Educating for health service reform: clinical learning, governance and capability – a case study protocol

The nurse practitioner is one in an increasing array of innovative service models in the health care workforce; others include the prescribing pharmacist [7, 8] and specialist physiotherapist [9]. Education of these new levels of clinician poses a unique challenge in that the roles cross traditional health discipline boundaries and consequently require a composite of skills, knowledge and expertise. Nurse practitioners manage complete illness episodes for patients and may be the only healthcare staff available, especially in regional or remote areas [10]. Research informed generic nurse practitioner standards were developed and implemented nationally in Australia in 2006 and recently updated [11, 12]. There has been strong support for the centrality of clinical learning as the optimum educational preparation with clinical rigour being maintained alongside the academic advantages of a Master’s degree from a tertiary institution [13]. A recent release of curriculum standards for nurse practitioner Masters’ degrees have confirmed the importance of dedicated clinical learning and teaching time and a move away from the apprenticeship system of training for advanced practice [11].

In nursing as in other health disciplines with advanced practice roles, there are often conflicting pressures between the clinical learning environment and the institution conferring recognition of advanced specialty practice. For nurse practitioners the institution conferring recognition is the university although for other health professions it may be specialist organisations such as professional colleges [14]. Tensions arising from the contrasting clinical and academic requirements are sometimes hidden and all too rarely addressed successfully. Part of the solution to these tensions, arguably the key component, is an effective clinical learning and teaching model that addresses the complexity of advanced clinical education.

In terms of the complexity required, most undergraduate clinical learning and teaching models focus on competence attainment, but there are few well-developed models for postgraduate advanced clinical learning [15, 16]. Capability learning is one promising conceptual model for learning and teaching at postgraduate level that has been used for nurse practitioners and warrants further explication [13, 17‐19]. A recent study conducted in collaboration with the Australian College of Nurse Practitioners (ACNP), identified a concise set of areas of advanced specialty practice or ‘metaspecialties’ for Australian nurse practitioners [20]. This proposed set is framed using contemporary language, informed by a national framework for nursing specialties [21] and previously identified specialty areas. The metaspecialties are: mental health care; aged and palliative care; care of people with long term conditions; emergency and acute care; child and family health care; and primary health care. These metaspecialties are not intended to be mutually exclusive and a nurse practitioner working within a particular scope of practice may need specialty standards from more than one metaspecialty.

In clinical learning and teaching the issue of governance has received scant attention and yet is essential for quality and equity in clinical education. There is considerable research on development of beginner level competency in health related disciplines, specifically in relation to skill assessment, but few studies address the issue of accountability of clinical education [22] or the relationship between workplace learning and curriculum governance. This is particularly relevant in nurse practitioner education where, to date, governance for clinical education has primarily related to legal and contractual arrangements; with scant attention to standardisation and quality control of clinical learning across specialities in line with the requirements of an accredited curriculum. An effective clinical learning and teaching model that addresses the complexity of advanced clinical education and acknowledges the importance of strong governance is needed so that integrity of curriculum content is assured [20]. This governance or quality control has not, to date, been addressed conceptually or theoretically. A comprehensive framework for educational governance is urgently needed to ensure that the education needs of the student; the safety of the clinical facility and the curriculum standards of the education provider are to be met.

In summary, there is disquiet internationally and silence locally about the governance of advanced clinical education, especially where this education occurs remote from the auspices of the awarding tertiary institution but is recognised in the final degree testamur. This research will elucidate a framework for educational governance of advanced specialty clinical learning and teaching. This study will also build upon current capability research [23].

Advanced and specialty clinical practice degrees are increasing in number at postgraduate level across many health disciplines to meet the healthcare needs of the community. While learning is concentrated in the clinical domain (the workplace) under the supervision of skilled professionals (clinical workplace supervisors or mentors), the qualification is awarded by universities. Moreover, clinical workplace supervisors or mentors may or may not have formal university affiliation and or postgraduate degrees or teaching qualifications. These conditions potentially raise issues of accountability and quality control between clinical domain and university. To bridge this possible divide, a governance framework would provide a more seamless approach to the assurance of quality control in advanced specialty clinical learning and teaching. An extensive review of the literature was undertaken to investigate discussion of both quality control and the utilisation of clinical competency standards in clinical learning and teaching for advanced specialty practice healthcare disciplines. Within the literature, scant discussion of educational governance in this context was evident. For the purpose of this study, our working definition of the term ‘educational governance’ encompasses evidence (or a lack thereof) for the curriculum integrity and quality control of advanced specialty clinical learning and teaching. A model of clinical learning and framework of education governance will be informed by the nurse practitioner standards framework, recently updated [11] and the model for nurse practitioner education [17]. The latter included an evidence based framework that emphasised the importance of clinically derived competencies (now more commonly referred to as standards at this advanced practice level) and incorporated a pedagogical approach to learning through the development of capability [11].

Capability learning provides the education model and will inform the development of a governance framework for learning and teaching of complex clinical skills and knowledge. Capability draws on the work of Schon [24] applying a constructionist approach and the notion of the reflective practicum or thinking in practice. Forneris argues that this understanding provides insight into how educators can help students to ‘create new knowledge and new action’ [25]. Capability has been used since the 1990’s in the context of understanding learning and teaching and to inform evaluation methodologies for practice in a range of professional occupations but scholarly dissemination of its application has been very limited until recently, primarily to its use in computer training [26]. Despite its value, capability has received very limited scholarly consideration in the field of education, in particular clinical education, where it can significantly scaffold knowledge generation. Its main application has been in the Trans-Tasman Nurse Practitioner Standards Project where the attributes of capability learning were all confirmed as being applied by nurse practitioners [13, 17, 18]. More recently it has been applied specifically in the area of emergency nurse practitioners [19]. The study will build on this recent extension of the application from generic standards to specialty clinical standards across several metaspecialties, focusing on generation of contemporary educational concepts and principles.