Experienced Nurse Rotation Scheme
Phase one evaluation

Section Four
Development to Date
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Section Four — The Development to Date of the Larger Action Research Study

The Experienced Nurse scheme as part of the Action Research study

4.1 Introduction

Since, in this report, the opportunity has been taken to explain and discuss Action Research as a methodological approach as well as explaining the methodology chosen for the Experienced Nurse scheme it seemed appropriate to also explain the development of the Action Research programme to date. It is hoped that doing so will provide useful feedback to stakeholders.

Prior to the collection of data for the evaluation of the Experienced Nurse Scheme and on a number of occasions over the following months, a number of taped conversations took place between Patrick Coyne, the Principal Investigator for the Nurse Rotation Schemes and Ricky Lucock, the Lead Researcher for the evaluation of the Experienced Nurse Rotation Scheme, Cohort One. The conversations have provided additional data that describe and explain the processes in the development of the Nurse Rotation Schemes.

It is interesting to note that these taped conversations, which were originally unplanned and arose out of the need for feedback and understanding of how the Experienced Nurse Rotation Scheme was developing, have grown into yet another spiral of the Action Research Programme. They are providing an interactively reflective record of the programme as it develops which can augment the reflections of the Principal Investigator and help to keep the programme on track.

4.2 The Concept of the Experienced Nurse

Although, in 1.4 there was a Discussion of terms used in the introduction the concept of the Experienced Nurse was not one of them. This was because the Principal Investigator had argued that, as with other aspects of the Action Research Study this was an evolving concept that was not, initially, clearly defined.

In the context of the findings in Section 3, it becomes important to discuss the evolution of this concept. The key components of the concept were the capability for negotiating and changing things and the ability to influence the use of time in the workplace.

The original working definition was of someone who was ten years post registration; interested in his or her job; G grade or above; keen to develop his or her skills and who wanted to carry on working in health and nursing. Ideally, the Principal Investigator would have liked to use the term ‘Expert Nurse’ which he felt would fit the above definition but he was afraid that would deter many practitioners from putting themselves forward.

In the event, because of those who eventually came forward, it was found there was a need to expand the definition to include practitioners who were other than G grade or above; considered themselves to be experienced; were keen to work for the NHS and to develop their skill but who were only two or three years post registrations.

Any further discussion of the Experienced Nurse will be dealt with in 4.4 when the criteria for selection are discussed.

4.3 Advertising the project and the response to that advertisement

It should be noted here that of roughly 2,000 nurses in the two Trusts approximately 200 would have been eligible to join and when the Experienced Nurse Rotation Scheme was first advertised there was a considerable amount of interest. However, few people later came forward and said they wanted to do the course. Two did and, fortunately, they were from different Trusts. The first, Justine Trippier, argued that the fliers didn’t make the scheme look attractive and the second, James Dalrymple agreed with her.

Justine became the operational lead for Central and North West London and James took on the same job in West London. Justine, James and Patrick Coyne (the Principal Investigator and Scheme Leader) became the local development group. James and Justine changed the advertisement to make it more explicit and more attractive and they became the local contact persons within their own Trust for people who expressed interest. They found ten more people to join a pilot course of twelve practitioners. Had there been more applicants there would have to have been interviews but in the event that problem did not arise. Unfortunately, and for reasons unknown, two practitioners dropped out of the course before either the RAL module or the evaluation began.

4.4 Selection for the Experienced Nurse Rotation Scheme

When the scheme leader debated the model for the scheme it was really clear to him that it could only be constructed and operationalised if those Experienced Nurses were truly experienced — i.e. they understood how to negotiate within their organisations overcoming barriers, influencing other’s perception of the scheme and getting their vision operationalised. He felt that if they weren’t capable of doing that then they wouldn’t be a chance of them surviving on the Experienced Nurse Scheme.

He saw, and sees, the capacity to negotiate as a key characteristic of an Experienced Nurse and his test for this was to put out the advert; have people contact him and then ask them to put that in writing to him; negotiate the time with their managers to come to some meetings, then to negotiate with their managers to go on the course and for their manager to sign. He argued that if those who showed interest could not carry out such negotiations there were two possible reasons. Either their part of the organisation was not supporting them or they did not have the skills to negotiate. Either way they could not come onto this pilot scheme. As was demonstrated in 4.3, some practitioners did not proceed with their interest but unfortunately it is not known why.

This notion that, for this scheme at least, the Experienced Nurse should be someone who has well developed negotiating skills was not arbitrary. The point about taking Experienced Nurses into the scheme is that they have the capability to negotiate and change things. If they don’t then, in the scheme leader’s view, they are not Experienced Nurses; they are nurses who are learning how to influence systems.

The argument here is that there are different levels of learning about how to influence systems but for this scheme the practitioner had to be able to influence his or her line manager and someone equivalent or a rotation would never be achieved. Another thing that the practitioner had to be able to influence is time — time for study and, whilst it was built into the project that there are fifteen academic days a year, the likelihood is that more might be needed for other pieces of work. The legitimacy for that would be that it was directly related to a product for the organisation.

A further criterion for being selected for the scheme was ‘being stuck’. Managers do not perceive Experienced Nurses as problem staff. They are not trying to re-motivate these practitioners or trying to manage and control their behaviours. Rather, the scheme is about supporting practitioners who want to work in the organisation but whose attempts to progress have been, for one reason or another, thwarted.

Another criterion was that the Experienced Nurse should have a desire to change the work area or the quality of care delivered per se within the NHS. Of course this was not confined to the applicants. There had to be an idea from all three sets of partners in the scheme that there is was desire to improve something in the real world.

And along with this desire there was also the need for the practitioners to wish to increase their abilities to influence and to realise that if you are an agent in an organisation then, as an agent, you can be more effective in contributing to the business of the organisation i.e. you have leadership skills. Again, there had to be a willingness on the part of the other partners to nurture that ability to influence.

4.5 What the Experienced Nurse Rotation Scheme has become

The key concepts for the rotation scheme were, and are, retention; job rotation; Work-Based Learning and a formalised education; Action Research; and improving Service Provision to Service Users.

The original idea was that there would be two job rotations i.e. moving in both the first and second year. It soon became clear that this would not happen. People were unclear about exactly where they wanted to rotate to and the time it would take to negotiate such a rotation suggested that it could not be organised in the first year. Consequently, and prior to the interviews for the Experienced Nurse Rotation Scheme, the group, together with the group leader, swiftly developed the model to be one job rotation at the end of the first year.

In the event, some people did manage to negotiate a job rotation quite quickly and soon rotated but others only managed to achieve a rotation of one form or another by the end of first year. The nice tidy idea of two job rotations or one at end of first year didn’t work exactly like that. The point to note here is that this is an evolving situation well in keeping with an Action Research Approach.

Because of the differences between the timing of the job rotations and preparation for Work-Based Learning, it became possible to do the job rotation and the project separately. Indeed, eventually there came to be four types of job rotation:

This idea was evolving when the interviews took place and may account for some of the confusion displayed in Section 3.

A key issue here is that everything was in flux. Everything within and outside of these practitioners was changing at that time. There should be some interesting narratives at the next interviews.

4.6 Educational components of the Experienced Nurse Rotation Scheme

From the point of view of the Trusts concerned and of the practitioners joining the scheme the educational component of the rotation scheme was intended to serve two major purposes, one to accredit previous experiential learning if achieved (see Appendix 2) through RAL and the other to support educationally the rotational intent of each practitioner (as declared by the Experienced Nurses at the point of application for the Rotation Scheme). It is important that the educational component should match the individual needs and aspirations of the individual practitioner otherwise it would not be facilitative.

The work based learning studies programme allows taught modules to be undertaken as long as the basic minimum module requirements for work based learning are completed, and where the student is required to achieve extra academic credits to gain a qualification. These extra modules have to be identified and justified as part of the student overall programme when they plan it in their Programme Planning Module.

Given these parameters, wherever a practitioner wants to take forward his or her career the educational programme can be designed, through negotiation with the university, to actually support that move. An example would be if a practitioner had been working in elderly care but wished to move into child psychiatry. Much of their knowledge and many of their skills would transfer e.g. how to write a care plan, how to assess, how to manage services and risk etc. but they would need to acquire some additional knowledge e.g. about policies, some technicalities, etc. and they would also need to have some ‘real world’ updating e.g. what really happens in multidisciplinary meetings. The educational component from the university would help them address the updating through taught modules undertaken with the university and/or through one or two projects. Again the practitioners, like most students in the early days of their studies, were only beginning to fully understand the possibilities and limitations when the interviews took place and this. may account for some of the confusion displayed in 3.1.6

Thus, providing the basic minimum module requirements for work based learning are completed, practitioners can undertake taught modules from the taught programme at the university, or they can do projects. The final qualification, determined at the programme planning stage, can be constructed through Work-Based Learning projects designed in the Programme Planning Module at the relevant level to achieve the learning outcomes required or through data gathering, researching knowledge generation projects that would be something like a master’s dissertation or BSc dissertation.

Alternatively, a taught module can be undertaken together with an assignment for a master’s degree e.g. if a practitioner was interested in doing a crisis intervention job where the main issue is assessment, he or she could take a level four clinical assessment module with the university and also, later, complete a dissertation evaluating how assessment is done in the crisis management service that he or she rotated into.

The RAL module is an important aspect of the Educational component of the scheme. As mentioned above, its primary purpose is to accredit previous experiential learning but that is based on in-depth reflection about where you have been and where you are going and that reflection could help the practitioner who, by definition in this scheme is ‘feeling stuck’.

In terms of people being stuck, unless they have some sense of where they are and where they have been it is somewhat difficult to think about where they might go next. Consequently, RAL is also important because it fits with the notion of ‘unsticking’ people i.e. allowing people to identify where they are and what they want to change.

4.7 Discussion of emancipatory work in the Experienced Nurse Rotation Scheme

This scheme is an opportunity for people to participate in the NHS if they wish to, as opposed to leaving. It is an opportunity for them to influence the evolution of a particular form of educational programme; to exert their own influence in the workplace through their projects, their degrees, and their paperwork; indeed, through whatever it is they decide to rotate into. There is an opportunity to share this learning with other people and demonstrate that this might be a model that they could use.

However, all the above is possible with Practical Action Research but may not occur because what would not have been taken on board is the need to examine, challenge and, perhaps, change structures in the situation, be they structures of the work place, of a theory, or of a culture. It is possible to undertake Practical Action Research and find that nothing has changed and conclude that you have failed. The emancipatory part is partly the realisation that it really isn’t your fault; that the system is preventing change and that it is the system that you and the other stakeholders have to work to change.

What is interesting in this particular situation is that the group of people who came to join the Experienced Nurse Rotation Scheme originally came to join something that was organised by a manager across two Trusts but they themselves became a group of experts within that large organisation but outside of traditional structures. Their expectation of this project and their influence on the organisation as a consequence of their choice to participate in it will, hopefully, help them to emancipate themselves through the influence they bring to bear on their organisation and Service Users. And, hopefully, the process of being a partner in an Action Research study of this kind will enable them to understand not only that there are systems that affect their choices about how things work but also that they can influence those systems.

4.8 Communication — Website and conferences

A website was set up in the early days of the Action Research project. The aim was to use the website for sharing knowledge and for facilitating knowledge generation. The address is www.nurserotation.com and the original concept paper that gained funding for the rotation schemes is on the website together with information that provides more insight as to what the projects are and their origins. In short, a very embryonic network is starting to form.

Another form of communication for sharing the nurse rotation scheme work and also learning about other people’s work has been two partnership conferences on nurse rotation. These were set up between Chamberlain Dunn Associates who accepted the financial burden, and BKCW and West London who, with others, provided the materials for the conferences. Forty to sixty people who were interested in rotation schemes attended each conference and on the basis of their interest some names and e-mail addresses were placed on the nurse rotation web page under their own network.

In this way, relationships have been set up with the Homerton Hospital; St Anne’s Hospital in Haringay; City and Hackney; and the South London and Maudsley Trust, all of whom are carrying out and developing rotation schemes. Other groups have shown interest.

In terms of the community that is affected by this project, it is still early days. There is a small network of people who are involved in developing rotation schemes and are in some form of contact with each other. However, that community can be visualised as being without boundaries. In something as large as the NHS the influences come from many places and it becomes difficult to actually place a boundary around something small within it because people are always coming through, policy documents are always effecting them, the external stakeholders structures are always altering. Any community within the NHS, no matter how small, is somehow or other directly linked with the DOH and with two or three steps the practitioners’ work can be at somebody’s policy desk. Similarly, the people who are employed to deliver a service and the people who are on the receiving end of it are part of that community. The latter are not active members of any of the development groups but perhaps that could be something for the future.

4.9 The emerging need for a Professional Nursing Supervisor

From the taped conversations between Patrick Coyne and Ricky Lucock it transpired that whilst the Experienced Nurses had received Line Management Supervision and Clinical Supervision they appeared to lack Professional Nursing Supervision, and had done for much of their careers. This conclusion was reached as a result of the regular requests made by a number of the Experienced Nurses on the scheme to the Principal Investigator/ Rotation Scheme Co-ordinator for support with their RAL claim. As tentatively implied in Section 3, it emerged that they had difficulty analysing the vastness of their knowledge and skills. This may have been because they lacked a clear conceptual model of Professional Nursing as a point of reference. Consequently, a large proportion of their capabilities would be distanced from their awareness (e.g. direct care; education and training; leadership and management; and evaluation and research) and therefore, difficult to access and assess.

Whatever the reason, the progress of a number of the Experienced Nurses was dependent upon the willingness and ability of the Principal Investigator/ Rotation Scheme Co-ordinator to provide Professional Nursing Supervision.