The Nurse Associate Trainee Deserves a HOTSHOT Education: A Reflective Signature Pedagogical Approach
By Philip T. Beckwith, School of Healthcare Practice, University of Bedfordshire
Concerns were raised at the 2017 National Trainee Nurse Associate Conference. The Associate Nurse Work-based Learning Signature Pedagogy creates constructive alignment to the work based learning units of the nurse associate programme and aims to address these concerns. However, attempts to locate a pedagogic approach for high quality learning and skills development have proved unsuccessful. Further exploration of Bloom’s (1956) taxonomy and Anderson & Karthwohl’s (2001) adaption of Bloom’s taxonomy have failed to align with Biggs’ (1999) model of constructive alignment and have led to the creation of the Higher Order Thinking and the Skills of Higher Order Thinking (HOTSHOT) taxonomy which redefines Higher Order Thinking Skills (HOTS). Additionally, a move away from Socratic dialogue to reflection enabled the evolution of the signature pedagogy framework into a reflective signature pedagogy framework. The Associate Nurse Work-based Learning Signature Pedagogy offers a solution to the concerns raised, based upon robust pedagogical theory.
Jones (2017, p. 109) declared that ‘we are now at a point where the test sites for associate nurses have been identified, Skills for Health are working with Health Education England but as yet, no educational framework has been published’. This new way of training and learning within the clinical setting presents a variety of challenges that require a new pedagogical approach. The accepted conventions were visited and where necessary challenged, allowing the emergence of new pedagogical thought.
In a recent exploration of Bloom’s (1956) taxonomy and Anderson & Karthwohl (2001)’s adaption of Bloom’s taxonomy, it was concluded that it is Bloom’s use of nouns and Anderson & Karthwohl’s insistent use of verbs that creates a dichotomy (Lewis and Smith, 1993) between higher order thinking skills and critical thinking (Beckwith, 2018). Lewis and Smith (1993) determined that scientific problem solving was the domain of higher order thinking skills and therefore posited that critical thinking was the domain of the social studies. Furthermore, Lewis and Smith (1993) endeavoured to define higher order thinking as ‘reasoning, critical thought and problem solving’ but their review of the literature available at the time contradicted this definition. They concluded that higher order thinking was a ‘conceptual swamp’ (Lewis & Smith,1993).
As part of a mixed method study, a systematic literature review was undertaken with the purpose of defining Higher Order Thinking Skills (HOTS) (Beckwith, 2018). This review produced a mixture of noun and verb keywords, much like the ‘conceptual swamp’ found by Lewis & Smith (1993), but closer analysis revealed not two keyword themes, but three keyword themes: activity nouns, synthesis verbs and implementation nouns (Beckwith, 2018) (Figure 1).
This revelation then led to mapping of the three themes to the Pyramid of Lower and Higher Order Thinking (Beckwith, 2018) (Figure 2). Mapping the specific types of nouns and verbs revealed that activity nouns are lower order thinking activators, synthesis verbs are Higher Order Thinking, and implementation nouns are Skills of Higher Order Thinking (Figure 2).
Figure 2: Pyramid of Lower and Higher Order Thinking
This means that Bloom’s nouns and Anderson & Karthwohl’s verbs can be replaced by the nouns and verbs indicated in Figure 1 (Beckwith, 2018). These nouns and verbs do not authenticate HOTS, but confirm Higher Order Thinking and the Skills of Higher Order Thinking (HOTSHOT) (Beckwith, 2018). The HOTSHOT taxonomy is compared to Bloom’s original taxonomy and Anderson & Karthwohl’s adaptation in Figure 3.
Having defined the components of the HOTSHOT taxonomy, the HOTSHOT taxonomy was mapped to Biggs’ (1999) constructive alignment model (Beckwith, 2018). This creates the Signature Pedagogy framework that was not possible using Bloom’s or Anderson & Karthwohl’s taxonomies alone (figure 4). This framework provides a structure that ensures quality, reliability, and consistency to the Nurse Associate Programme. With this strong structure in place, further needs of the programme can be addressed.
Figure 4: Associate Nurse Signature Pedagogy Framework
The Signature Pedagogy and the Nurse Associate Trainee
The Associate Nurse Programme requires trainees to move from novice toward expert practice in line with Benner’s (1984) transformation continuum, which asserts that nurses move from detached observers to involved performers as part of the novice-to-expert model. This is a well-established nurse education theory. Benner’s use of the ‘formation’ is described as something that ‘points to being constituted by the meanings, content, intent and practice of nursing rather than merely learning or being socialized into a nursing role in an external way’ (Benner et al., 2010, pp. 86-87).
This programme also requires trainees to demonstrate preparedness for registration with the Nurse and Midwifery Council (NMC) by meeting ‘The Code: Professional standards of practice and behaviour for nurses and midwives’ (NMC, 2015) to which the qualified Associate Nurse will be held accountable.
An assessment for the Associate Nurse programme requires trainees to:
‘Write an essay that offers an evidence based reflective style rationale as to why the work based skills (no more then 2) chosen for development in the second year of the course are relevant to the Nursing Associate’s area of practice and to the advancement of the work based role’.
‘The essay will reflect on the role of the Nursing Associate in their practice area providing care. Please include the two (2) selected skills in an appendix, added at the end of the essay, after the references’
(University of Bedfordshire, 2016)
All of these requirements demonstrate the enhancement of the Associate Nurse Signature Pedagogy Framework with the Reflection for Learning model (Beckwith, 2016). This reflective model will assist the trainee in reflecting upon clinical experience, develop self-awareness, and engage in critical thinking in order to move from novice towards expert, prepare for professional registration, meet the assessment requirements, and encourage lifelong learning via continuing professional development. Combining the Reflection for Learning model with the Associate Nurse Signature Pedagogy Framework requires an understanding of each phase of the Reflection for Learning model (Figure 5) (Beckwith, 2016).
Reflection for Learning
Reflection for Learning begins with the event (RfL step 1) where the student is asked to remember an experience and attempt to understand the actions and processes that led to the event (Beckwith, 2016). This is adapted for the Nurse Associate Trainee, who defines the event as the skills that have been selected for him or her to develop.
For the influence point (RfL step 2) in the reflective cycle, the student is asked to identify the reason for selecting this particular event. This leads the student to create a reflective question based upon their own experience (Beckwith, 2016). In step 2 the Nurse Associate Trainee, having identified the skills they wish to cultivate, will develop a reflective rationale, outlining his or her individual developmental needs as well as the potential to enhance the patient experience and service delivery.
The overview (RfL step 3) of the reflective cycle is where the student undertakes an analysis and is asked to research the event with the aim of expanding upon previous knowledge and developing in an evidence-based manner (Beckwith, 2016).
In step 3, the Nurse Associate Trainee is asked to analyse and research the desired skills with the aim to determine achievability and applicability to the band 4 Nurse Associate roles.
For the synthesis section (RfL step 4) of this model, the student is asked to take the evidence discovered or reviewed and apply this to his or her identified event demonstrating new evidence-based thinking and perhaps a different approach that will affect future practice (Beckwith, 2016). The Nurse Associate Trainee will undertake the development required to attain the defined new skills and apply these skills to his or her practice. Each trainee must evaluate whether local policy will need to be altered to reflect the Nurse Associate Trainee as the named person to practice this particular skill and address any accountability concerns.
The personal development plan (RfL step 5)of this reflective model asks the student to formalise synthesis achieved in the previous step by creating a plan to continue to employ this new learning and identify resources needed in order to re-encounter the identified event once again (Beckwith, 2016). For the Nurse Associate Trainee this step is modified to encompass the reflective essay outlined in the trainee’s assessment brief, exploring and analysing their journey, and outline how they will maintain currency and competency in these skills up to and beyond registration.
The signature pedagogy framework (Figure 4) can now be populated with the five steps of the modified Reflection for Learning model, giving rise to the Associate Nurse Work-based Learning Signature Pedagogy (Figure 6).
Figure 6: The Associate Nurse Work-based Learning Reflective Signature Pedagogy
Some educators advocate the use of Socratic dialogue as an effective way to guide trainees in the transfer of analytical thinking to professional skills (Coughlin, McElroy and Patrick, 2009). However, as the Trainee Nurse Associate programme is uniquely individualised to each student, this delivery style would be limiting.
Another traditional training technique in a wide variety of health professional programmes is ‘see one, do one, teach one’. Coughlin, McElroy and Patrick (2009, p.379) cite the Best Practice report whereas ‘in addition to experience, students can more rapidly develop problem-solving expertise by… observing how experts solve problems’. These authors also assert that students must observe experts many times in order to improve performance.
This accepted cognitive apprenticeship concept of ‘observing how experts solve problems’ for optimal learning is addressed in the Associate Nurse Work-based Learning Signature Pedagogy (figure 6) as this concept is synonymous with lower order thinking: activity nouns ‘critical thought’ and ‘reflective thinking’. When the trainees observe the expert, critical thought occurs at the time of the observation and continues with reflective thinking of the event observed. This then leads the trainee to move from lower order thinking to the Higher order thinking through the synthesis verbs ‘elucidating’ and ‘problem solving’ (Figure 6). In this way the student is able to use this experience to begin to move from novice to competent trainee through the ability to problem solve around this event.
Coughlin, McElroy and Patrick (2009) counter that this is merely the trainee mimicking the expert and may learn just enough to pass the related assessment without actually gaining the understanding required to practice in a safe manner. However, the implementation verbs of the HOTSHOT taxonomy ‘production’ and ‘justification’ require the student to justify through his or her assessment and therefore demonstrate understanding giving both robustness and credibility to the signature pedagogy.
Recently Anna Beckett (2017) delivered a presentation entitled ‘Evaluating the Impact of Nursing Associates: Emergent Findings’. A concern highlighted in this presentation was the need for quality assurance between programmes due to the variety of structures that have emerged. The Associate Nurse Work-based Learning Signature Pedagogy (Figure 6), with its constructive alignment and reflective structure offers a robust, defined and consistent, yet flexible, structure to the work-based learning component of the programme. This would offer the quality assurance expected of a pre-professional programme.
Beckett (2017) also indicated three areas of nursing associate training that requires further improvement that includes streamlining the workload associated with the programme, promoting awareness and understanding of the new role and training programme, and addressing unwarranted variation in the trainees’ work based learning. The Associate Nurse Work-based Learning reflective Signature Pedagogy (figure 6) addresses all three considerations.
Streamlining the trainee workload associated with the programme is addressed by providing a structure for the trainee to utilise to organise skill development. Promoting awareness and understanding of the new role and training programme is addressed by the trainee’s creation of his or her personal development plan to aid in maintaining competence and currency in skills attained. Addressing unwarranted variation in the trainees’ work based learning can be achieved by following the established structure, despite personalisation for each trainee, and provides consistency throughout the programmes.
Recently concerns were raised at the 2017 National Trainee Nurse Associate Conference regarding the streamlining of the workload within the programme, promoting awareness and understanding of this new role, addressing variation in the trainees’ work based learning and the need for quality assurance between programmes due to the variety of structures. The Associate Nurse Work-based Learning Signature Pedagogy creates constructive alignment to the work based learning units of the nurse associate programme and addresses these concerns.
Attempts to locate a pedagogic approach for high quality learning and skill development proved unsuccessful because Bloom’s (1956) taxonomy and Phol’s (2000) adaption of Bloom’s taxonomy failed to align with Bigg’s (1999) model of constructive alignment. Further exploration of these highly regarded taxonomies lead to the creation of the Higher Order Thinking and the Skills of Higher Order Thinking (HOTSHOT) taxonomy which redefines Higher Order Thinking Skills (HOTS). Additionally, a move away from Socratic dialogue to reflection enabled the evolution of the signature pedagogy framework into a reflective signature pedagogy framework.
The Associate Nurse Work-based Learning Signature Pedagogy offers a solution to the concerns raised based upon robust pedagogical theory at the midway point of the current pilot programmes with recommendations for re-evaluation of the work-based learning component when appropriate.
Anderson, L., Krathwohol, D. eds. (2001) A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives. Allyn and Bacon.
Beckett, A. (2017). 'Evaluating the impact of Nursing Associates Emergent Findings', National Trainee Nurse Associate Conference. De Vere Grand Connaught Rooms, 61 - 65 Great Queen Street, London, England 22nd November 2017. Lomdon: Health Education England, pp 1-9.
Beckwith, P, T. (2016) Developing higher order thinking in medical education through reflective learning and research. Journal of Pedagogical Development. 6 (3). p. 23-31
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Benner, P. (1984) From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
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Biggs, J. (1999) What the teacher does: teaching for enhanced learning, Higher Education Research & Development, 18 (1), pp. 57-75.
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Coughlin, C., McElroy, L. and Patrick, S. (2009) 'See One, Do One, Teach One: Dissecting the Use of Medical Education's Signature Pedagogy in the Law School Curriculum', Georgia State University aw Review, 26 (2), pp.361-416.
Health Education England (2017) Nursing Associate - shared narrative. Available at [https://www.hee.nhs.uk/sites/default/files/documents/nURSING%20Associate%20narrative.pdf] accessed 10/01/2018
Nursing & Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London: Nursing & Midwifery Council.
Jones, T. (2017) 'How will the nursing associate role fit within the neonatal workforce?' Journal of Neonatal Nursing (23), pp 109-111.
Lewis, A. and Smitrh, D. (1993) 'Defining higher order thinking', Theory in to Practice, 32 (3), pp 131-137.
University of Bedfordshire (2016) ASP008-2 Unit Information Form, Luton: University of Bedfordshire. pp.1.
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