Section Three — Findings and Discussion (Continued)
3.10 Value of the scheme for the clients of the experienced nurses taking part in the scheme
Writing this sub-section has been a rather frustrating experience because of what had to be omitted. Confidentiality and above all in this case, anonymity, are of paramount importance in research of this nature. The projects that have been or are being implemented as a result of the Experienced Nurse Job Rotation Scheme are, or will be, of significant benefit to patients and clients as well as to colleagues and to the NHS as a whole. However in most instances, to describe them in any but the briefest of terms would inevitably identify the individuals who are undertaking them and thus expose some very personal comments.
3.10.1 Good service
One example that can be identified without such fears relates to Kevin’s comment in 3.1.4 when he was explaining how he had used reflective practice in his work. He said,
“We’ve done the ground work for individual services and that’s good for the clients because they get good services and it’s good for us because we get the contracts to set up the services. Hopefully the department that we’re working with have got the confidence that we have new ways of thinking that will be led by us. I think that benefits everybody.”
3.10.2 Partnerships with service users
Another quote from Kevin comes from when he was referring to the value to the National Health Service. He said,
“And that comes with service users as well. You’ve got to get service users on board because they’re the people who the service is for. So I think what I’m doing is benefiting everybody really.”
3.10.3 Research projects
The value to clients was evident from the description of the projects and from the explanations of what is taking place but not all of the experienced nurses spoke other than in passing about how clients had benefited from the nurses being on the scheme. This was possibly because, in some cases, they were only indirectly involved with clients. Nevertheless, in much of what was said about the value of the scheme to colleagues and the Trust or health service there was an implicit reference to clients.
For example, Jonathan referred indirectly to the benefit to clients when he said,
“What’s happening now, for example, is that I’m doing something that appears to be quite pioneering or so I’m finding out. I’m working alongside a service user, both of us in an equal partnership, doing a .... course for people. It’s a twelve week thing and it really seems to have taken off. All the service users are really keen on it; it’s got a lot of plaudits.”
3.10.4 Suitability of staff for the scheme
Another indirect example arose when Kevin was discussing who the scheme might be suited to (see 3.14). His comment was about those participating in the scheme but it shows the potential of the scheme to benefit clients/ patients. He said,
“With a lot of people who take on a degree, it’s all about themselves; it’s all about their careers. But, certainly the group I was in, I don’t think there were many people who were like that. We all wanted to do it, not just for ourselves but for the client group that we’re looking after.”
When talking about what his colleagues had gained Colin said,
“And that had a knock on effect for the relatives, children or loved ones, which then benefited my colleagues.”
3.10.5 Impact of research on research participants
Colin added,
“Day to day I was very aware of not wanting to encroach too much on people’s time and space. I took myself off and did my research and it probably impacted more on my research subjects, the .... workers. And again, I hope that would have benefited the work they do with their clients.”
3.10.6 Improving communication skills
Chris argued,
“I can see the client benefit as well because again, the way I think and I speak with clients has changed. I speak with the clients in the same way that I speak with the .... . I use reflective practice within the framework of counselling now. When I have a session with a client I always go back to when the client started with me and discuss how far we have gone and what we are achieving together and what we need to do in order to move forward. Something may not have worked in the past and we may have to find something alternative that may work in the future. So again, we are reflecting on the intervention and trying to find a new solution. So that has been very constructive.”
3.11 Value of the scheme for the organisation / Health Service
Everyone but Jonathan had something to say about the value of the scheme for the Trust or Health Service. This is perhaps understandable since Jonathan works in a university but it should be pointed out that its value was implicit in parts of what he had to say.
3.11.1 Medium/long term
Chris’s response to this topic is worrying. It indicates the importance of a change of employment or at least a secondment or rotation as a requisite of the scheme. As mentioned earlier (3.3.1) he had returned to his original job from secondment and the completion of his master’s degree did not lead to any form of change in his employment. Chris did not refer directly to what the Trust had gained. Instead he argued,
“The Trust has a personal development plan for any individual. It’s up to each individual to decide what they want to do. Not everyone wants to be academic. My aim is to progress up the ladder. If you want to go into middle and higher management you have to have a degree. That’s a requirement. When I requested to go on this programme they agreed to support and fund me. But I am in conflict when they invest in me but they don’t use me. This is where the problem lies. I have asked management why they are investing so much and not taking advantage of it but I don’t get an honest answer so I don’t know how to answer this question.”
However, there were some positives in Chris’ situation. I suggested,
“I take it, from what you said that you’ve told me it would be worth them doing it again?”
Chris responded,
“Well, it depends! My view is that each individual has a different sort of goal. I have shown that my colleagues have benefited and the clients have benefited and that the Trust has benefited indirectly in a way by giving service to clients. But each individual has a different sort of goal. If you want to satisfy the client, the Trust and your staff, it’s going to be a difficult goal to achieve. My aim was to move on, but although I have not moved on so far, I have enriched myself from an empowerment point of view. I do my job better and I have more confidence. I would encourage the Trust to have this kind of scheme or project again because I can see that people benefit and the patients benefit although you cannot really measure this.”
My probings with Tania did not seem to be effective and from what she had said it did appear that she has not linked up her aspirations with her achievements and gained satisfaction from this. Consequently, after she had explained what she had achieved by going into a new post and setting up a new service I said,
“So, if we just look at what you’ve done since you started, although you can’t put it down to anything on the course and to nobody else but yourself, the clients have benefited, your colleagues have benefited and, presumably, the Trust has benefited a lot.”
3.11.2 Trust Board of Directors
To this Tania responded,
“Oh yes! I mean, my research dissertation is .... . There’s a Trust board steering group for .... and they’ve requested a single piece of work be done within every other borough within the Trust and they’ve taken my questionnaire as a guide for people to look at. So the research has been taken on.”
In the light of previous comments she had made, I said,
“But that may have been done anyway?”
and Tania replied,
“Yes! It gives you the framework and it gives you the timescale and it gives you a structure to do it so maybe it guides you a bit because I had to do it for the course.”
3.11.3 Retention
Colin’s response will resonate with those who originally set up the scheme. He said,
“The Trust has retained me. I think I was getting to the level on the ward when I was ready to leave and I might have looked outside the Trust so in terms of staff retention it’s been helpful.”
He added,
“And they’ve now got a graduate nurse whereas before I only had a diploma. I’m more actively involved in teaching and educating than I was so that’s an extension of my job role. That’s with students and staff at the .... I mentioned.”
I asked Colin how he would sell the Experienced Nurse Job Rotation Scheme to the Trust. He replied,
“I’d go back to what it was that caught my eye in the beginning. It was that flyer saying, ‘Are you stuck in a rut’? I think a lot of people perhaps feel unappreciated and unmotivated in their jobs and I think it’s a way to challenge yourself. It was very stimulating, the learning and certainly the rotation aspect was really, really beneficial.”
3.11.4 Partnerships
Kevin, who is now working in the voluntary sector, explained,
“We constantly get feed back. We’re really praised about this new service and you don’t get that from statuary agencies because they’re quite static, not a lot happens but they wanted to develop it and that’s because we’ve not shoved my ideas, we’ve grown them there and made them feel part of it. But that’s because I believe in what I’m doing and I believe these services are right and I’ve got to make them believe that as well. Once I’ve got them on board then we’ll work together. Partnership work can be quite corny; it doesn’t really mean a lot but if you can get it and you can do it right it’s brilliant, you get a brilliant outcome from it. You’ve got to get people on board, you’ve got to get your partners on board; you’ve got to make them feel that they actually own something before they’ll become successful. If it’s just lip service you won’t get anywhere and you’ll get pulled up for it. As soon as something goes wrong it becomes your responsibility rather than shared responsibility so it’s important that you develop the partnership and bring peoples’ ideas on board.”
3.11.5 Encouraging reflection upon practice
Judith explained what the Trust had gained in the following way,
“I think all learning, as somebody gains personal development or has knowledge that they didn’t have previously, can only be of benefit to the service because it will be put into practice. How do I put my reflection into practice! I can encourage others to reflect and I have encouraged all the staff to actually start building up their own portfolio already. I know as a nurse, we should have our own portfolios. But it was never encouraged. It was said in e-mail or a memo, ‘you must keep your portfolio going’.”
She then went on to explain how she had encouraged her staff to build up their portfolios and added,
“So, that has been the learning and I suppose in a way that has helped the service.”
3.11.6 Harnessing the creative energy of motivated staff
Richard’s comment referred to other members of the group rather than to himself or his work. He said,
“Its interesting because if you look at the group, some of them are very strong and determined… they certainly don’t fall in line with the normal, pleasant nurse; they are very determined individuals who stand up against organisations and you can see that in quite a few of them. They want to be recognised for who they are and for their contribution; not for being difficult and obstructive. And I can see four people in the group who have got that label and I don’t think they are like that at all when you get to know them. They are people who believe in what they’re doing because they believe it’s good for the patients but they’ve found it difficult to work in the organisation. They want something for themselves and that’s a big thing for me. In terms of value for money it’s about having people who, sometimes, managers say are difficult staff to manage and that’s because they are not average staff but are bright staff and your bright staff will always answer back. And I think that’s something about those staff who are resilient and I think the organisation will benefit from getting these people onto courses where they can go off and find out a bit about themselves and have the insight to apply that where they’re working.”
3.12 The nature of the modules
When the interviews for the first Experienced Nurse Job Rotation Scheme study (Lucock & Coyne 2003) took place people were unsure of what the modules were to be. The topic is of only passing interest to this study but it might help to put things into context and the following shows that even having completed the scheme participants were still somewhat vague about what they had done. This highlights the earlier argument that what someone would think relevant on one occasion may differ on another. It also highlights what was discussed earlier about people remembering much more if they were taking part in a focus group study where discussion within the group can stimulate the raising of many issues if time allows. However, Colin was preparing for a first degree whilst Richard was preparing for a Masters degree so there may have been differences.
Colin’s discussion of the scheme in general narrowed to a discussion of its educational aspect. I asked,
“What were the modules?”
Colin replied,
“We did a research proposal and a research project but before then it was a module accrediting points from courses we had attended. And we also did a literature review which led onto the research proposal. Things had a certain order and logic to them which was essential, I think.”
When discussing the RAL module Richard said,
“At the time it was, ‘I don’t particularly want to do this and I don’t particularly want other people to read it’ but it was certainly useful and then I whizzed through the other two modules. They were research planning, project planning and there was another one in the middle to do with research techniques or something.”
3.13 The group of participants on the Experienced Nurse Job Rotation Scheme
This scheme depended very much on the self motivation and self direction of the experienced nurses themselves and it was, to a large extent, a form of ‘distance learning’. However, the members were part of the group and in the first study of the Experienced Nurse Job Rotation Scheme (Lucock & Coyne 2003) some members indicated that they had great hopes for the group as a unit. Consequently it seemed important to discover if it had, in any way, contributed to the individual success of its members. As the following quotes indicate, the results were ambivalent and it is clear that the various members of the group went away with very differing perceptions of what had occurred.
Tania and Chris held similar views. The other quotes are representative of the rest of the group.
3.13.1 Forming sub-groups for self help
In her first interview Tania had discussed the value of learning within the group and I now asked her how effective the group had been in this respect. She responded,
“Well, of course, we didn’t really meet, or people didn’t turn up to meetings. I think groups are always helpful but again, priority wasn’t given to it because we felt nothing was achieved out of the meetings. Colin, myself and probably Jane attended most of the meetings and everybody else just came in and out as they wanted which gets away from the whole purpose of meeting. I was quite positive about the group when I started but now, probably not.”
Chris said,
“All the group members had good intentions to meet but we never did. It may have been time factors but there were also different interests. We were from the same Trusts but not from the same departments. There were a few tutorials together but we never met outside of those tutorials and at some point we lost track of what every member of the group was doing.”
Colin’s initial comment suggested a rather different scenario and this led me to say,
“So you did meet as a group. I got the impression that people were concerned that that wasn’t happening.”
He replied,
“Oh, no! People had to show a level of commitment and attend seminars and meetings. It didn’t always happen. Some people were away on holiday and it didn’t always happen as planned.”
I asked how often group meetings took place and Colin’s response was,
“It depends on where we were in the scheme. They were more frequent to begin with. It was monthly to begin with and then towards the end it got to about three monthly.”
I then asked,
“And did you meet up with other people off your own bat so to speak?” and Colin replied, “No, I don’t work that way so I chose not to but other people had sort of study groups.”
However, Colin did say at one point,
“What I got most out of meeting as a group was critiquing each others work and presenting it to the group which was an essential part of the assessment.”
3.13.2 Support
In his discussion of the tutor’s part in the Success of the RAL module Kevin had commented,
“But also, there was the support network of the group at the time which was very helpful. We were all supporting each other and that was useful.”
I asked,
“Supporting in what way?”
and Kevin replied,
“Well, just getting in contact with each other when we needed to get projects done and meeting up and taking about what we were doing and what we were thinking. That made you think you weren’t just doing it by yourself; you were doing it as a group. Sometimes when you were struggling a bit, if you knew other people were struggling it helped you to think, ‘Well, at least it’s not just me’. I think academically, Jonathan had done a lot of stuff and he was more experienced than us. He’d done the Thorn course. But we all had skills and a lot of positives that we used with each other. It was just a belief thing; I just don’t think we believed that we could do it. We had years of experience but we didn’t have any experience academically and we could encourage each other to do as well as we could.”
Jonathan said,
“The thing is, there was the peer support that showed you you’re not the only person like this and that gave you some confidence to realise you could move forward.”
On another occasion he was discussing the way in which he would like to develop a new course he was considering developing and said,
“But also, following the example of what I learned from the course, where we had the group meetings, I guess you could say that they would end up by being like action learning groups.”
3.14 The type of person who would benefit from the course and who would benefit the Trust
The interviews were quite unstructured with the topics either suggested beforehand or arising form the discussion. Neither Judith nor Jonathan got around to discussing this topic but it was interesting to note how strongly the others appeared to feel about it.
There does appear to be a thread running through all the responses but they are sufficiently varied and interesting to be worth quoting from each of them.
3.14.1 Stuck
When I first asked Tania,
“What sort of person would gain most from this approach, she responded, “I don’t know because it was aimed at people who might have been stuck in a rut and I’m actually sure those people on the scheme would have fought their way out of that anyway. You can see that those people who really need it are probably not going to go for it anyway.”
I asked,
“Do you mean people who could really do with shaking up a bit?”
Tania responded,
“Yes! They’re not going to go for it so I don’t know.”
3.14.2 Qualification
However, she responded somewhat differently when I argued,
“Most supervisors thought the D/E rotation scheme was very good but one or two said, ‘It’s really when you get to our level that you need a degree because you can’t move further if you haven’t got the qualifications’. I wonder if that is who it would benefit most; people who are getting disillusioned.”
At this point Tania said,
“Yes, it would benefit in that position; people who, maybe, have been at F for a while and need to know how to make that transition to G or H. It’s mostly about having the opportunity to perhaps change something or to do some research. I’m supervising one at the moment who’s quite stuck and doesn’t know how to move. If she had the structure of the scheme to do something and given time to do it… if she was given study time to do something that was work related where she can go through all the R & D consortium it would help. People just working in an F grade or even a G grade position aren’t going to do that because they’re going to prioritise client care.”
I asked,
“So it’s a case of finding the people who have got ideas?”
Tania responded,
“It’s about giving those people time to do it. That’s what it does for you. It gives you a sort of get out clause to say, ‘No, I’ve got to do this. The organisation has asked me to do this’.”
I posited,
“And you can use that, presumably, as a lever with middle management?”
Tania’s reply suggested the possibility of the scheme itself being used as a lever to help with negotiations. She said,
“Yes, because they have to agree before you can start.”
Colin was, I think, referring to the new employment that came as a result of the scheme when he remarked,
“I think to keep going for three years you’ve got to really enjoy your job for a start and be quite self directed. At a later date you’re not spoon fed at all. My time management has improved because you do have to do your full time job and fit your study in as well. I learned the hard way about time management in that I started trying to do this after work. But then I went to my manager and said could I use work time to use the computer in and that was fine. You just have to negotiate and get things agreed.”
3.14.3 Negotiation
I commented,
“So, to sum up, the success of this depends very much first on you enjoying your work and also on the cooperation of other people and, of course, on the quality of the supervision that you get.”
Colin answered,
“Absolutely! And you’ve got to be able to negotiate and ask for what you need.”
I replied,
“So you’ve got to be a bit pushy…”
and Colin agreed. Kevin commented,
“Oh, I think it’s for people who did not become so down trodden that they can’t motivate themselves. They can actually have enough enthusiasm to want to go and do a degree or do something that’s going to challenge them a bit. It’s that sort of person. People who are a little bit fed up really because they’re demotivated in their current job and don’t see any challenges in it any more. I certainly think a possible option would be to start off with your managers, relatively senior people. You’d look at your managers and say, ‘You’ve not got a degree but would you like to put in your experience and develop some sort of academic qualification’? We think we can support valid offerings for people to go to courses or giving them time off almost for good behaviour’. If you identify a select group and the one for me is ward managers… ‘We know you’re a ward manager, we know you’re under pressure and we know that you have ridiculous outcomes to try and meet but, in order to do that, do you think we can make you a good leader and a good manager by supporting you through doing something like the RAL’? We actually think your experience is invaluable and we want to help you to get some kind of qualification’. I think you would develop a lot of really positive managers. You know, if you allow your managers to do it that can cascade down to their staff.”
3.14.4 Unsuitable
I asked Kevin if there were any people who would not be suitable for a scheme using RAL and work based learning and he said that it would be people who,
“Are willing to put the work in because they want a degree at the end of it. I think that sort of person is not the right sort of person for the RAL.”
I asked,
“Because they would just do surface RAL?”
and he responded,
“That’s right! It’s all about inside! It’s about feelings and it’s about the working of the group and it’s about actually seeing what you can do to improve, not just yourself but your environment. With a lot of people who take on a degree, it’s all about themselves; it’s all about their careers. But, certainly the group I was in, I don’t think there were many people who were like that. We all wanted to do it, not just for ourselves but for the client group that we’re looking after. I think we were all generally good nurses but somehow had lost it and had forgotten why we became nurses. Once you get that back, it’s a good feeling to have.”
3.14.5 Motivated
Chris argued,
“I have a first degree and so have been through the traditional way of learning. I wanted to try a different way of learning. People who could qualify to go on the scheme have to be highly motivated and self directed. These are the qualities I would think of. I’m an example in that I am motivated and self directed. The tutors were around with the module directives and everything but I had to take control of my own work. This is where someone with an aptitude for doing their own work rather than being supervised will succeed. I am quite independent in what I do so I can relate to this kind of course but I don’t think it would be the right programme for someone who was has always been supervised or has been guided. They have to be quite motivated, quite independent and at a high level of the hierarchy. It isn’t suitable for someone who has just gained a nursing qualification. But also, on the down side, if people have been around for a long time and have had no exposure to any traditional learning I think it would be tough. It isn’t because they are senior and have been around for years but because they need to have the drive and the motivation.”
Richard said,
“I would recommend it to people who are committed. And they have to be committed.”
I had also asked him if the Trust should continue with the Experienced Nurse Job Rotation Scheme and he replied,
“The only way the Trust should go on with it is if they are very clear what group, in particular, it works best with. And the group that I see that it works best with… there was four people in that group who were amongst the most talented nurses I have ever seen, I can honestly say that. I certainly wouldn’t hesitate in recruiting them into my organisation and it’s recognising that there are wild cards in organisations and that the way you deal with wild cards is, in some ways, to set them a challenge. And I think the challenge was, ‘Well let’s see what you’re worth’. And I think that’s what wild people like; they like a challenge.”
3.14.6 Consolidated
Judith said,
“I think it would be good for other people. There are staff like me who need this course because, for whatever reasons, we haven’t completed academic courses previously. We’ve learned on the job and we need to be able to consolidate it. However, we are the staff who tend to get on behind the scenes. We get on and keep the service running and maintain the service and develop the service. We are less likely to put in the time for ourselves to develop ourselves.”
She added,
“But there would be people who would jump at the chance if it meant time out and they considered it to be an easy option and they would say. ‘Yes, I’ll do that’, and then just focus purely on the time it would take. It’s not an easy course. It doesn’t mean that the work is any easier. If you go on a modular programme you are given a set start and finish time and then there is an assignment every end of term and maybe a practical piece of work to do. That does take time but this also takes time. It’s not any easier, in fact it’s more difficult but there would be some who’d say, ‘Oh yes, I need all my time to do this. And that’s all they’d be doing, sitting at their computer typing out ...”
Here I interrupted and asked,
“But they’re not the ones who really need it?”
And Judith replied,
3.15 — Difficulties regarding the educational aspects of the scheme“I don’t think so. I think there are two groups of staff. There are those that are there because they want to be there and they feel that they have got a lot to offer and feel that they are doing a valuable piece of work. And there are some that are there for their own benefit, financially or a stepping stone or until something better comes up or just to pass the time. And whether they would gain anything from this programme, I don’t think so other than just the qualification at the end of it. That’s what they would get.”