Learning in Clinical Practice - Essay Example

Learning in Clinical Practice Introduction Quality care and cost containment are the expected norms by both providers and consumers in today’s health care system. The evident and rapid changes in the past few years demand that hospital management and registered nurses provide competence in service delivery, in addition to the safe development and learning environment of the nursing graduates in providing nursing care (Mandin, H., Jones, A., Woloschuk, W. and Harasym, P. 1997, 173-179). Thus, role of mentorship and supervision play very important role for the learning environment. It’s not that we don’t basically know what mentoring is; it’s not that it can’t be defined. There are plenty of definitions including some handy, sound-bite sized ones that range from the spiritual and almost purply poetic picture of mentors as leading us along the journey of our lives (Kinney Marguerite Rogers, Donna R. Packa, and Sandra B. Dunbar 1993, 89-96). We trust them because they have been there before. They embody our hopes, cast light on the way ahead, interpret arcane signs, warn us of lurking dangers, and point out unexpected delights along the way. Mentoring is a process that increasingly used in management development and the skills and techniques learned on the management development programme are put into practice through the support and help of an experienced manager back in the workplace (Allery, L. A., Owen, P. A., & Robling, M. R. 1997, 870-4). Main Body Learning environment did occur most frequently when the supervisor kept an equidistant position. This position is not only an open, non-judgemental, non-competitive attitude, but also includes the keeping of a continuous and stable focus on the RNs reconstruction of his interaction with the patient: in other words, viewing the nurse-patient interaction as a "system" with its own boundaries and frame. The patient can discover new material in the object as the analyst fails largely or completely to meet the patients expectations in certain areas-particularly the area of difficulties--which have previously always been fulfilled by virtue of unconscious steering mechanisms. Similarly, dynamic factors that frequently stimulate conflicts seem always to be present in the supervisory system and influence the learning process. Nevertheless, it is possible and desirable to maintain the frame and boundaries around both the patient-analyst and the candidate-supervisor systems. In most large hospitals there are orientation programs for employees, with instruction in hospital organization, policies and procedures. These learning and orientation is sometimes further informal instruction on the practical aspects of the nurse’s responsibilities in the ward. (Means in large hospitals not only formally but they also teach indifferently nurse’s responsibilities that is also believed to be very effective). It can be seen that this type of centralized orientation program provides an overview of the hospital and provide knowledge and skills relating to the environment. Care, W. (1996, 27-30) describes importance of supervision and mentorship from three points of view: an organizational phenomenon, a structural role and a type of interpersonal relationship. The organizational phenomenon. The mentor is given the authority to introduce the RN to the culture and operation of the hospital, thereby assisting with socialization of the employee. The hospital culture is unique, and through this process of socialization the RN may be made aware of the prevailing attitudes and values of the organization. Structural role phenomenon. With this aspect, primary emphasis is on the role development of the RN (Freeth, D., Nicol, M. 1998, 455-461). The mentor uses his/her professional experience in the work environment to guide the registered nurses in bridging the gap between theoretical knowledge and clinical practice, thereby increasing his/her level of independent functioning. Interpersonal emphasis. Where the emphasis is interpersonal, the mentor nurtures the nurses. This relationship is described as similar to that of a parent-child relationship. The older adult nurtures and educates the immature, younger individual. The effectiveness of the mentorship program can be related to the kind of relationship the mentor establishes with the nurse. The supervisor as a member of a training institute has not only the status, but also the power and responsibility to judge, evaluate, and influence the status of the candidate/trainee. Another aspect of supervision becomes highlighted by using its Swedish equivalent, "handledning”, which means "to lead by the hand", to help a younger, less experienced, less skilled, less knowledgeable colleague, candidate, or trainee to gain knowledge, skill, and experience (Freeth, D., Reeves, S., Goreham, C., Parker, P., Haynes, S., Pearson, S. 2001, 21, 366-372). Supervisor must keep in mind there is great more difference between new RNs and the one who are from a long time and learning environment help them to work more effectively. Thus in this environment, the supervisor may be perceived as a teacher, tutor, mentor, or someone to relate to, rely upon, and identify with; alternatively he might be experienced as judging or controlling in the interest of the trade or the body of professionals, or as a delegate of the "institution"(Clarke, B., James, C., & Kelly, J. 1996, 171-180). In the latter sense he can be a rival to fight with or one to whom the trainee must submit. Supervisor and trainee can meet in an isolated, secluded room with the intention of working on their task: the trainee to learn, the supervisor to teach. Nevertheless, they are part of the organization in which they work and are influenced by it and are influencing it with more or less realistic expectations and ideas connected with the culturally defined roles and status of the participants. These roles obviously have great potential for satisfying unconscious fantasies and transferential scripts. The trainees relationship to the supervisor is a composite of intrapsychic expectations and external "realities" (Barr, H. 2002). The task of the institute is to educate and ease the trainee. The trainee is thus a pedagogic unit or object of teaching and a therapeutic unit". The parties concerned have to deal simultaneously and on different levels with a number of options. Supervisors can be used to defend or defeat a faction, an idea, or a plan or to represent one "school" against another. The major task for supervision is to create a setting in which the capacity to learn can develop. To achieve such conditions is not easy and can be complicated by the trainee as well as by the supervisor. How can supervision enhance and safeguard the difficult task of learning, to help the trainee to understand the patient and his own involvement in the intricate interaction that evolves between patient and trainee therapist and between trainee therapist and supervisor? Is there any one way to do it, or are there as many ways as the interactions or even episodes that one studies? This uncertainty is further aggravated by the as yet unanswered question of whether we adjust our working strategies to the particular problems or impose our favorite strategies to confront them. Human understanding and ways of dealing with tasks and problems depend on, are influenced by, and are expressions of mental "structures" (Lichstein, P., & Young, G. 1996, 406-9). A cognitive style, which is a stabilized disposition of perception and cognition; a working style, related to the selective use of basic concepts and theories; and the defensive style, composed of character traits, transferences, counter transferences, counter-resistances, counter identifications, and so forth are a difficult task to depict these structures and to understand how they aid or hamper the process of learning and teaching. It is essential to establish a good "learning alliance" in supervision. This is based on the mutuality of goals in work that are dearly stated as well as experienced by both trainee and supervisor. The supervisor has to be "holding" and "containing" towards the trainee. By holding, I mean the establishment of a phase-specific security in the working relationship; by containing, I mean the provision of an emotional and cognitive "space" to enhance the trainees recognition and understanding of his conscious and unconscious experiences of interacting with the patient. The keeping of the frame in supervision and observing the consequences of breaking it is of crucial importance to be able to comprehend the complex interaction between patient, analyst, and supervisor. Frame has stationary aspects, such as agreements on goal, payment, and methods, and general rules for supervision as well as for the supervised therapy; and a mobile aspect, which is the continuous reflective review of doing the work together. Among supervisory techniques described in the literature are: • structuring the supervisory and/or therapeutic interaction directly and indirectly; • giving information on principles, dynamics, and technique; • clarifying, by calling the trainees attention to some gap or ambiguity in his observation and/or understanding; • reformulating and checking preconceptions; • confronting the trainee with misconceptions, distortions, warded-off counter transference reactions; • Exploration in relation to content of the ongoing process, or of the ongoing relationship; • expounding, such as supporting, informing, summarizing; • giving general technical or strategic suggestions; • discussing the formulation of goals for the actual treatment; • directing the trainee, and prescribing strategies for future sessions. (Varekojis, S.M. 1999). The teacher can be questioned about his aims, intentions, and concerns as well. Learning is more subtle: it is difficult to determine if it has occurred, if it is functional, and if it is an illusory "reduction of cognitive dissonances"(Moore, S. M. et al., 1996, 165-187). The following statements can define the main assumptions concerning learning: • According to a basic assumption, humans organize their actions to reach certain goals in accordance with their interpretation of a specific situation; • Learning is directed, or at least strongly influenced, by the existing internal structures; • Conscious and unconscious intentions as well as the security principle and the use of psychological defenses interfere with the processing of information; • Aspects of learning that are related to imitation and identification is influenced by the quality of object relationships. (Rudmann, S. V., Ward, K.M., Varekojis, S.M. 1999, 109-112) The distinctive character of knowledge is organization, dependent on operations belonging to various developmental levels. One expects that trainees learn in two ways: assimilative and accommodative. Assimilative learning means that the new information is added to the previous, thereby increasing already existing knowledge. The therapist can add newly gained experiences, observations, information, and theory to those he already has, which then become enriched, differentiated, and consolidated. Accommodative learning means that encounters with new information result in a fundamental modification of existing cognitive schemata, so that the new encounter can be dealt with. To deal with the information, the trainee must actively engage himself in warding it off or "accommodating" to it by restructuring previously held knowledge, points of view, and theory (Zwarenstein, M., Reeves, S., Barr, H., Hammick, M., Koppel, I., Atkins, J. 2002). Nursing administrators believe that educators need to do more to prepare new graduates to be competent; nursing educators declare that the expectations of employers are unrealistic and should be adjusted to the reality of today’s beginning practitioner; and they further claim that today’s nurses have many capabilities and can quickly acquire greater skill competence (Rudmann, S. V., Ward, K.M., Varekojis, S.M. 1999, Mandin, H., Jones, A., Woloschuk, W. and Harasym, P. 1997). The correct type of learning and orientation environment is extremely important in assisting the RNs adapt to the real world practice of nursing. When the orientation program is not individualized, stressing instead the institution’s policies, procedures and formal lines of communication, it neglects the ongoing practice needs of nurses in the workforce with limited unsupervised clinical experience. Following a centralized orientation program, the graduate arrives in the ward where clinical, social and organization learning needs are often undertaken informally and inefficiently by nursing staff. Implementation of a mentorship program will decentralize orientation and provide opportunities for the graduate to integrate theory and practice. Time limits need not be strictly enforced; the mentor and nurse would work together while a need was perceived. The time could vary in length from a few weeks to several months (Freeth, D., Reeves, S., Goreham, C., Parker, P., Haynes, S., Pearson, S. 2001). The unit benefits by a mentortorship since it maintains quality of learning and efficient nursing care. The nurses are assisted, at ward level, by the mentor in his/her role transition from a student to a registered nurse. The integration of theoretical and clinical components of orientation is fostered by the one-to-one nurse and mentor approach. The mentor accomplishes clinical orientation more quickly and less stressfully than traditional methods. Supervision, combined with a support mechanism as offered by the mentor, aids in the consistency of clinical experiences and recognition of individual learning needs of the nurses (Mandin, H., Jones, A., Woloschuk, W. and Harasym, P. 1997). Skills and knowledge are developed by the RNs, while he or she maintains confidence in delivery of care, therefore becoming a more effective member of the ward; the mentor has potential to promote early confidence and to generate the positive, enthusiastic attitudes so essential to good staff morale. The mentor role is one of responsibility. It also has advantages for the nurse, and the hospital. There are rewards and satisfaction in the role of the teacher and model for the nurse when selected as a mentor. The mentor role increases the registered nurse’s self-esteem, as he or she is being recognized for clinical expertise, teaching ability and professionalism. Due to this additional challenge of mentoring, it leads to an increase in job satisfaction. Another advantage of the mentor role is that it provides a mechanism for development of senior staff. Mentors reported that the mentoring experience promoted their growth and development by strengthening both their clinical and interpersonal skills. They saw this experience as a means of enhancing their professional practice as a mechanism for clinical advancement without assuming a traditional management role. Finally, a mentor benefits the hospital by acting as a recruitment tool. RNs are attracted for their initial working experience since the scheme offers a thorough clinical orientation. The mentor, when implemented in the hospital, offers the RNs a ‘competent role model who is involved on a daily basis in decisions, processes, and protocols of patient and unit management, and who is able to derive satisfaction from the work setting without extensive role deprivation or frustration.’ A mentor teaches practice nurses to use a wide variety of skills and techniques to take care of patients. A problem-solving or nursing process approach is generally accepted by professional and educational groups; practice, licensing, and accrediting bodies; and the institutions where nursing is practiced as an appropriate framework for nursing practice and activities (AMH 92, 1992; Holloway, 1993; Hudak, Gallo, and Lohr, 1990). This approach includes assessing and diagnosing patient problems, planning and goal setting for individual patient needs, intervening for each problem, and evaluating results. Pain and anxiety are examples of patient problems for which nurses might intervene. In hospitals, nurses might be involved in direct care of patients, management, teaching, research, or consultation regarding patient care. Nursing roles in hospitals may also encompass coordinating the multiple services involved in patient care. Mentors should provide a supportive environment that enables the nurse to develop his/her advanced clinical practice in the specialty area of nursing, and in relation to the delivery of services to explicit populations. (Burns, Nancy & Grove, Susan K. 1997, 53- 57) Problem- based learning is also an approach which mentors helps practice nurses. A problem- based is not a course that begins with a series of lectures; it begins with a problem-situation which the nurses have to begin to deal with in a problem- based tutorial. Typically, then, having been presented with a problem-situation, mentors teaches nurses to work co-operatively in small groups in coming to grips with the problem, in formulating it adequately, in identifying what they need to learn in order to deal with it and so on. Problem- based learning places the nurses at the centre of the learning process and emphasizes co-operative learning. The role of the mentor becomes a resource for the nurse, facilitating their learning rather than being merely a purveyor of information. This method of learning has many implications which range of useful and relevant knowledge. Besides Problem- based learning approach, ‘Provides feedback through evaluation’ experienced by nurses is also proves to be very effective (Kinney, Packa, and Dunbar, 1993). Other studies have shown that nurses identified evaluation/assessment as anxiety-producing in clinical situations, whereas the present inquiry suggests that nurses find the evaluative role valuable in dealing with difficult/challenging situations (Ooijen, Els van 2000, Burns, Nancy & Grove, Susan K. 1997). These contrasting results may reflect the actual role of the clinical facilitator in a different learning environment. As well, the philosophy, structure and implementation of assessment may have been reflected in how useful nurses perceived the ‘evaluative’ role of clinical facilitators to be. The integrated view of evaluation taken in a problem- based learning acknowledges the pervasive presence of evaluation in human action and understanding. in nurses evaluations of hypotheses about a case they are studying, of the quality of information used in reaching tentative decisions, of the plan of action they develop for the purpose of improving the situation under consideration and of how well a plan of action might work in practice (Holloway Nancy Meyeokr 1993). McSherry, R., Simmons, M., & Abbott, P. (2001) points that place of evaluation as an integral part of nurses learning is made quite explicit in problem- based learning. Evaluating situations whether theoretical or practical, professional or academic is an important part of any learning. Without evaluation, particularly in the form of reflective evaluation on what is to be or, later, has been learned, how it has been learned and for what purpose, learners can easily lose their way in a mass of seemingly unrelated information. Moreover, Supervision generally produces other benefits for the nurses. While the nurse instigates to explore other significant relations in and around the patient’s life she might become conscious of other intrusion which would take about societal and personal alteration. Supervisor teaches the nurses the prospect to become aware of numerous things by forming a relationship within which the nurse’s impulsiveness and originality can appear as they enthusiastically concretize diverse relationships and instigate to discern through this procedure somewhat of the complication of an individual’s life (Bernard, J.M. 1998). Conclusions Thus, in nursing therefore clinical supervision or mentorship is for the reason of enhancing professional functioning. There are numerous good descriptions of clinical supervision. The purpose of supervision or Mentors is to provide a supportive learning environment that enables the nurse to develop his/her advanced clinical practice in the specialty area of nursing, and in relation to the delivery of services to explicit populations. Mentors teach nurses how to use a wide variety of skills and techniques to take care of patients. Among them is Problem- based learning that helps nurses to cope different problems in different situation. Work Cited Brian Martindale, Margareta Mörner, María Eugenia Cid Rodríguez, Jean-Pierre Vidit; Karnac Books, 1997 Mandin, H., Jones, A., Woloschuk, W. and Harasym, P. (1997). Helping Students Learn to Think Like Experts When Solving Clinical Problems. Academic Medicine, 72 (3), 173-179. Allery, L. A., Owen, P. A., & Robling, M. R. (1997). Why general practitioners and consultants change their clinical practice: a critical incident study. BMJ, 314(7084), 870-4. Care, W. 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