise. In what follows, there are many comments that reflect dissatisfaction with one or more placements together with the reasons for that dissatisfaction. It should be understood that there is a dynamic between the perceptions of the key stakeholders. The organisations were seeking to find good nurses to provide at least basic nursing care for patients in need in hard to staff areas whilst rotatees were looking for interesting and diverse placements within which to learn and to develop confidence. These differences provided an opportunity for mutual achievement when they complemented each other. However, when one set of needs outweighed the other, dissatisfaction, disrespect and feelings of being abused emerged.
3.4.2 Placements: emerging theme
‘Placements’ was not a theme offered for discussion to the rotation scheme nurses. Rather, the participants were offered the theme, “rotation experience”. However, as explained above, many of the comments on that theme reflected dissatisfaction and it was decided to create this new theme of ‘placements’ to differentiate the two. Consequently, the theme ‘rotation experience’ is presented below in a much reduced form.
Each of the rotation scheme nurses had something to say about their rotation placements and, as with other topics, they fell into various groupings, the largest of which were those who, however they experienced their placements, had some misgivings about the way in which those placements came about. It should be noted that the respondents were interviewed over a period of time and consequently some had embarked on their third placement whilst others had experienced only two.
3.4.3 Rotation nurses who were satisfied with all their placements to date
3.4.3.1 A good and busy learning environment
Four of the rotation scheme nurses were satisfied with all aspects of their rotation placements. For example, Caroline explained that, like most of the rotation scheme nurses, her first placement was on an acute ward. She said,
“That was very good, I enjoyed it. It was a good team; it makes a very good team. You learn quite a lot from that ward. It was very busy and it could be very tiring at times.”
She then commented,
“My next placement was on an ICU”, and ICU was very interesting. I had quite a lot of very good experiences on ICU in terms of the forensic history etcetera. It’s quite different. The acute ward was different from the ICU. In the ICU you come into contact with clients under home office restrictions and so on, so it was a great experience. You meet a lot of clients with a similar diagnosis but when you consider their presentation, sometimes it’s quite different based on their culture, background, their individuality, the way they were brought up, differences in the way people want to be treated, differences in the way they want to be approached. So you’d never think they were clients with the same diagnoses. You must treat each case based on their individuality.”
Possibly, Caroline’s comments were partly influenced by the fact that there tends to be more time available to spend with clients on an ICU than on an acute ward.
I asked about the staff on that ward. Caroline responded,
“The staff were good. It was very supportive; they were a very supportive team. She went on to say, “The second placement, the thing good about it was they were all very supportive.”
3.4.3.2 Supportive
In positivist research, the question would now arise as to what is meant by ‘supportive’. However, in this form of research, the term ‘supportive’ means whatever the participant understands it to be in just the same way that ‘pain’ is whatever a patient experiences. This does not mean that attempting to define ‘supportive’ in this context would be inappropriate. Rather, it would require a different study and a different, more abstract, form of research approach.
3.4.3.3 Expectations met
When I asked Holly about her placements, she remarked,
“Well, I think it’s good to be going to different areas and I’ve been lucky in that I’ve been to places I wanted to go. I started off on an acute ward and that was what I wanted to start off with really because they’re very busy and fast places and you need to use a lot of different skills and have a lot of information about the mental health act and those kinds of issues. I was kind of thrown in at the deep end a bit when I started there last year.”
3.4.3.4 Fear due to lack of ward leader
It is not possible to write about Holly’s second placement without identifying it.
However, she was enjoying it and gaining much experience. Returning to her first placement she said that she had enjoyed it but added,
“When I was on the acute ward I think I was really thrown in at the deep end. It was unfortunate timing because the week I started the manager left and so the whole place was chaos really. I don’t think I was given adequate supervision at the time and I was quite scared at being left to my own devices really. Nothing bad happened and I got through it and hopefully, it made me pick things up quicker. But I think that it was quite unfortunate because there was no strong manager. A new manager started a few months after that and she was very good. It was difficult in that way but then I don’t see how that would be any different if I was on a rotation or just starting somewhere as permanent staff.”
3.4.3.5 Reflective experience which highlights the intrinsic demands of care services
I asked John if the scheme had lived up to his expectations and he answered,
“Yes, more or less! I mean, there’ve been various issues on the ward and problems on the ward but that’s what you’d find if you were working on one of those wards.”
This comment provides yet another example of how the detailed nature of the data acquired from in depth interviewing can help in the avoidance of uninformed speculation. It would be easy to speculate that John’s ability to see the nature of the wards as they really are, and his ability to differentiate these from other issues arose from insights acquired from the work based learning degree; and indeed that could be so. However, it is equally likely that John’s insights arise from his previous experience.
John had been nursing for some time before joining the scheme and spent his first placement on the acute ward where he was employed when he joined. He said he had been happy to stay there and was also happy with both his second placement in intensive care, which is what he had wanted, as was his third placement. He had been on this third placement for some time and was now being employed there. He stated,
“I’ve got a place as an acting F grade at the moment. I started a week ago. I’m on the intake services and we don’t actually know what’s going to come in and how busy we’re going to be. Everyone does work on the intake service but it’s on a rota and this is our day in there.” He added, “It’s been very nice here.”
3.4.3.6 Length of placement
Clive was only vaguely positive. He had said that the rotation part had attracted him because
“…as a student you do some placements but the placements on the rotation scheme are for about eight months so I felt I would gain a lot of knowledge and skills in different settings over eight months.”
However, he seemed reluctant to speak in any depth about his placements. He simply remarked,
“It has been good and my expectations have been met to a certain extent.”
3.4.4 Rotation nurses who were satisfied with one placements but not another
It is worth noting at this point that it is not possible, from this study, to ascertain if the order of ‘good’ and ‘poor’ rotations is salient. A ‘good’ first rotation could lead to high expectations for the next one whilst a ‘good’ second rotation could come as a pleasant surprise. Similarly, the extent to which any individual is affected by positive or negative experiences will be influenced by many factors. Further research could, perhaps, provide pointers.
3.4.4.1 Support from university tutor
Two of the rotation scheme nurses were pleased with one of their placements but not with the other. For example, Sarah explained,
“The first placement was good. I was on (name omitted) ward which is a rehabilitation ward. It was alright because it was learning. I was new and probably a bit naïve because I had just qualified. So that was more of an eye opener. But, because I was going to college, it gives you an awareness as well so you know what’s wrong and what’s right. So, going to college has helped as well because it complements the whole system and you know where you’re going wrong and where you’re not. So that has given me the confidence as well because I can challenge people a lot more here. I can say, ‘Well, things have not all been done because I can see that it’s not good enough’.”
Sarah’s comment about college, when she said,
“It gives you an awareness as well so you know what’s wrong and what’s right”,
This is important for the scheme. Education, particularly of the work based learning kind, can help to identify and clarify the correct and the wrong ways of doing things and can help the rotation scheme nurses to cope with issues, and engender change.
3.4.4.2 Retaining factors
Sarah continued,
“When I came in, I think the rotations were more important because it was about gaining the experience. Unfortunately, I haven’t had the most pleasant of experiences so that has probably changed. Now I’m focussing more on the degree part because it’s more interesting. It’s something that motivates me and I can see possible changes that can be made. However, I have tried to introduce some of the changes but people are not willing to introduce change.”
It is not possible to quote Sarah about her second and current location except to say that it is a high dependency ward which is a lot more difficult partly because there is high staff turnover and, as Sarah said,
“The turnover is very high and it so difficult to constantly work with new staff and be consistent… have that kind of consistent approach.”
She added,
“I used to be a lot more involved on the rehab ward. I’ve found the high dependency ward quite stressful and I am thinking, ‘What am I doing here’, and I’ve questioned my practice a lot more because I can’t see what therapeutic thing we’re doing besides containing them. I’m just doing the ward routines and that’s it. I question myself as to what I am doing on this high dependency ward. If you look at what I did on the other ward, there were people with quite a variety of illnesses which I could relate to and help. So, it’s a lot more difficult here because every day is a constant. You find yourself arguing and those kinds of things.”
3.4.4.3 Positive leadership
Michael explained,
“I’ve been on a female long stay ward. It’s kind of rehab or, I would say, there are many personality disorders and dual diagnosis. The manager was very, very positive towards the course. She was really nice and encouraging and she said would I like to work with her when I’d finished the training. I said to her, ‘I haven’t decided where I want to work really. I want to carry on and see my plan of where I want to be. I don’t want somebody choosing for me’. She accepted that.
“I really enjoyed it there. There was clinical supervision; they have groups under supervision; they have meeting with the staff. On the ward I’m on now I haven’t had one single staff meeting and that’s after six months. You imagine staff meetings are a chance for you to air things. All you see is they’ve got the information book and you see all sorts of crap that staff will be writing against each other and those things should… It’s like splitting the team. There’s not a team sometimes when you work.”
Michael was not sure where he was going next but after his experience on the second placement he was feeling very anxious.
3.4.5 Misgivings as to how the placements were arranged
The group who had some misgivings about the way in which those placements came about had various concerns. They are dealt with here in order of the severity of those concerns starting with the least severe. Again, it is important to note that the misgivings do not necessarily mean that placements were not both enjoyed and useful.
3.4.5.1 No community placement
Because it would identify Kim’s location, I will begin her comments part way in. After she had joined the scheme and chosen the hospital in which she would work, she had discovered that her choice would mean that there would be no opportunity to work in the community on her final placement. Kim said,
“Initially I was angry. I thought that I had probably made the wrong decision. They gave me the wrong impression. But now, because I have started doing the course I get to take as much as I want from the course and I will be then able to implement it in this environment. So now I don’t really see the disadvantage I have got. But initially I thought I was going to be disadvantaged. The course is designed in such a way that it can help you whatever client group you are working with because it is work based.”
3.4.5.2 Retaining factors that rescue the situation
Kim’s comment, which includes high praise for the educational part of the scheme, demonstrates that even when the rotational part of the scheme does not work perfectly from the point of view of the rotatee, the situation can be rescued by the individual concerned meeting his or her own needs by making good use of the available resources.
In this instance the cause of the problem was the nature of the placement but, in hard to staff areas, it will always be possible, even likely, that the conditions will be far from perfect. That being so, in order to minimise wastage, it may be that more attention should be given during selection to the kind of capacity demonstrated here by Kim. However, this is not the only factor that makes for success as can be seen below when quotes from Tony are presented.
Kim’s next comment also highlights a characteristic of hard to staff areas, at the same time demonstrating how motivation and good leadership can actually arise from difficult circumstances brought about by a lack of resources.
3.4.5.3 Learning through risk taking
Kim was fairly positive about her placements saying of her first one,
“It was great but then I wasn’t very lucky in terms of the resources that were there because there they had a lot of people off sick and most of them were team leaders. So, although they really wanted to support me they didn’t really have the resources to do it. And that was so for a good half of the placement. But what I managed to get from it was, because they didn’t have people to support me I ended up having five beds by myself, trying to do different things. I started taking charge of the ward within two months of being on the ward. So, I actually learned from that experience. And the ward manager there was very supportive and so it was a very good experience. Also, it coincided with when we were doing the assessment module at the college so leading on an admission ward doing a lot of assessments and also doing some college work, or doing the assessment tools at college, was excellent.”
She added,
“Now I’m on a rehab ward, a medium dependence ward, which is going well on the whole but there I have had a few problems with staff here and there.”
3.4.5.4 Late decisions about placements
Robert’s first placement had been on an acute adult ward and his present one was with elderly care. Asked where his next placement would be Robert responded,
“At the moment I seem to be in a cloud about what the next one will be because the counterparts in the other Trust already have an idea of where their next rotation is. But when I rang the coordinator, I was told that we wouldn’t be told until later.”
I asked if that was rather unsatisfactory and he said,
“It’s supposed to be in June, the end of June. I suppose time will tell. Last week I discussed it with my ward manager and he told me he has not had any gist about where the next rotation is most likely to be and that I should discuss it with the nurse manager here. I wanted to speak to her last week but she was not available because she was on another assignment elsewhere.”
Robert continued,
But when I asked him if there was any chance that he would be able to his reply was,“I would prefer to go to a rehabilitation ward because I’ve done acute and elderly.”
“Well, like I just said, time will tell.”
3.4.5.5 Recruitment to and retention within the organisation
I asked Robert what he had thought about his rotations but his reply seemed to refer more to the Trust. He said,
“It’s not been too bad. At least I’m achieving the desired result which, basically, has to do with staff recruitment and rotation. By May or maybe early June I will have been almost sixteen months with the Trust which at least the Trust has been able to retain.”
Robert’s response when I asked him if he would stay with the Trust demonstrates the importance of the effective management of the rotation scheme. He replied,
“Well depending on where… if the next rotation is not too favourable I will possibly leave. If the next rotation is quite favourable and it’s quite good, I don’t think I will have cause to leave.”
3.4.5.6 Satisfaction and retention
The same applies to Ruth who was happy with her present placement. She said,
“It has worked well because I am actually quite satisfied with the ward that I’m on just now. It’s an admissions ward and it’s flowing, and it’s exciting and stimulating; I tend to get bored quickly. It keeps me going, you know, and I’m quite happy with working there. Of course, I’m going to college and you get ideas and bring them back into work and you share them with colleagues and stuff. So, I’m actually finding that quite good. So, it has worked out. I’m quite glad that I joined the rotation.”
3.4.5.7 Staying in the placement
Referring to the next placement, Ruth, who had worked on one ward in the hospital before joining the scheme, commented,
“I’ve been on three different wards in this hospital and really, if it was a case that I could stay on where I am now I would be happy to do that but if I have to move on to another ward in this hospital I just might take a walk. You don’t want to leave on those negative experiences. That’s one of the biggest bones of contention at the moment, people wanting to move around. I mean, I myself would like to move around but I’m quite happy where I am at the moment. If I can stay on there that’s fine but if not, I don’t think there’s anything else we could learn here.”
‘Staying on’ was an issue that came up throughout these interviews. When people fail to move on to their next rotation this prevents someone else from moving in and thus reduces choice for others.
Questioned about her first rotation, Ruth who had worked for six months between gaining her diploma and joining the scheme, answered,
“My first rotation wasn’t too bad, you know. It was on a high dependency ward. I stayed there for six and a half months. It’s supposed to be eight months but because of the way the course started, we ended up having to cut it short. It was better than where I was before. So, in a way, I got what I wanted. I stayed there for six months because I wanted to establish myself, which was the bees knees.”
3.4.5.8 Overcoming disappointment
David’s experiences really highlight some potential pitfalls if the scheme is not managed effectively. David, who had had considerable experience before joining the scheme, had been disappointed that his first placement was on an acute ward because he already had experience of that sort of environment. However, he seemed to have accepted that as inevitable commenting,
“So, I said to myself, ‘I’ve never worked in anything but acute’, and I was very disappointed from the very first. But I got over that and worked for the eight months. I always make the most of what I do. I consoled myself that I’d never been on an acute in ward in London so I just decided, “Ok I’ll just make the most of it then’. So yes, it was a great experience.”
So David had turned a disappointment into a success which, as discussed when presenting quotes from Kim, is an important capability for rotation scheme nurses but there were feelings that he carried with him that could surface if he was faced with further problems.
3.4.5.9 Lack of orientation and induction
In general, David’s concerns were with the run up to a new placement rather than the placement itself but he did comment about the start of his first placement in a way that once again shows up the problems faced in hard to staff areas. He said,
“Well, to begin with I was upset about orientation. I constantly asked for it but I never got it. I was just told that, ‘Because you’re experienced, you just have to tell us what you want to know’, and I said, ‘It is not about that. It is a standard procedure that you orientate people who are new. Whether I know or I don’t know the fact is that I know that I do not know this environment. Yes, I can use my experience but it is my right to be orientated fully on the ward with somebody to go through the induction pack’. I have the Trust induction, no problem that is a standard one but on the wards… I don’t know about other wards but on this specific ward induction or orientation was very, very poor.”
3.4.5.10 Progressive disappointment and lack of choice
Further problems did arise for David when the time for his second placement came around. He exclaimed,
“The second one, I was very, very disappointed. I went through a lot of emotions and upset and all this because, prior to moving, we were given forms to fill in and make choices and the choice that I made was rehab, because I remembered that in the list there was rehab. So, to my surprise when I received a placement it was on another acute ward and I just went absolutely… I was upset, totally upset.”
David then went on to explain that he had found little support from those organising the scheme, stating,
“And there was no support for us whatsoever, not even, ‘We understand, we’ve made a mistake’. There was nobody to take responsibility. You just had to accept that, there’s nothing that can be done. I was upset because when I applied for the rotation scheme I’d already applied at the (hospital name omitted) and they were begging me but I thought that this looked like a good opportunity. I’ve always wanted to go to the (hospital name omitted) but when I saw this I just put that aside. Coming across all these disappointment I was really upset. At the time I prepared myself. I thought, ‘I’m just going to look for a job because I’m not doing another eight months in acute’”
David’s next comments would inevitably identify both him and the person with whom he was communicating. Suffice it to say that he did eventually get another placement and, as he put it,
“…and so, at the last minute, I went to the ICU”. He added, “That’s where I spent the last eight months. That was absolutely great, it was a great experience because I’ve known sections forty eight, forty nine, forty one, all these forensic sections but I’ve never actually worked closely with people who have been on those sections. I’ve learned a lot.”
3.4.5.11 Successful negotiation
David’s experience shows that the possibility of complaining and negotiating does exist but nevertheless his anxieties continued with his third placement. He understood that he was to move into the community but, as the time drew near, he found that the placement was in doubt. He said,
“I phoned (name omitted) who said basically that there were no community placements. I said, ‘This is a joke. I think it’s time I looked for a job. I’m not going to do this again. I’m not going to go through this again’. I was very upset because I was thinking that nearly two years of my life had been wasted. I could have got a job and I would be somewhere by now. I’ve wasted my time joining the rotation and this is just not going well. I wrote a very long letter. I didn’t know who it was for but I just decided to express all my feelings in this letter.”
3.4.5.12 More than filling gaps — career planning
David then spoke about his conversations with various people and the anxiety over what would happen to him. He said,
“That was my very last week and I was thinking that this is the last week and I have no idea where I am going, whether I’ve got a placement or not and I cannot stay in the ICU because they won’t have my funding either because they’ve got somebody coming to replace me. So it seemed that it just meant that I was not going to have any job and to me it felt that the rotation was just about cheap labour. The attitude seemed to be, ‘Ok, so you’re filling in gaps where there is a shortage and it’s not really about you. You just have to go there and hence all of you have to go to acute because that’s where they have a shortage of nurses basically. Why should you replace in other areas that you are really interested in’. So, I was quite upset and that’s when I just decided to put everything in writing. Then I was left a message on the Wednesday saying that I’d got a place there. That was the Wednesday before I started on Monday.”
3.4.5.13 Respectful and timely communication
David’s next comment, together with responses from other rotatees, indicates that being informed in good time about placements is a key issue for any rotation scheme. In answer to a question from me he said,
“Yes it was very stressful, especially when it comes to being placed.”
3.4.5.14 Community placement
In relation to his community placement I queried,
“So you’ve been here only a week. How does it feel up to now?”
He replied,
“It is very different. It is the kind of experience I’ve been longing for. I know it’s not going to be easy but I will make the most of it.”
3.4.5.15 Staying in placement when she did not want to
Ellie was unhappy with all aspects of her rotations. I had asked her why she decided to come on the scheme and she had answered,
“It seemed like a good idea at the time because I didn’t really know what area I wanted to work in or what to expect. So it seemed promising that I’d have three placements in different areas and then, after that I figured that I’d know exactly where I wanted to work.”
I then asked if that had proved to be the case and she replied,
“No, because I’ve been on (name omitted) ward for the last year. When I started in May, I was supposed to move on in October but I was told that I had to stay on here for another eight months”.
I asked why that was but much of her reply would identify people. She finished her explanation by saying,
“…so I was one of the unfortunate ones who didn’t move.”
She explained that some people moved and some people didn’t move but she didn’t know what that depended on. She did add,
“Some people within this Trust did move but then people at the other Trust, I think most of them, moved. Just about half of us moved from this Trust.”
Ellie had been on elderly acute assessment and was going on to adult acute. I asked her how she felt about that and she replied,
“Not very keen any more. I’m just sort of doing it because I have got this far on. But I’m not as keen as I was when I started although I’m very happy socially.”
3.4.6 Rotation scheme nurses who did not rotate
Two of the rotation scheme nurses interviewed had not rotated in spite of that being a specific part of the scheme. Both had similar reasons for not rotating and their reasons cause one to wonder if flexibility in this matter might or might not be a useful strategy.
Tony said,
“When I joined it I felt that having done a lot of temping in the past and having just recently finished my training that moving on would actually not be a problem and I think… where I went initially, I ended up staying there. It is an acute ward and I found it quite overwhelming at first because I trained in Scotland.”
3.4.6.1 Feeling comfortable plus ‘having’ to stay
I asked what made it overwhelming and he replied,
“Just the environment; quite chaotic; very loud with a lot of anger and aggression which I hadn’t really encountered previously so there was… at that time there were issues within the team but a core of strong team members. I started in April, so we’d be moving in October and that would be six months. I really felt that moving after six months was too early for me. I’d not got accustomed to things and I hadn’t actually got to a point where I felt comfortable. That was all a part of what was coming in front of me and I knew that so I didn’t really want to pick myself up and go somewhere else. I wanted to be able to feel comfortable and know that when I did move on that it was the right time to move on. So, I ended up doing two rotations there. And then I’ve got another job now at (place omitted) which is actually permanent. So, I won’t be moving again but I just didn’t feel ready to move which was quite interesting because when I read the advert I thought, ‘Yes, this will be easy. It will be very much like placements when you were at college’, but I think the difference between being a student and being trained was that the expectation of the role is quite different and the responsibilities are quite different. I just couldn’t move myself again; I had to stay.”
I asked Tony if he had any problems about not rotating and he replied,
“Fortunately, what happened for me was that I actually felt at the time that to stay with what I was doing was more important … and I think also because I’d had a lot of change in my own personal life and I just needed to have something solid. So, I was prepared to say, ‘Well, if I can’t… if this isn’t an option then I’ll come off the course because I need to do what’s right for me’. Then I spoke to my manager and my sector manager and she was very keen that I carry on with the academic side of it if I was happy to do that. So, there was a time when I thought it might not be ok but it was.”
I then asked about his present placement but he replied,
“This is actually a post that I applied for. Whilst I was working on (name omitted) I was doing some night shifts to find out about the (name omitted) service here and from that I was seconded in and from there I was asked if I wanted to apply for a position; a permanent position because the whole department’s expanding. So I did.”
3.4.6.2 Working as a team
Tony added,
“And also, I think, in (name omitted) because it is a smaller team because of the nature of the service, it works as a consistent team, whereas on a ward the team that you work with changes on a daily basis and there are some styles that work better together than others and the notion of actually creating a team although important to managers was not, maybe, so important to some of the people that work there which, again, I found quite stressful. Whereas in (name omitted), team work is quite important to everybody, because it’s a relatively young team as it stands at the moment. So we’re keen that that’s one of the things that we foster amongst ourselves.”
3.4.6.3 Accommodating different work needs
Tony had made a permanent move into a dynamic new area and all the indications are that he will be successful in a leadership role. However, his progress appears to be different to that of David and Kim in that he clearly needs security both in his surroundings and in his contact with a team. Such needs are not, by themselves, weaknesses.
3.4.6.4 Being asked to stay
Anne did not join the scheme immediately after gaining her diploma. She explained,
“And then I was employed at (name omitted). First I was on (name omitted) ward for the elderly for about six or seven months and then joined the rotation scheme. Then I went to (name omitted) for three months and on (name omitted) ward as my second rotation. I was actually asked to stay on (name omitted). I like working on this ward. It’s an acute ward and it’s a good ward. It’s very interesting and I decided to stay on it and the ward manager decided to facilitate for me.”
Anne had said that what drew her to the scheme was the opportunity to rotate so I asked if she had just decided that she didn’t want to rotate any more. At first she said that it was her manager that had decided for her, (presumably because she offered her a permanent post), but then she added,
“I just realised I probably… it was constant changes, you know, change is not for me. It’s probably not for me. I just get so comfortable. I was just comfortable here so I decided to stay on.”
3.4.6.5 Staying but encouraging others to rotate
It is difficult to draw conclusions about Anne’s reasons for not continuing to rotate. Particularly since she went on to explain,
3.5 — Rotation experiences“Well, what I do, I will encourage people. I say, ‘It’s good. You need to grow and if you do it will help you’. So, I encourage them to join. You know, I tell them, ‘It’s no use if you start off and you just stay in one place. Get a feel of different areas. You have to be objective’. Even I can be objective even though I stayed and didn’t go on the last placement. I think if, you know, someone young… because most of them are younger than I am, some of these are twenty something; twenty one. They’ve just finished. It’s good that they go and they get a feel… consolidate their training because, remember, when you are in college doing the diploma you go to some places for six weeks or three months. When you are starting to understand the meaning of your studies you have to go somewhere else, whereas on rotation the placements are of eight months. So, by eight months you’ve gained confidence; you’ve gained knowledge.”