Article Facilitating learning in the community with lecturer–practitioner posts Bernadette Shepherd, Ann M. Thomson, Sue Davies and Karen Whittaker Bernadette Shepherd BA, MSc, RGN, Nurse Teacher, School of Nursing, Midwifery & Health Visiting, University of Manchester, Gateway House, Piccadilly South, Manchester M60 7PL, UK Ann M. Thomson BA, MSc, RGN, RM, MTD, Senior Lecturer in Midwifery, School of Nursing, Midwifery & Health Visiting, University of Manchester Sue Davies BSc, MSc, RGN, HV, Lecturer in Nursing, Department of Gerontological and Continuing Care Nursing, University of Sheffield, UK Karen Whittaker BNurs, MSc, RGN, HV, Health Visitor, Higher Broughton Health Centre, Bevedon Square, Salford, UK (Requests for offprints to BS) Manuscript accepted: 23 September 1998 The purpose of this paper is to present a case study of the perspectives of their role of a group of community lecturer–practitioners and a community teacher, who referred to themselves as ‘community facilitators’. A qualitative design was used and data were collected by semi-structured interviews. These were transcribed and content analysis was undertaken. All participants provided a liaison role between the college and the community practitioners, prepared students for their clinical experience and assisted in relating theory to practice. The participants described how they managed the role and how they supported each other. Developing small teams of facilitators may provide a bridge between teachers and practitioners and can serve as a basis for further study of the lecturer–practitioner role. Introduction In 1993 the English National Board (ENB) for Nursing, Midwifery and Health Visiting commissioned an 18 month study to assess the continuing education needs of community nurses, midwives and health visitors in relation to their responsibilities for teaching and assessing pre- and post-registration students. A two-stage study was undertaken. In Stage I a postal questionnaire was sent to all education establishments in England which provided courses incorporating community experience (Thomson et al. 1996, 1999, Whittaker et al. 1997). This allowed the identification of three education centres and their clinical practice areas for indepth study in Stage II. Stage II had two parts. Firstly, postal questionnaires were sent to community practitioners, their managers and teachers of community courses in the three centres. At the end of the questionnaire respondents were asked to indicate if they were willing to be interviewed for the second part of the study. None of the lecturer-practitioners reported to be working in the three study sites indicated their willingness to be interviewed. As the questionnaires were annonymous we are © 1999 Harcourt Publishers Ltd unaware of their reasons not to volunteer. However, the research team felt it was important to seek the views of this type of practitioner and, therefore, approached and interviewed a group of lecturer–practitioners who came to the attention of one of us (BS) in relation to another project. The report of this stage of the project is referred to as the ‘Case Study’ in this paper. Before describing the methods used in this part of the study and the roles and function of this group of practitioners a brief review of the literature on the role of the lecturer–practitioner is presented. Literature review Lecturer–practitioner posts are becoming more popular in some health districts and, although slow in its development, this type of post appears to be creating and developing a role which attempts to bridge the theory–practice gap between nurse education and practice. Davies (1989) points out that seasoned observers might question what road this new role might take. Many changes in nurse education have been underpinned by theory–practice issues. Lathlean (1995) argues that solutions to the theory–practice Nurse Education Today (1999) 19, 373–385 373 Facilitating learning in the community with lecturer–practitioner posts gap and the problematization of theory and practice have been addressed over time in the development of the lecturer–practitioner. The ‘birth’ of the lecturer–practitioner is considered to have occurred in an attempt to understand the reciprocal arrangement between theory and practice (Lathlean 1995). As already noted lecturer practitioners first developed in the UK in the 1980s, most notably in Oxford (Lathlean & Vaughan 1994). Promotion of reflective practice (Schon 1991) exerted influence upon the clinical developments in Oxford. The title ‘lecturer–practitioner’ has been adopted by a number of colleges of nursing and interpreted in a variety of ways. Role definitions have broadened in areas of the UK outside the Oxford area and individuals are given the independence and freedom to implement the role (Davies 1989). Subsequent anecdotal evidence suggests that the role has become ambiguous for practising lecturer–practitioners and their colleagues (Burke 1993). The lack of standardization of the role inception and role performance contribute to this problem and provide additional sources of role ambiguity (Hardy & Conway 1978). On the other hand, Harrison (1992) argues that if nursing and midwifery are to provide effective leadership we, as nurses and midwives, must risk new approaches to partnership between education and service. For the purposes of this paper the definition that was accepted was of a community nurse who was employed in both a clinical setting and an educational institution. The integration of practice and the teaching of nursing is essential (ENB 1985). However, there are many reports of student nurses’ practical experience not matching what they are taught in their educational institution (Bendall 1975, Alexander 1983, Gott 1984, Jones 1985, UKCC 1986, Vaughan, 1987, McCaugherty 1991). In the UK the post of clinical teacher was originally developed to bridge this gap but was unsuccessful because of the blurring of roles and lack of authority in practice and teaching (Wright 1984, Inglesby 1985, Lowrey 1986, Robertson 1986). A second initiative designed to overcome this problem was commenced in the late 1970s (Ashworth & Castledine 1980) whereby two university lecturers both worked in a clinical area and taught in the University. This was followed by reports of other such initiatives (Wright 1983, 1988, Lathlean 1992). In the late 1980s there were 374 Nurse Education Today (1999) 19, 373–385 reports of further developments in order to close the theory–practice gap and the term ‘lecturer–practitioner’ began to appear in the literature (Vaughan, 1987). Lathlean (1992) suggests that the notion of lecturer–practitioners arose both to ameliorate the problems experienced with other approaches to bridging the so-called ‘theory–practice gap’ and as an alternative which, ideally, was designed to be an integrated part of a new system of managing nursing practice and facilitating nurse education. The lecturer–practitioner posts stemmed from ‘concern about the difficulties experienced by both practitioners and educators in finding a match between what was being done in practice and what was being taught in theory, as well as a fundamental belief in the value of practice as the origin of such nursing theory’ (Vaughan, 1990, p 106). Although lecturer–practitioner posts exist in a number of health trusts and colleges of nursing and midwifery, there appears to be only one health authority, Oxfordshire, where lecturer–practitioners in large numbers (currently more than 70) are an integral part of both the nursing service structure and the educational institution (Champion 1992). An extensive literature search revealed limited empirical work on the lecturer–practitioner role. To date there has been little systematic evaluation of the role, although it is still, perhaps, too early to evaluate the success of this approach. Three reports of empirical work in this area were found (Lathlean 1995, NHSME 1997, Thompson et al. 1998), all published after the data collection for the study reported in this paper. Lathlean (1995) examines the role of the lecturer–practitioner in Oxford. The empirical work was conducted in three inter-related parts: an ethnographic participant observation study of a small number of lecturer practitioners; a study of the perspectives of others about selected facets of lecturer–practitioners’ work; and a study of all lecturer–practitioners working in Oxford. In her ethnography, Lathlean (1995) initially chose a purposive sample of five cases because they were the only instances of the phenomena at the time of the study. The ethnographic participant observation of the study of individual practitioners was conducted in three chronological stages, referred to as Ethnography 1, 2 and 3. The fieldwork lasted from 1989–1992. All the participants were observed and © 1999 Harcourt Publishers Ltd Facilitating learning in the community with lecturer–practitioner posts interviewed. The second part of the study involved in-depth interviews with those who worked closely with four of the five lecturer–practitioners that she had been observing. The sample size was 27. The purpose of the third part of the study was to understand lecturer–practitioners working lives generally. A questionnaire, developed following the ethnographic work, was sent to 59 lecturer–practitioners in Oxford. Lathlean’s (1995) findings indicated that the lecturer–practitioner role has inherent strengths and weaknesses. On the one hand, the idea of a lecturer–practitioner as educational manager of practice is powerful, although Lathlean argues that the organizational conditions have to be conducive for the functioning of the role. On the other hand the suggestion that lecturer–practitioners should bridge a theory gap is flawed as this is based on a misconception of the ‘theory–practice’ problem. The proper concerns are multi-dimensional rather than unidimensional. Lathlean’s (1995) findings do, however, indicate that having lecturer–practitioners located in both practice and education means that they use their analytical skills to promote understanding of theory and practice. Key aspects of the role appear to be: involvement in curriculum development; the organization of students’ learning in clinical placement and developing effective strategies for teaching and learning through practice, including the use of reflection on practice and the development of learning contracts. The National Health Service Management Executive (NHSME 1997) commissioned a study designed to give information about lecturer– practitioner roles. A postal survey of all NHS hospitals and community trusts in England was conducted. Questionnaires were sent to 398 nurse executive directors and 303 were returned, giving a response rate of 70%. One hundred and twenty-three (42%) trusts reported having lecturer–practitioner posts. The main reasons for establishing these posts reflected the original thinking behind the concept, that is to facilitate the application of theory to practice and to promote effective collaboration between education and service. None of these ideas are discussed in any detail in the report. However, the report is important in that the key © 1999 Harcourt Publishers Ltd characteristics of lecturer–practitioner roles in England are provided. The importance of establishing mechanisms which promote dialogue between the Health Service and education at all levels in order to form partnerships and develop a shared view of the way forward is highlighted (NHSME, 1997). The third study (Thompson et al. 1998) was a qualitative evaluation of 14 lecturer–practitioner posts working in one college of midwifery and nursing in the north of England. The respondents agreed with Lathlean (1995) that for them to be effective in their role they needed support from both clinical and educational managers. They felt they were able to bridge the ‘theory–practice’ gap, and in particular for students, and they also reported on the difficulties of ‘serving two masters’ (Thompson et al. 1998). The remaining literature on the lecturer–practitioner role comes from comment articles. Burke (1993) argues that there are underlying problems with this role in that the demand of serving two masters, with the expectation of performing at 100% for both may be seen as two full-time jobs. This places the lecturer–practitioner in the double imposition of developing two roles at a credible level. Unless there is adequate support given to the lecturer–practitioner from both service and education, as suggested by Lathlean (1995), they will not be able to develop expertise and therefore credibility in both roles. The growth of this type of specialist role may well be inhibited by recent changes in the organization of the Health Service (DoH 1989). With hospitals gaining trust status and colleges of nursing moving into higher education the contractual arrangements that would have to be negotiated to make the role feasible may make the lecturer–practitioner role another victim of the health service’s market economy. However, Harrison (1992) argues that if nursing is to provide effective and relevant leadership we, as nurses/midwives, must risk new approaches to partnership between education and service. With shrinking health care budgets, lecturer–practitioners provide a unique opportunity to maximize resources by demonstrating expertise (Tamlymn & Myrich 1995). No literature was found on lecturer–practitioners working in the community. Nurse Education Today (1999) 19, 373–385 375 Facilitating learning in the community with lecturer–practitioner posts As already stated, the lecturer–practitioners reported to be working in the three centres in Stage II of this project did not volunteer to be interviewed. Therefore, a group of practitioners known to one of us (BS) through another study were included in the study commissioned by the ENB (Thomson et al. 1996, 1999, Whittaker et al. 1997). Background to this part of the study In 1992 the College of Nursing and Midwifery which took part in the Case Study moved away from the traditional pattern of nurse education to providing a pre-registration Diploma of Higher Education in Nursing Studies (Project 2000). The introduction of diploma courses, which have more of a community orientation, has led community practitioners to become more involved in the educational preparation of future nurses (Whittaker et al. 1997). In the early stages of the diploma programme, it was recognized that community practitioners would need to undergo some form of preparation and would require ongoing support. The ENB consultative document on the preparation of mentors and supervisors in the context of Diploma of Higher Education in Nursing Studies (Project 2000) courses (ENB 1989) broadly recommends the facilitation of role development for mentors and supervisors. This facilitation may occur through small group work, study days or short courses. It was with these thoughts in mind that the college began to look at the roles and responsibilities of nurses who were involved in both community practice and education, and consider ways of bridging the gap. Within this context, a small team of community facilitators was established to operate similarly to lecturer–practitioners in that they had responsibility and authority for both practice and education. In order to maintain a credible practice input, the facilitators contributed 50% of their time to education and 50% to practice. The facilitator team included two health visitors and two district nurses, all responsible to a senior manager in practice. In their educational role they were managed by a community nurse teacher, who was classed as part of the facilitator team. Funding for these posts had been determined on the basis of their level of responsibility and all 376 Nurse Education Today (1999) 19, 373–385 four facilitator posts were graded ‘H’. Two community trusts each provided 50% of the funding for a health visitor and district nurse. The college provided the remaining 50% of funding. The posts were set up primarily to act as a liaison between community practitioners and the college. The facilitators contributed to tutorials, lectures and curriculum development within the college and carried a caseload when working in practice. Methods The research presented in the case study is a qualitative investigation into the perspectives of their role of a team of community lecturer– practitioners and a community nurse teacher working within a College of Nursing and Midwifery. A qualitative design is based on philosophical assumptions and is conducted by applying corresponding rules (Rew et al. 1993). It argues that social settings are complex, made up of individuals with different perspectives, behaviours and intentions, and can only be understood by studies that reflect this complexity, that value the ‘lived experiences’ of those within it, and the meaninings that attach to their behaviour (Hammersley & Atkinson 1983, Burgess 1984). This case study approach required the analysis of contemporary phenomena within their ‘real life’ context (Yin 1984) and provided a detailed and multi-perspective account of experiences within the case study setting. The research methods employed were selected in order to identify how the subjects explain ‘reality’ in their own terms. The sample chosen was a purposive one (May 1993). Purposive is a non-probability sampling method in which participants are chosen for the study according to the likelihood of their being able to talk with the same insight on the topic in hand. Five in-depth interviews were undertaken, four with lecturer–practitioners who referred to themselves as ‘community facilitators’ and one with their related community nurse teacher. The semi-structured interviews loosely followed the interview schedule used in the interviews for the main study with the 24 respondents in Stage II (Thomson et al. 1996, 1999). These interviews lasted approximately 45 minutes. The interviews were conducted in a conversational style in an attempt to gain insight © 1999 Harcourt Publishers Ltd Facilitating learning in the community with lecturer–practitioner posts into the facilitators’ dual role. The findings are presented in relation to the main issues explored in an attempt to describe the role. Probably the most daunting challenge confronting anyone conducting qualitative research is what to do with the data collected (Sandelowski 1995). Numerous methodological texts propose analytic schemes designed to permit the emergence of categories or themes from the data. These range from simple to the highly complex. It seemed appropriate in light of the literature to draw on Hammersley and Atkinson’s (1983) approach to qualitative analysis, which draws on Glaser and Strauss (1967). They suggest the process of analysis begins with careful reading of, and familarization with, the data gained. Early reading and transcription of the data as an ongoing process assisted in the identification of emerging concepts and initial categories. Major themes emerging from each interview were highlighted. The data were critically analysed and questioned (Hammersley & Atkinson 1983) and eventually descriptive themes emerged which provide a framework for the presentation of the substantive issues raised during the study. The research team was not required to present the study to the Local Research Ethics Committee. However, all respondents agreed that the interviews could be tape recorded and were assured of the confidentiality of the data. Findings The characteristics of the five people in this team were: • Age range: 40–50 years • Gender: all were female • Graduates: 2, 2 in process of studying for degree and one to start in 1995 • Time in post: 6 months–4 years • Time working in community 6–11 years. Issues which emerged repeatedly from Stage II questionnaires to practitioners and managers (Thomson et al. 1996, 1999) included the unpreparedness of students for community placements and a lack of communication between educational institutions and community nursing and midwifery services. It would appear that the model described in this case study attempts to address these issues. © 1999 Harcourt Publishers Ltd Community facilitator liaison role The four community facilitators shared central beliefs that their model of liaison could be a possible way forward. All believed that for the role to be fully effective, a significant amount of time has to be spent within the practice setting and for the role to be truly effective it must encompass a degree of ‘hands on care’ with or without students. They stated that such direct involvement with patients and clients enhanced clinical credibility which, the facilitators argued, is vital for strengthening the links between education and service. For example: As a facilitator one of our main roles is to break down the barriers between college and the service side, this is a slow process but I think we have a lot of credibility with our practice colleagues because even though we are now 50% in college we actually came from practice rather than being set down amongst them. (Facilitator) The facilitators identified their liaison role as one which highlighted the actuality of community nursing within the college. This was confirmed by the community nurse teacher: The community facilitators highlight the realities of the community for teachers within the college by the very fact that they are aware of the pressures that are on practitioners within the community particularly now with all the political changes. The increased demands on community practitioners to facilitate students on an ongoing basis can be stressful for some staff, as was apparent in many of the responses to our survey. The community nurse teacher highlighted that the facilitators were able to anticipate stressful situations: The facilitators are able to judge what placements would be most effective for the students, what placements perhaps should have a break from students so that relationships with the college do not break down, so we anticipate this before it happens through the facilitators. If a placement has a break from students because of pressures of work then next time round it will hopefully be a positive experience for student and practitioner. (Community Teacher) Nurse Education Today (1999) 19, 373–385 377 Facilitating learning in the community with lecturer–practitioner posts Certainly, the practitioners in the centres which formed the main part of Stage II of this study would have appreciated a break from what seemed to be a relentless stream of students through the practice areas (Thomson et al. 1996, 1999). Building up relationships that are positive and valued by both practitioners and educators, and by students was a considerable task and one which the facilitators viewed as a major strength of their role. For example: We have a lot of credibility with students and teachers … hopefully the teachers, but most of all with our practice colleagues within the community because they know that we know the realities of the community because we are still working within the community carrying a caseload. We are still there doing it and the students are not able to say … You knew what it was like five years ago but you are not doing it now … because they know we have an active role. (Facilitator) In general, the facilitators were aware of the constraints experienced by educators in fulfilling their liaison role. They did not suggest that the facilitator role should replace the nurse teacher role: rather they saw their roles as different but complementary and they stressed the need to work together with nurse teachers for the benefit of students and community practitioners. They argued that the complementarity of the two roles allowed the nurse teachers and the community facilitators to learn from each other, in that the facilitators now appreciated the philosophy of the teaching institution, and the community nurse teacher commented that she appreciated the clinical reality of the setting in which the student learnt and the practitioner operated. The following comment highlights the issues: As a community teacher I am working with the facilitators as a team, we are working together and thinking about what we want to get involved in within the college and the main priority for myself is that we work together and get involved in education that is community focused. (Community Teacher) Data from the questionnaires demonstrated that practitioners had difficulties contacting nurse teachers and one community midwife reported that the student acted like a ‘telephone line’ 378 Nurse Education Today (1999) 19, 373–385 between midwife and teacher in order to overcome this problem (Thomson et al. 1996). Some of the interviewees in the Stage II study suggested that nurse teachers should carry a bleep (Thomson et al. 1996). When asked specifically about how available they were to practitioners and students, facilitators reported that they carried a pager. For example: Practitioners and students know that we can be contacted by paging us … we are easier to find than personal tutors. I think we do a very good job keeping everyone in touch, and we are willing to interchange our role as the need arises, we are findable and because we are, the phone calls have increased–practitioners know we are readily available and can contact us on any issue. (Facilitator) The picture which emerged was of a team with a well specified role which enabled the individuals to work together in a unified way: Working in a small team facilitates excellent communication, we do not have to go through any levels, we are very autonomous. (Facilitator) Student preparation In response to the questionnaire in Stage II, many practitioners expressed dissatisfaction with the preparation of students for their community placements. Whilst some of the supporting comments confirmed this, others, such as that students were sent into the community too early in their course and that they lacked knowledge of nursing/midwifery procedures, suggested that the practitioners were not fully aware of changes consequent upon the introduction of the diploma level pre-registration programmes (Thomson et al. 1996). Data gathered during interviews with practitioners supported the notion that students were unprepared but also again suggested that for many practitioners, the issue was also their own preparation for what to expect (Thomson et al. 1996, 1999). The facilitators agreed that a strong liaison role between the education centre and practice was essential to ensure that preparatory mechanisms are in place. The community teacher reported that the facilitator team had ‘taken the trouble’ to communicate effectively with practitioners, so preparing them © 1999 Harcourt Publishers Ltd Facilitating learning in the community with lecturer–practitioner posts to provide an optimal learning experience for the students: They have the ability because they work 50% of their time in service to see perhaps when the P2k students are not prepared adequately and address this issue. (Community Teacher) The facilitators stated that during the early stages of introducing Dip HE students to the community, there was a particular need to prepare community staff to meet some of the new demands and expectations of the new programme: I feel a lot of community staff did become threatened initially by P2k students and that was part of the reason the community facilitator team was set up–to prepare the practitioners in what to expect from the students. (Facilitator) The facilitators stressed the importance of meeting and sharing information with practitioners within their own setting as a major part of the facilitator role, in order to prevent community-based staff becoming isolated. The facilitators stated that before they started their post practitioners felt isolated from the educational world. For example: There used to be one enormous meeting within the college of nursing in which community staff and hospital staff were invited and that was just a waste of time and a disaster because community staff did not feel it was their meeting … it was so long that no-one could discuss anything—40–50 people there. (Facilitator) The issue arising from the facilitators’ comments suggested that their philosophy included valuing and supporting community practitioners as well as informing them about the assessment process. Keeping practitioners involved and up to date as to the learning needs of the students was a major part of their dual role: We have four meetings a year within (… Trust) and this is a format for us to pass on information from the college about the students and clear up any issues. Those are small meetings and we find them very productive with exchange of ideas. This is something we have established as part of our © 1999 Harcourt Publishers Ltd facilitator role and practitioners really appreciate the idea of community only meetings in the community. (Facilitator) The links were good and ongoing relationships were forged which ensured that staff were up-to-date and well supported regarding educational issues and assessment: We prepare practitioners by regularly seeing all community staff and explain curriculum content and inform them of any changes, we also try to catch new staff as they join. (Facilitator) During adult branch evaluations, invite senior manager and branch students and all district nurses attend, get 100%. The evaluations have been so good that we have decided to drop them. The district nurses and health visitors are so motivated we have very good contact and sort out any issues as they arise. (Facilitator) Data arising from the practitioners via the Stage II questionnaires suggested that practitioners felt that CFP students, in particular, were not prepared and lacked background knowledge and experience of community practice (Thomson et al. 1996). In many cases, it was suggested that these students came too early in the course and were unaware of the role of community staff. However, the facilitators raised the issue that in their area, certain practitioners had commented that branch students lacked particular skills: Practitioners complained that adult branch students module 6 did not know about aseptic technique. In the interim we did two things, we put on a workshop for the students and we informed the practitioners. Because of the nature of prior placements students may not have the opportunity to develop some clinical skills and indeed this was not the true nature of the P2k programme. (Facilitator) The facilitators shared central beliefs that expectations and anticipation of community practitioners in relation to DipHE students were, in part, based on their own personal experience and education: I feel practitioners expectations’ of the students are now quite realistic. To begin with they probably expected too much from P2k as Nurse Education Today (1999) 19, 373–385 379 Facilitating learning in the community with lecturer–practitioner posts they were used to 3rd year RGNs who were skilled young nurses coming in with a lot of practical and interpersonal skills. Part of the important preparation we do with community nurses is to actually explain that P2k students are very new and their level of skills are not great nor are they meant to be. It was a problem initially dispelling myths but as community facilitators we have addressed it, now we work on new staff. (Facilitator) The smooth transition of students into the community involved detailed preparation of the students: We spend whole days with CFP/branch students (does not include mental health and learning disability). With the CFP students we introduce the concept of PHCT. We correct a lot of misconceptions about all the community roles. We cover rules of confidentiality through what to wear and how to be acceptable in someone’s home. Students also meet their supervisors prior to placements. (Facilitator) Non-NHS institutions The facilitators all reported that established systems for ensuring liaison between service and education were firmly in place and working effectively. As a result they felt, as a team, that it was necessary to move the focus of their liaison role away from the primary health care team to non NHS institutions within the community: We feel the practitioners do not need us as much as the placements run very smoothly, we tend to support our students now in non NHS institutions far more often. There is a clear understanding of the students’ needs within these placements … non NHS institutions are not educationally biased. (Facilitator) This response was echoed by the community nurse teacher who said: We have identified problems with non NHS placements in that people perhaps are not using EC directives in moving and handling and we can offer them packages. Myself and the facilitators do placement profiles. My role is focused on non NHS placements, I go out 380 Nurse Education Today (1999) 19, 373–385 and do a lot of visits. We have also found that students expect to work with ill patients and find it quite difficult when their placements are with healthy children for example in a classroom setting. My role and the facilitators’ role is to get students to see the value of understanding the benefits of looking after children in a normal environment. The value of facilitating the understanding of what was expected from the student within nonNHS placements often involved a three way system: facilitator–practitioner–student. This provided opportunities for practitioners to gain insights into the needs of individual students. Relating theory to practice The issue of relating theory to practice was explored with the community facilitators. They all commented that their responsibilities from joint education and clinical roles allowed them to facilitate the integration of theory and practice in a number of ways. In particular, they felt credible in the eyes of the students, both in practice and education: Because we are in practice and in college, we have credibility with the students and are able to see both perspectives of the course. (Facilitator) The benefits of practising and carrying a caseload allowed the facilitators to demonstrate to students the approach to nursing they would wish them to develop. Working with students as a community facilitator offered them a unique opportunity to influence the development of future nurses while still remaining skilled in practice. Theoretical teaching in isolation was recognised as idealistic by one facilitator. In order to apply theoretical teaching to practice she described a critical incident when she asked a patient to come in to the college and speak to a group of Dip HE students: We help the students understand sensitive issues. For example, draw from my own caseload—I had a chap who cared for his wife for fifteen years. She had a chronic illness and this affected his relationships with his children, work, etc. The lady died and this man felt worthless. After a suitable period I asked him to come in and speak to the © 1999 Harcourt Publishers Ltd Facilitating learning in the community with lecturer–practitioner posts students about his experience and highlight to them the dilemma of being a carer. The students homed in on him–they were listening to issues about carers from a knowledge base. He was able to make explicit the dilemmas which textbooks cannot highlight. I felt this experience enabled the students to be more sensitive and the patient benefited too. He has agreed to come and speak to different groups of students on a regular basis. It is a major strength of our role that we can draw from practice. (Facilitator) Facilitators stressed the importance of preparing the practitioners who are supervising the students. They reported regular meetings with the supervisors to explore with them the specific learning focus for the students on placement so that the supervisors knew exactly what the students were ‘trying to get to grips with’. The facilitators shared the belief that by describing the curriculum, defining objectives and giving support and guidance to the supervisors they were able in turn to assist the students in relating theory to practice. This view was supported by the community teacher: One of the advantages of these dual roles is that they facilitate the placement supervisors to understand the theoretical input and make it appropriate to the practical situation. One of the facilitators remarked that the team had benefited from contributing formally and informally to lectures, meetings and the curriculum within the college and this had caused them to think differently. They now understand why nurses needed a theoretically focused course as opposed to the old RGN apprentice-style training. The facilitators now had a better understanding of curriculum and ‘educational jargon’ which enabled them to translate course content to practitioners to facilitate better understanding: When I first took on this role, coming straight from practice–it felt very strange. I went to educational meetings and they were talking about taxonomies, levels etc, I wondered what on earth they were talking about. Whereas I feel I understand it much better now and I want to learn a lot more. Understanding educational jargon has helped me to convey this understanding to practitioners because © 1999 Harcourt Publishers Ltd this is not the knowledge you normally have as a practitioner. (Facilitator) Managing the roles One of the major challenges faced by the community facilitators was the merging of roles. Adopting the multiple roles of nurse, teacher and student (all except one of the team were undertaking degree courses), often within the space of one day, was described as physically and emotionally demanding. Working within two very different systems, education and service, did not necessarily mean that hours worked between the two organizations were evenly apportioned, which can lead to extra demands: The main conflict I have is time. When I am working during my clinical time I want to do as much patient care as I can, but with all the administration and paper work coming into district nursing now … that gets done at 7pm. (Facilitator) Challenges and pressures within the practice setting included carrying a case-load where resources were limited. This was not so much an expression of resentment about carrying a caseload but more an awareness of pressure being put upon them because of low staffing levels and lack of time: I feel my role would work better if you have the right staffing levels. I spend my two clinical days in a GP practice which has 7000 patients. There are only two of us (the other district nurse works full-time in the practice). When I spend two days undertaking my educational role in college and one day studying for my degree, my colleague picks up my caseload and I find that very stressful as I feel it is hard on my colleague. Ideally, I need another half to support my clinical role. (Facilitator) Despite these difficulties, this particular facilitator was keen to stress her total commitment to the facilitator role. She stated that having an educational and clinical role keeps you ‘so in touch’ with practice colleagues: For example, I went to a supervisors’ and assessors’ meeting the other day which was during my clinical day. I went along as a Nurse Education Today (1999) 19, 373–385 381 Facilitating learning in the community with lecturer–practitioner posts practitioner this time, not in my dual role as facilitator. However, facets of my role came into everything. I was able to discuss student placements within my district with my colleagues–the role is so interlinked. (Facilitator) However, the facilitators experienced frustration within the college-based half of their role. This stemmed, in part, from being perceived by some college staff as not being able to teach because of the lack of a recognized teaching qualification. As a result, limits were sometimes placed upon how much facilitators could contribute to curriculum development. One facilitator suggested that this may, in part, be due to the fact that historically the college did not provide district nursing and health visitor courses. She felt this had led to misconceptions about the teaching ability of community practitioners: There is a poor understanding within some sections of the college about what district nursing and health visitor training entails. I have found that my CPT training has not been valued, but if we can channel those sort of things through the community teacher who does have credibility within the college … I think it will lead to a positive expanding role educationally. (Facilitator) Working within the educational setting also represented a very positive aspect of being in a dual role. Specifically, the facilitators valued the opportunity to exchange ideas and experiences with nurse teachers and to gain a different perspective on their own practice through the process of sharing. Similarly, the community teacher identified that the facilitators brought the realities of community practice into the academic setting for teachers and students: The community facilitator role is very much a role of liaison between the college and service, between individual tutors and practitioners, and again a liaison between the student and college and the student and placement supervisor. (Community Teacher) Despite the challenges, the facilitators described how occupying the combined roles of teacher, nurse and student had influenced their own practice in a personal way. Similarly, while 382 Nurse Education Today (1999) 19, 373–385 not claiming to be experts, they described how they felt able to influence other nurses in their practice, by raising issues that the practitioners may have been unable to see. It would appear that working within a small team had many benefits which included the ability to share responsibilities and support each other and the strength of being able to utilize their different skills: We give each other support–this is vital as we have such a fragmented week … we all have expertise in different areas and we feed off each other. (Facilitator) The motivation to bring together their collective skills and ‘make the team work’ was vital. Having a community nurse teacher heading the team provided an important link with the college to prevent separation. Through the structure of their various roles and by the ways in which they went about their work, as shown through their attitudes and beliefs, they appeared to be constantly attempting to bring theory and practice together. The focus for this was very much the community practice domain and indeed if they had to make a choice they would stay practice based: I am very committed to my clinical role and if ‘push came to shove’, clinical would win over education. (Facilitator) Discussion Presented in this paper are the findings from semi-structured interviews with four community facilitators, who appeared to be functioning in a lecturer–practitioner role, and their related community teacher. In reflecting on the research approach adopted it was felt that it was successful in achieving the aims of the research. However, due to the small number of participants and absence of systematic sampling that is characteristic of qualitative research (Bryman 1988) a lack of a generalizability becomes a basic limitation. However, the goal of naturalistic inquiry is not for generalization (Lincoln & Guban 1985) but rather to unveil the nature, essences, characteristics and meanings of phenomena as fully and completely as possible, and within particular contexts. Nevertheless, we would argue that any researcher practising the © 1999 Harcourt Publishers Ltd Facilitating learning in the community with lecturer–practitioner posts same conversation method would probably find similar data from interviews with participants from the same cultural context. However, the data can, of course, be analysed and interpreted from different points of departure. A methodological limitation and concern worthy of note within this study was the reliance on data gathered through a single interview. A period of participant observation may have provided useful examples, possibly reinforcing some of the findings from the interview data. A longitudinal study of the community facilitators over a period of time, exploring participant observation and interviews may have strengthened the internal validity of this study by allowing for continual data analysis and reflection on the differences between observational and interview data. The concepts discussed in this study may not be exhaustive of community facilitator practice since the practice reported here is limited to a specific area of facilitation, namely for the Diploma of Higher Education in Nursing Studies programmes. The interpretation presented here is based upon data gathered from the facilitators themselves and from one community nurse teacher. A complete understanding of the merits and drawbacks of the role would require the perspectives of practitioners, students and possibly those in receipt of care. Further analysis of this joint role of practice could validate these findings and reasonably produce new insights. However, there is very little existing empirical work on the role of the lecturer–practitioner and we found no reports of any in the community. Therefore the findings in this paper could be used to form a basis for development and further evaluation of similar roles within the community. In their national study exploring the changing role of the nurse teacher in England Carlisle et al. (1997) report that the lecturer–practitioner role, with a 50% split in clinical and teaching work was seen as the major method of ensuring that the teacher maintained clinical competence and credibility. The findings from this Case Study support the suggestion that the lecturer–practitioner role is one possible way of helping skilled nurses to stay in close contact with clinical care while, at the same time, advancing their career (Burns 1994, Vaughan 1994, Luker et al. 1996, Thompson et al. 1998). It would appear that within the college under © 1999 Harcourt Publishers Ltd study and two of its related practice areas the DipHE course, with its increased community component, had encouraged teaching and community staff to find ways to improve communication between service and education. In the Stage II questionnaires the need for better communication between teachers and practitioners had been emphasized throughout the questionnaire, no matter what the question being asked (Thomson et al. 1996, 1999). One response, as described here, had been to develop a small team of lecturer practitioners who refer to themselves as community facilitators. Baillie (1994) argues that if gaps between education and practice are not to be widened by the wholesale shift of nursing education into higher education, nurse teachers will need to retain their clinical links. The movement into higher education can open up a new and exciting dimension for the lecturer–practitioner (Rhead & Strange 1997). The combined role demonstrates that the gap between academic subject specialism and working in the clinical area can possibly be bridged. The role described here takes very seriously the conclusions of Cave (1994), who insists that to avoid erosion of the nurse teacher role by both highly qualified specialists in higher education and more knowledgeable, articulate practitioners, it is necessary to ensure that academic knowledge is integrated into and applied to practice. Lecturer–practitioners with their responsibility for educational modules can articulate theoretical knowledge, which can provide an up-to-date, research-based framework for students and clinical staff. However, when considered in relation to the current trend for lecturer–practitioner posts, the findings from this study suggest further areas for investigation. There is a need for a tool to evaluate the effectiveness of this role. Such an evaluation would have to take account of changes in the profession, both in practice and education, and in organizational and financial changes in the provision of health care services. The evaluation would need to include an assessment of the expected outcomes of lecturer–practitioner roles, namely the enhancement of the quality of nursing care and student learning, the professional development of staff and relations between service and education. The findings described here suggest that developing small teams of facilitators may Nurse Education Today (1999) 19, 373–385 383 Facilitating learning in the community with lecturer–practitioner posts provide a bridge between teachers and practitioners and can serve as a basis for further study of the lecturer–practitioner role. References Alexander M 1983 Learning to nurse: integrating theory and practice. Churchill Livingstone, Edinburgh Ashworth P M, Castledine G 1980 Joint service-education appointments in nursing. Medical Teacher 2: 295–299 Baillie L 1994 Nurse teachers feelings about participating in clinical practice: an exploratory study. Journal of Advanced Nursing 20: 150–159 Bendall E 1975 So you passed nurse. Royal College of Nursing, London Burke I M 1993 The future of the specialist nurse teacher: two different models explored. Nurse Education Today 13: 40–46 Burns S 1994 Lecturer practitioner: the reality of students: In: Vaughan B, Lathlean J, eds Unifying nursing practice and theory. Butterworth Heinemann, Oxford Burgess R G 1984 In the field: an introduction to field research. George Allen and Unwin, London Carlisle C, Kirk S, Luker K 1997 The clinical role of nurse teachers within a Project 2000 course framework. Journal of Advanced Nursing 21: 314–324 Cave I 1994 Nurse teachers in higher education–without clinical competence. Do they have a future? Nurse Education Today 14: 394–399 Champion R 1992 Professional collaboration: the lecturer practitioner role. In: Bines H, Watson D, eds Developing professional education. The Society for Research into Higher Education and Open University Press, Buckingham Davies J 1989 Who or what are LPs? Senior Nurse 9 (10): 22 Department of Health 1989 A strategy for nursing. Department of Health, London ENB 1989 Preparation of teachers, practitioner teachers, mentors and supervisors in the context of Project 2000. MAT/NE July. English National Board for Nursing, Midwifery and Health Visiting, London Glaser BG, Strauss A 1967 The discovery of grounded theory: strategies for qualitative research. Aldine, Chicago Gott M 1984 Learning nursing. Royal College of Nursing, London Hammersley M, Atkinson P 1983 Ethnography: principles in practice. Tavistock, London Hardy M, Conway M 1978 Role theory perspectives for health professionals. Appleton Century Crofts, Norwalk Harrison F 1992 Leadership through alliances. Canadian Nurse 88 (8): 20–23 Inglesby L 1985 From the outside looking in. Senior Nurse 3 (4): 10–11 Jones J A 1985 A study of nurse tutors’ conceptualisation of their ward teaching role. Journal of Advanced Nursing 10: 349–360 Lathlean J 1992 The contribution of lecturer practitioners to theory and practice in nursing. Journal of Clinical Nursing 1: 237–242 384 Nurse Education Today (1999) 19, 373–385 Lathlean J 1995 The application and development of lecturer practitioner roles in nursing. Ashdale Press, London Lathlean J, Vaughan B, eds 1994 Unifying nursing practice and theory. Butterworth Heinemann, Oxford Lowney E 1986 The impact of the nursing process on the role and function of the clinical teacher. Nurse Education Today 6: 60–63 Luker K, Carlisle C, Kirk S 1996 The evolving role of the nurse teacher in the light of educational reforms. English National Board for Nursing, Midwifery and Health Visiting, London May KA 1991 Interview techniques in qualitative research: concerns and challenges. In: Morse JM ed Qualitative nursing research: a contemporary dialogue. Newbury Park, California McCaugherty D 1991 The theory–practice gap in nurse education: its causes and possible solutions. Findings from an action research study. Journal of Advanced Nursing 16: 1055–1061 National Health Service Management Executive 1997 Lecturer practitioner roles in England. Department of Health, London Rew L, Betchel D, Sapp A 1993 Self as an instrument. Nursing Research 42: 5 Rhead M, Strange F 1996 Nursing lecturer/practitioners; can lecturer practitioners be music to our ears? Journal of Advanced Nursing 24: 1265–1272 Robertson C M 1986 Clinical teaching: a historical perspective. Nurse Education Today 6: 97–102 Schon D 1983 The reflective practitioner: how professionals think in action. Temple Smith, London Tamlyn D, Myrick F 1995 Joint nursing appointments: a vehicle for influencing health care change. Journal of Advanced Nursing 22: 490–493 Thompson J, Thomson AM, Shepherd B 1998 An evaluation of the lecturer-practitioner role in the Manchester College of Midwifery & Nursing, Occasional Paper No 4. School of Nursing, Midwifery & Nursing, University of Manchester Thomson A M, Davies S, Shepherd B, Whittaker K 1996 An investigation into the changing educational needs of community nurses, midwives and health visitors in relation to the teaching, supervising and assessing of pre and post-registration students. English National Board for Nursing, Midwifery and Health Visiting, London Thomson AM, Davies S, Shepherd B, Whittaker K 1999 Continuing education needs of community nurses, midwives and health visitors for supervising and assessing students. Nurse Education Today 19: 93–106 UKCC 1986 Project 2000, a new preparation for practice. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London Vaughan B 1987 Bridging the gap–teaching roles in nurse education. Senior Nurse 6 (5): 30–31 Vaughan B 1990 Knowing that and knowing how; the role of the lecturer practitioner. In: Kershaw B, Salvage J, eds Models for nursing 2. Satan Press, London Vaughan B 1994 Setting the scene. In: Lathlean J, Vaughan B eds Unifying nursing practice and theory. Butterworth Heinemann, Oxford © 1999 Harcourt Publishers Ltd Facilitating learning in the community with lecturer–practitioner posts Whittaker K, Davies S, Thomson AM, Shepherd B 1997 A survey of community placements for educational programmes in nursing and midwifery. Nurse Education Today 17: 463–472 Wright S G 1981 The role of the clinical teacher in general nursing. Unpublished MSc thesis, University of Manchester, Manchester Wright S 1983 The best of both worlds. Nursing Times Oct 19: 25–29 © 1999 Harcourt Publishers Ltd Wright S 1984 Piggy in the middle. Senior Nurse 1(11): 12–15 Wright S 1988 Joint appointments: handle with care. Nursing Times 84 (1): 32–33 Yin RK 1984 Case study research design and method. Sage, Newbury Park, CA Nurse Education Today (1999) 19, 373–385 385