Vol. 4 Issue 4
One model of clinical education practice brings nurses together to learn from each other
'There is no learning without action," stated John Shibley, an organizational learning consultant.1 His statement asserts learners must actively do something to develop knowledge, skill and abilities.
In nursing, all too often we think of our personal learning and development in terms of what conference we should attend or which book we should read to advance our professional learning. Worse, in healthcare organizations, the mental model of learning is sometimes limited to what is offered in the staff development catalog.
While these offerings are essential as part of the repertoire and services clinical educators deliver, they fall short in their ability to transform information to knowledge and influence change in nursing practice. What's more, budgets for continuing education are limited, further compromising learning by programmed instruction.
Given these constraints, how can nurses learn what is needed to provide nursing care to the ever-increasing complexity of patients? The answer is right before our eyes. Peers, colleagues and the practice environment itself represent a crucible of learning for the practicing nurse.
From a research standpoint, nurse educators know nurses learn best when knowledge can be applied in real work situations. Informally, we learn from sharing our experiences with colleagues. Truly, experience is our best teacher. At Covenant Healthcare in Milwaukee, we have formalized the "informal" by engaging in a reflective learning process called "action learning."
Learning From Experiences
In search of effective, evidence-based staff development practice, clinical education leadership at Covenant has standardized to a single model as part of an overall strategic learning infrastructure.
Action learning is a process in which a community of practitioners comes together regularly to help each other learn from their experiences.2 In business, action learning is applied at the executive level in leading companies such as General Electric and Dow Chemical. Here, problem-solving about the most complex organizational issues is accomplished and, in the process, learning occurs.
At Covenant, action learning has been applied successfully at the staff nurse level in much the same way. Our complex practice arena lends itself nicely to this framework.
"Action learning works because it provides nurses tools they can apply right to practice," said Lowine Sarbacker, MS, RN, clinical education coordinator. "That's why at all levels throughout the organization we've incorporated the action learning methodology in all our educational efforts."
Professional Practice Community
The action learning model at Covenant is both a philosophy and a framework for staff development practice (see Figure).3 Learning happens in the context of a professional practice community, or a small group of people who have worked together for a period of time, sharing similar goals and interests. They are "peers in the execution of real work." This could be a clinical nurse specialist group, a new graduate nurse group or a student nurse group, for example.
At the heart of action learning is the action-reflection cycle, a continuous process of action and reflection that results in increased knowledge and results. As nurses engage in conversation and reflective processes about their most difficult challenges, they problem-solve together with peers, creating new knowledge and perspectives that cannot be gained through textbooks or the classroom. Facilitated by an expert learning coach, action learning focuses on real-time application and analysis through reflection on action and results.
Over time, nurses develop skill and knowledge, expanding their capacity to learn and capability to perform. Competency is developed and actions are more effective in producing favorable results. In much the same way, teams and organizations learn to reflect together and capture "lessons learned" to make decisions about strategic goals and actions collectively; a phenomena sometimes referred to as "building intellectual capital."
Examples in Action Nurse Residency
Our marquee action-learning process at Covenant is the establishment and evolution of nurse residency. Amidst a national trend to establish nurse residency as an effective on-boarding process, we have defined nurse residency as a learner-focused, postgraduate experience designed to support the development of competency in nursing practice.4
Named "Practice Long by Starting Strong," by nurse residents themselves, this action learning set is focused on application of concepts to practice. Nurses in their first year of practice engage in a mentoring relationship, monthly learning sessions, and pre-work and post-work application activities. They engage in reflective dialogue about their practice with peers, content experts and learning coaches.
One of the goals of nurse residency is to build capacity for critical thinking.
"Nurse residency has assisted me in integrating problem identification, investigation and solving with the complex mix of patients I take care of. In addition, I have been able to utilize the nursing process to streamline my professional practice," stated Becky Rice, BSN, RN, a nurse resident from the surgical-orthopedic unit at St. Francis Hospital.
Nurse Intern Program
Nurse internship at Covenant has been well-established and serves as our feeder program for entry into practice as a graduate nurse. Nursing students who have started their clinical practicum supplement their learning by working under the direction of an experienced nurse. They work in either a department or in a purposeful rotation to several departments.
Similarly, nurse interns also engage in conversational practice grounded in their experiences. As a result, nurse interns tend to socialize and transition more effectively from their early exposure to the system.
Cohort Student Practicum
As part of a focused strategic initiative, Covenant partners with area academic colleges and universities to more effectively address broader issues within the profession. Through our partnership with UW-Milwaukee, as part of our cohort arrangement, juniors and seniors experience a deeper immersion in one healthcare system by having clinical experiences exclusively at Covenant.
System clinical leaders conduct regular learning sessions with the students using an action learning framework. Frequently, a "learning in circle" approach engages the students in topics they select as areas of focus.
"You can see the excitement of the students as they learn from each other and those nurses with more experience," said JoAnn Appleyard, PhD, RN, clinical assistant professor, College of Nursing, UW-Milwaukee. "Because they select the topics, the students are engaged from the beginning, and even the more reticent students become animated as they realize their observations and experiences are valued by others in the group. The most important aspect of action learning is that it is a shared experience. Students who participate in the circle begin to realize this will be essential to their personal and professional growth and development throughout their lives."
Critical Care Fair
Tina T. Smith, MS, RN, clinical educator, St. Francis Hospital, developed an annual event she calls the "Critical Care Fair" as a means of involving staff as peer instructors. The event features an annual theme and hands-on stations developed and implemented by nurses. Peer instructors, serving as experts, emphasize learning and development rather than evaluation.
The Critical Care Fair is an excellent illustration of a professional practice community among critical care nurses. Nurses steeped in relative experiences draw upon their skills and talents to develop their peers.
Karen Walk, RN, ICU nurse, commenting on last year's fair, said the event involved more than learning from each of the stations. "It was learning with each other."
A Network of Scientists
Excellence in staff development practice does not happen without the concerted and united practice of a network of clinical educator practitioners eager to test and reflect on innovations in learning methodology. At Covenant, a team of more than 60 clinical educators, clinical education leaders and specialists set the supportive framework for the practitioner's effective learning. This team gathers on a regular basis to share experiences, collect data about the system's learning needs, network and socialize, as well as attend to their own learning needs.
Action learning as a framework more effectively serves the needs of the clinical team in practice, guides the clinical education team and connects with the learners on their level in real time. By focusing on action and reflection, the learning process comes to life.
"The ability to deliver excellent care in this rapidly changing healthcare environment requires every clinician to be a lifelong learner," asserted Pat Schroeder, MSN, MBA, RN, FAAN, senior vice president and chief nursing officer, "This model, created and brought to life daily by passionate clinical educators, creates a clear impact on results. In the context of evidence-based practice and research-based knowledge, we must connect our learning to relevant experiences, and we must apply what we learn to make it stick. The action learning model makes a difference."
1. Shibley, J. (2004). A simple introduction to organizational learning. Retrieved Feb. 14, 2006 from the World Wide Web: http://www.systemsprimer.com/what_is_org_learning.htm
2. Marsick, V.J., & Watkins, K.E. (1999). Facilitating learning organizations: Making learning count. Brookfield, VT: Gower.
3. Herdrich, P., et al. (2005). Action learning in a professional practice community. Washington, DC: The Library of Congress.
4. Herdrich, B., & Lindsay, A. (2006). Nurse residency programs: Redesigning the transition into practice. Journal for Nurses in Staff Development, 21(7), unpublished manuscript.
Bob Herdrich is regional director, clinical education, Covenant Healthcare System Inc., Milwaukee.