nts

Faculty of Health and Social Care, Peel House Campus, University of Salford, Albert Street,

environment in which learning occurs. It demonstrates how a UK pre-registrationnursing student engaged on a problem-based learning curriculum supported by avisionary mentor was able to combine aspects of critical thinking, problem solvingand evidence based practice to enhance care delivery.c 2005 Elsevier Ltd. All rights reserved.

Problem-basedlearning;Childrens orthopaedic;Nursing;Mentorship;

Editors comment

practice setting. needs will be supported by appropriate membersof the inter-disciplinary team.

The joint publication from the Department ofHealth and The English National Board reinforcedthe necessity for collaborative working partnerships

1361-3111/$ - see front matter c 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.joon.2005.07.003

* Tel.: +44 161 295 2774; fax: +44 161 295 2963.E-mail address: b.burns@salford.ac.uk.

Journal of Orthopaedic Nursing (2005) 9, 127133

Journal ofOrthopaedic NursingBackground

Learning for pre-registration student nurses occurswithin a complex environment, which has both aca-demic and clinical components. The academiccomponent provides nurses with the educationalcontent, which supports learning within the clinical

The clinical learning environment is an integralcomponent of any nurse education and trainingcurriculum. These clinical placements must complywith guidelines Placements in Focus (ENB/DOH2001) and facilitate the learning needs of studentsaccessing the placement. Pre-registration studentshave an expectation that their identified learningPersonal and professional development is central to life long learning for nurses and health care professionals generally. This casestudy explores some of the issues using a pre-registration nursing students experience in the childrens orthopaedic setting. PDInformation technologyManchester M30 ONN, UK

Summary This paper focuses on a single case study to unravel the complex careKEYWORDSBernadette Burns MA, BEd (Hons), RGN, RSCN, ONC, Lecturer in Nursing *Utilising information techproblem-based learning sresolve practice dilemmaorthopaedic settingology andrategies toin a childrens

www.elsevierhealth.com/journals/joon

to be enhanced between Higher Education Institutes

Pre-registration nursing students require supportfrom clinical mentors who have undergone formal

of key skills taught in the classroom to enhance the

of care delivery.

to the pelvic fractures (Dandy and Edwards, 1998).

128 B. Burnseducation and training for the role and understandhow the curriculum outcomes can be achieved inthe clinical practice setting. A variety of factorsimpact on clinical learning experiences, these in-clude the nursementor relationship, ease of ac-cess to educational support systems, sensitivelyplanned duty rotas, staff student ratios, workloadbalance and many more factors. However, fromthe students perspective access to quality mentorsupport is fundamental to the successful achieve-ment of practice-based outcomes (Koh, 2002; Pappet al., 2003). The importance of this studentmen-tor relationship will be discussed through the pre-sentation of a case study.

The student had commenced the final place-ment in the third year of training having completeda theoretical module, which focused on childrenwith complex care needs; it was the second weekin clinical practice. Action plans identified theneed to manage the care of a child with complexcare needs and be involved in clinical decision mak-ing activities surrounding all aspects of care deliv-ery. These action plans were closely linked to thestudents academic assignment. Nicklin and Wilson(2000) identify that action plans form part of a sup-portive learning relationship allowing learningopportunities to be maximised and encouragingstudents to take ownership of problems, whilstreceiving supportive facilitation from their mentor.

Theory underpinning curriculumdelivery

The theoretical model underpinning the nursingcurriculum was Benners (1984) novice to expertmodel. Students commencing nurse-training movefrom novice in their first year, through the ad-vanced beginner stage and in the third year movetowards achieving competence. The philosophy ofproblem-based learning (PBL) supported the deliv-ery of curriculum content and enabled the transferand National Health Service Trusts (UKCC, 1996;UKCC, 1999). These organizations were required towork harmoniously ensuring student nurses in train-ing were fit for purpose and practice. This was to beachieved through a variety of mechanisms includingeffective mentor preparation, reinforcing the needfor evidence based practice and enhancing the roleof clinical and educational audit. These elementswere aimed at improving the quality of studentsclinical learning and ultimately improving the qual-ity of care delivered to the client.Personal and professional development

The student undertook a re-assessment of the childsneeds at the request of the mentor, which would as-sist in meeting the outcomes identified within theaction plan. The case-notes indicated that theorthopaedic consultant had conducted a medicalexamination and reviewed the X-rays. The cervicalspine was intact and the cervical collar could be re-moved. The pelvic fractures were not infiltratingbladder structures and there was no risk of peritoni-tis. The catheter was to be removed to minimise therisks associated with long term catheterisation.

Whilst conducting the client re-assessment thestudent was uncertain of the names of the bonesthat formed the pelvic girdle and requested clarifi-cation from the clinical mentor. This proved to bethe start of a learning journey for both student andCase study

The care setting was a childrens orthopaedic ward.The client was a female adolescent involved in aserious road traffic accident in Europe and flownhome to England by air ambulance three days follow-ing the accident. Injuries sustained included un-displaced fracture of the left pubic ramus and ashear fracture of the left ala bone of the pelvis. Onarrival on the ward a soft cervical collar was evidentand a Foley catheter had been inserted as part of theemergency care received, but also to assist in thechilds comfort throughout the air journey. Pughsskin traction had been applied to provide stabilitypractice learning. Glen and Wilkie (2000) definePBL as a student centred process, which encour-ages independent learning and allows students toidentify gaps in their understanding of relevantclinical problems.

PBL was facilitated via The Onion Model (Darvilland McLoughlin, 2001) where care delivery is di-vided into four domains:

Personal and professional development; Care delivery; Care management; Professional and ethical.

The inner circles of the model (Fig. 1) ensure theholistic needs of the client are addressed includingpsychosocial, spiritual, cultural and physiological.This model was used to unravel the complexities

Onion model.

Utilising information technology and problem-based learning strategies 129mentor. Ward based text-books identified the loca-tion of the superior and inferior Pubic Rami but didnot identify the location of the ala bone (Dandy andEdwards, 1998) and the mentor acknowledgeduncertainty re the location of this bone.

Nolan (1998) found that students who feel re-garded as part of the nursing care team; give anadded bonus to the learning environment addingto the body of professional knowledge. The studentwas encouraged to utilise the information technol-ogy skills developed within the university and ac-cessed the ward computer to search forinformation surrounding the location of the ala

Figure 1(Oakey and Doyle, 2000). Furthermore, the avail-ability of upto date resources materials and accessto the Internet are essential tools in the mainte-nance of a quality learning environment (QualityAssurance Agency, 2001).

Using Ask Jeeves (www.ask.co.uk) as a quicksearch engine and using ala bone as the keywords,information was retrieved on the location of thebone. The ala is a small bone which provides stabil-ity to the posterior pelvis by attachment to spinalvertebrae. Furthermore, the ala ligament runsfrom the posterior pelvis to the base of the skulladding further support to the pelvis (www.photo-search.com2004). This diagram was subject tocopyright and the student printed off a differ-ent version from the university home page(www.isd.salford.ac.uk/resources/eresources/int-eractivehip2004) (Fig. 2) and added this to wardbased resource. Academics may argue that web-sites such as Ask Jeeves do not always produce ac-cess to quality resource materials but as an initialsearch engine it gave a prompt answer. The seniorradiographer was contacted, and interpreted thepelvic X-rays providing the student with a copy ofthe X-rays to label and use as a teaching aid. Anexample of an X-ray demonstrating fractures of LPubic Rami was downloaded from (http://www.trauma.org/cases/classic001.html).

Armed with this new information an in-depth pa-tient re-assessment was undertaken utilising anadaptation of the Roper Logan and Tierney Modelof Nursing (Roper et al., 1990). The problems wereidentified as:

Figure 2 The ala bone.

Inability to ambulate (mobilising) due to a frac-

bly some local damage to the pudendal nerve.Uncertain of the location of this nerve the Internet

to be based on custom and practice rather than evi-dence. Sackett et al. (1996) discusses the increasingemphasis placed on evidence based healthcare andhow healthcare professionals need to analyse theavailable evidence. The student focused on thedecision making processes that had influenced caredelivery. An online article by Muir (2004) enhancedknowledge in this area. Muir cites Carroll and John-sons (1990) information processing model and theseven stages of temporal decision-making wereused to review clinical decision-making:

1. Recognition of the situation2. Formulation of explanation3. Generation of other ideas4. Information gathering5. Making judgements

130 B. Burnsonce again proved a valuable resource for obtainingphysiological diagrams (www.gmedmedia/web-lec01/lec24, 1999) (Fig. 3).

A neurology textbook identified that the puden-dal nerve is occasionally damaged in pelvic frac-tures and can initiate sensory pain in theperineum region (Gilroy, 2000). The nerve routepassed close to the fracture sites and pressure onthe nerve was increased during bedpan use. The in-ter-disciplinary team had been targeting pain med-ications to relieve bone pain rather than nerve painand the pain management plan was revised to takeaccount of the complex nature of the pain.tured pelvis. Communicating about the management of painassociated with the fractures and the anxietysurrounding the accident itself.

Problems related to eliminating focused on theunwillingness to use bedpans because of pain.

Nutrition (eating and drinking) problems focusedon ensuring sufficient dietary intake of foodsthat would aid bone healing.

All of these problems were interdependent andPBL strategies were used to address professionaldevelopment issues in the clinical setting.

Care management

Issues surrounding eliminating identified severalfactors requiring clarification. Since the removalof the Foley catheter and removal of the skin trac-tion on day four, the childs pain had worsened. Thiswas verified through review of the medicine admin-istration sheet and the pain assessment chart. Painhad been scored at a maximum four on the adaptedWong and Baker faces scale (Day and Jonas, 1998)and dispensing of pain medication increased follow-ing the use of bedpans. The child complained of ashooting pain, originating in her left groin and trav-elling into her hip each time a bedpan was used.

Several issues required addressing and the prob-lem posed by the student to the mentor was: Is theconstant raising of the pelvis during the insertion ofbedpan destabilising the fracture site. The studenthypothesized that a contributing factor associatedwith the enhanced pain experience surroundedthe removal of Pughs traction which had providedsome limited stabilisation to the pelvis when usingbedpans. The mentor encouraged the student toseek answers to these questions. The consultantwas the expert and explained that there was possi-Gabapentin was introduced, which has a positiveeffect on neuropathic pain. The mentor had com-pleted a paediatric pain module studying the useof Gabapentin in the orthopaedic setting and pro-vided articles (McClain and Ennevor, 2000; Harden,1999). These authors identify that the mechanismsthat generate neuropathic pain are varied andcomplex, but are frequently associated with crushor compression injuries similar to those experi-enced in road traffic accidents. Wilder et al.(1992) acknowledges that there is often a psycho-genic component to neuropathic pain when experi-enced by children.

The student accessed the Internet to enhanceknowledge surrounding neuropathic pain in chil-dren. University education had informed the stu-dents learning surrounding levels of evidence, andthe expert opinion of the consultant, the mentorand the lead pain nurse proved valuable resources(Tarling and Croft, 2002). The student raised con-cerns with the mentor that care delivery appeared

Figure 3 Proximal course of the pudendal nerve 1988.

6. Hypothesize: Take action the job which include ward management, care

the understanding that holistic assessment is thecornerstone of quality in care delivery. The mentor

Utilising information technology and problem-based learning strategies 1317. Dissemination

The decision to remove the Foley catheter hadplayed a crucial role in the enhanced pain experi-ence and this decision was not taken using a riskversus benefit approach.

The risks were perceived as the development ofa urinary tract infection as evidenced by the liter-ature surrounding long term indwelling catheters(Simpson, 2001). This corresponds to the recogni-tion stage of Carroll and Johnsons model. How-ever, the benefits of retaining the catheter hadnot been explored or discussed with the child. Withimproved knowledge of the underpinning physiol-ogy it was argued that if the catheter had remainedin place then the pain associated with bedpanusage could be minimised until the fracture wassticky, around day ten. These actions supportedby good hygiene standards could reduce the riskof acquired urinary tract infection, formulationand generation. Information gained from reliabledatabase sources had provided insight into the is-sues influencing care delivery, information gather-ing. The mentor acknowledged that the acquisitionand utilisation of Web based literature did not formpart of her key priorities. However, working collab-oratively with the student had allowed the mentorto develop key skills in the area of database search-ing. Papp et al. (2003) explored how students learnin the clinical environment and found the moresupportive the relationship between student andmentor the more learning is enhanced.

The student raised many valid questions whichthe mentor alone was unable to answer. Chowand Suen (2001) evaluated student nurses learningexperiences in the clinical environment and whendiscussing the role of mentors as advisors andguides, students identified that some mentors weretask orientated and had a mind-set of sticking toward routine. The mentor acknowledged that itwas routine practice to remove bladder catheterswhen no underlying bladder pathology was evident;however no clinical guidelines were available tosupport these actions, which caused the mentorto reflect on the knowledge base from which theyoperated, making judgements. The mentor hadbeen qualified for 7 years and successfully com-pleted a teaching and assessing in clinical practicecourse five years previously. Indeed the mentoridentified that the questioning of decision makingin clinical practice did not figure as a key compo-nent of the pre-registration curriculum at that time(Nicklin and Wilson, 2000).

The clinical mentors role is complex and has tocompete with a variety of other responsibilities ofallowed the student to undertake a comprehensivereview of care which resulted in improved under-standing of the origins of the childs problems. Thissupportive and facilitative role allowed the studentthe opportunity to access the evidence to supporther clinical decision making. These actions supportfindings from Spouses (1996) research study whoafter analysing the studentmentor relationshipfound it could be supportive of student-centredlearning and dovetails closely with the philosophyof PBL.

The revised plan of care was discussed with thechild to ascertain her understanding of the care shewas receiving. The anxieties associated with theaccident were causing disturbed sleep patternsand the student felt that the child might be expe-riencing post traumatic stress acknowledging thatshe was afraid of falling asleep (Rogers and Guer-nay, 2001). The flashbacks were a psychologicalcomponent of the injury, which appeared to inten-sify the pain experience which also supports Suresh(2000). This information was shared with thedelivery and continuing professional developmentand include the pressure of home and family (Phil-lips, 2000). The mentor acknowledged that contin-uing professional development had not featuredhigh on the personal agenda but completion ofthe pain module had re-awakened the need toquestion practice.

The student hypothesized that the medicalmodel of care required challenging. If nursing staffhad engaged in meaningful discussions with the con-sultant, expressing concerns that the removal of thecatheter may potentiate pain associated with thefractured ala and bedpan usage, then the decisionto remove the catheter could have been delayed.This would have allowed nursing staff to develop agreater insight into the origins of the pain and hope-fully improve the overall management. Carroll andJohnson (1990) suggest that these actions demon-strate sound clinical decision making is taking placeand consultant feedback changed the way care wasmanaged, demonstrating improvements to clientcare through multi-professional working.

Care delivery

The care delivery system should meet the clientgroup care needs and provide continuity and con-sistency in all aspects of care delivery. The studentacted as an associate nurse to the named nurse(Department of Health, 1992) and operated from

clinical mentor and the house officer and with the

cussed. It was explained that by applying tractionto the lower limbs this relieved the pressure on

and ethical aspects of care delivery which re-

tice were at the students fingertips and accessedby using key skills of information technology and

132 B. Burnsthe fracture site (Dandy and Edwards, 1998).However, the removal of the traction would notaffect the healing of the fractures but was possi-bly a contributing factor to the disturbed sleeppatterns experienced. The child acknowledgedthat she had insufficient information when takingthe decision to have the traction removed whichreinforced the need to gain full informed con-sent. The ability to link these practice eventsto prior learning facilitated increased understand-ing of the Frazer guidelines (1996) and priorknowledge of child development identified thata 14 year old should have sufficient cognitiveability to understand the issues involved. The stu-dent relied on her knowledge of child protectionEvery Child Matters (DOH, 2001), which clearlystates that, childrens views should be taken intoconsideration when planning interventions.

The mentor found time to listen to the stu-dents concerns and felt that some important is-sues were being raised surrounding professionalchilds consent she was referred to the clinical psy-chologist (Carter, 1994). Furthermore, the pain re-lief medication was upsetting her digestion whichmade her reluctant to eat; it was also difficult toeat when lying flat on one pillow.

Whilst awaiting the psychology referal, theX-rays were used to explain the nature of the inju-ries and how these contributed to the pain experi-enced when moving onto a bedpan. The child wasencouraged to read about her injuries and the wardschoolteachers provided a website where she couldfind out more about her injuries. Gradually shebegan taking limited lessons and work sent in byher school, was used by hospital teachers (DfEE,1996). Input from the play specialist was requestedand appropriate distraction techniques were devel-oped to support pharmacological painmanagement.A numerical pain rating scale was substituted for theWong and Baker scale and the child was encouragedto score and describe her pain and engage indecisions surrounding pain management.

Professional and ethical

It became evident that these actions wereempowering in nature, allowing the child to be-come involved in decisions surrounding her carerather than being a passive recipient. One aspectof care she questioned surrounded the removal ofthe Pugh skin traction on day five. Once againdecisions surrounding risk versus benefit were dis- problem solving. The orthopaedic consultant held

overall responsibility for the childs care but thenamed nurse remains professionally accountablefor the continuity of care. The medical model pro-vided only part of the answer to the childs prob-lems and some nurses had become taskorientated and were unwilling to challenge prac-tice. Other nurses were practicing with a limitedknowledge of anatomy and physiology and thishad a direct impact on the quality of care deliv-ered. Access to clinical experts allowed for clarifi-cation of problems and led to improved ways ofworking. However, information gained from reli-able Internet sources allowed the child to beviewed, holistically and the psychosocial needsassociated with the impact of trauma were ad-dressed. This had been a valuable learning experi-ence for both student and mentor and thesupport gained from each other was beneficial topatient care. The ward setting proved to be a valu-able learning environment (DOH/ENB, 2001). Thestudent reflected and understood why these eventshad reinforced the selection of childrens nursing asa positive career choice. Indeed the events hadquired further exploration. The mentor had facil-itated new learning and supported the studentthrough some difficult learning experiences (Nurs-ing and Midwifery Council, 2002). It was impor-tant that these experiences were disseminatedto the wider healthcare team with the hope ofinfluencing future practice. These actions corre-spond to the final stage of Carroll and Johnsons(1990) model. Following discussion with the wardmanager student and mentor presented this casestudy to a multi-professional audience includingpre-registration student nurses, qualified nurses,radiography staff, house officer and the ortho-paedic consultant. Nurses tend not to get in-volved in multi-professional case presentationsyet the benefits of inter-professional workinghad proved beneficial to patient care. Childrensnurses must value their nursing uniqueness andshare this with other healthcare professionals.At the end of week one, a comprehensive mul-ti-professional, evidence based plan of care wasdeveloped, which had a direct impact on thequality of future care delivery and achieved thegoals identified in the students action plan.

Conclusion

Answers to problems identified within clinical prac-

provided a deeper insight and understanding of

Nursing Standard 16 (19), 3842.McClain, B.C., Ennevor, S., 2000. The use of gabapentin in

Nicklin, Wilson, 2000. In: Nicklin, Kenworthy (Eds.), Teaching

Nursing and Midwifery Council, 2002. Code of ProfessionalConduct. NMC, London.

www.qaa.ac.uk.Rogers, P., Guernay, K., 2001. Phobias: nature and assessment.

Utilising information technology and problem-based learning strategies 133pediatric patients with neuropathic pain. Seminars in Anes-thesia, Perioperative Medicine and Pain 19 (2), 8387http://gateway.ut.ovid.com/gw1/ovidweb.cgi .

Muir, J., 2004. Clinical decision-making: theory and practice.Available from: http://www.nursingstandard.co.uk/archives/ns/vol18-36/.Acknowledgement

I would like to thank Dorothy Lothian (Pain Nurse)for her expertise when discussing the use of Gaba-pentin for the management of neuropathic pain.

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Carroll, J., Johnson, E., 1990. Decision Research: A Field Guide.Sage, California.

Carter, B., 1994. Child and Infant Pain. Chapman Hall, London.Chow, F.L.W., Suen, L.K.P., 2001. Clinical staff as mentors in

pre-registration undergraduate nursing education: Studentsperceptions of the mentors roles and responsibilities. NurseEducation Today 21, 350358.

Dandy, D., Edwards, D.J., 1998. Essential Orthopaedics andTrauma. Churchill Livingstone, London.

Darvill, A, McLoughlin, M., 2001. The Onion Model, Pre-Registration Diploma in Nursing Curriculum, SalfordUniversity.

Day, A., Jonas, D., 1998. Management of paediatric pain.Community Nurse 4 (2), 46, 4850.

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Department of Health, 2001. Informed consent. HMSO, London.Department of Health, 2001. Every Child Matters. HMSO,

London.English national Board/Department of Health, 2001a. Place-

ments in Focus. English National Board, London.Frazer, 1996. Gillick v West Norfolk and Wisbech Area Health

Authority [3 All ER 402 HL].Gilroy, J., 2000. Basic Neurology, third ed. McGraw-Hill, Detroit,

p. 605.Glen, S., Wilkie, K., (Eds.) 2000. Problem-based learning in

Nursing. A new model for a new context, London.Harden, R., 1999. Gabapentin: a new tool in the treatment of

neuropathic pain. Acta Neurologia Scandinavia (Suppl. 100),4347.

Koh, L.C., 2002. Practice-based teaching and nurse education.Available from: http://www.nursing-standard.co.uk/archives/ns/vol15-30/7-41.

Roper, N., Logan, W., Tierney, A., 1990. The Elements ofNursing. Churchill Livingstone, London.

Sackett, D., Rosenberg, W.M., Gray, J.A., Haynes, R.B., Rich-ardson, W.S., 1996. Evidence based medicine: what it is andwhat it isnt. British Medical Journal 312 (7023), 7172.

Simpson, L., 2001. Indwelling urethral catheters. Availablefrom: http://www.nursing-standard.co.uk/archives/ns1546/47/53.

Spouse, J., 1996. The effective mentor: A model for student-centred learning. Nursing Times 92 (13), 3235.

Suresh, S., 2000. Chronic Pain Management in Children andAdolescents The Childs Doctor: Journal of Childrens Memo-rial Hospital. Available from: http:www.childdoc.org.

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Further reading

Proximal Course of the Pudendal Nerve, 1988. Available from:http://www.gmedmedia/weblec01/lec24.

Richtmeiser, J., 1999. The basics of the pelvis and theperineum: The proximal course of the pudendal nerve.http://oac.med.jhmi.edu/Weblec/Weblec01/lec24.html.

Wong, D., Baker, C., 1988. Pain in children: comparison ofassessment scales. Pediatric Nursing 14 (1), 9017.Oakey, D., Doyle, M., 2000. A Strategic Approach to Undergrad-uate Key Skills Development: Salford Key Skills Project, FinalReport, University of Salford.

Papp, I., Markkanen, M., Bonsdorff, M., 2003. Clinical environ-ment as a learning environment: student nurses perceptionsconcerning clinical learning experience. Nurse EducationToday 23, 262268.

Phillips, T., 2000. Practice and Assessment in Nursing andMidwifery: Doing it for real English National Board, London.

Quality Assurance Agency, 2001. Available from:professional role issues and the student felt fit forpurpose and practice (UKCC, 1996).

and Assessing in Nursing Practice. Bailliere Tindall, London(Chapter 9).

Nolan, 1998. Available from: http://www.trauma.org/cases/classic001.html.

Utilising information technology and problem-based learning strategies to resolve practice dilemmas in a children " s orthopaedic settingBackgroundTheory underpinning curriculum deliveryCase studyPersonal and professional developmentCare managementCare deliveryProfessional and ethicalConclusionAcknowledgementReferencesFurther reading