Supporting professional nurse socialisation:

Findings from evidence reviews

Juan Carlos Rejon

Research Analyst, RCN

Chris Watts

Research and Innovation Manager, RCN

Appended report:Professional Socialisation: Insights from reviews of organizational culture and performance, Mark Newman & Catherine O’Keeffe, EPPI Centre

Appended report: Social learning tools: are we online? Juan Carlos Rejon, RCN

REPORT SUMMARY

This report explores what is known about the professional socialisation of nurses, and explores strategies to supportpositive socialisation of nurses. The evidence reviewsidentifycomponent areas of socialisation where efforts may be focused, and looks tokey influences and tools in the context of the health care environment.

Key findings

  • Professional socialisation of nurses is a broad and complex topic. The terminology is commonly used as an ‘umbrella’ terms for a number of component activities relating to the education and assimilation of nurses into the professional environment.
  • Socialisation may be usefully understood ascharacterised by four attributes: learning, interaction, development and adaptation. These attributes build upon three precedents: comprehensive orientation and educational programs, competent role models and adequate field experience. This report offers a picture of effective socialisation through considering these component attributes and precedents.
  • Socialisation has a strong learning component. Learning can be formal (classes, workshops and online events) or informal on the job learning (observing, asking peers, through trial and error, working with others, coaches and mentors).
  • Characteristics of an environment that is conducive to learning include the use of a multi-disciplinary team in the delivery of teaching and assessment of educational processes, together with dedicated time, resources and assigned research staff that involve learners.
  • Inter-professional education at undergraduate level may benefit ‘positive socialisation’, preventing stereotyped attitudes towards other health care professions and fostering positive attitudes towards the principles of team work.
  • Team training is a successful approach to improving process measures (e.g. reducing missed orders for treatment) and outcome measures (e.g. reducing mortality).
  • There is some evidence to suggest that much of professionallearning is informal. Likewise, some evidence suggests most of the investments that organisations make on learning are made on formal learning.
  • Mentor experience is key in facilitating bothformal and informal learning, and therefore supporting ‘positive’ socialisation. Mentors support students with difficulties associated with a new environment, increaseself-esteem and help socialise students into the nursing role through the development circles of supportive friends and colleagues. Students learn, and may assimilate, leadership attributes by observing those displayed by mentors.
  • Preceptorship experience is valued by newly qualified nurses, particularly when paired with preceptors who demonstrate high levels of authentic leadership. Preceptorship can have a positive effect on engagement and retention across all staff.
  • A working environment that promotes perceptions of fair treatment towards staff has a positive effect on staff motivation and commitment to organisational goals. The value of a style of transformational leadership rather than authoritative top down practice has been observed in healthcare literature through links to safety initiatives, safety culture and improvements in safety outcomes.
  • Engagement and wellbeing of staff is beneficial to an effective socialisation environment. There is strong evidence suggesting a positive relationship between staff wellbeing and engagement, staff reported patient care performance and patient experience of care.
  • Assessment and improvement of organisational culture – the working environment in which the socialisation process takes place in the main – is much discussed as a key component in improving quality of care. However, assumptions that organisational culture is well defined or conceptualised may be misplaced, making it difficult toattribute a predictive casual relationship between organisational culture and organisational performance.
  • There arepotential benefits in seeking to measurehow organisational culturemight impact interventions to improve quality, safety and performance. These are: providing an informative overview of where a service stands; identifying areas that lag behind informing ongoing improvement;and, bringing issues about safety, quality and performance to the forefront of discussions.
  • Social media may be playing a role in nurse socialisation. Integrating social learning tools into the work stream for professional and organisational purposes could enhance informal learning. Used effectively, these tools facilitate co-creation of content, a movement from 1-way to 2-way forms of communication, and favour a sharing approach to knowledge.

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  1. INTRODUCTION

This report presents the findings of a set of evidence reviews exploring what is known about the professional socialisation of nurses. The overall review question was:

What is known about strategies to support socialisation of nurses; promoting ‘positive’ socialisation and mitigating for ‘negative’ socialisation?

Socialisation is a broad, complex topic and is frequently used as an ‘umbrella’ terms for a number of component activities relating to the education and assimilation of nurses into the professional environment.

Given this complexity, a single review approach might provide scant understanding of the constituent elements of the socialisation process. For the purposes of this report, we have taken a pragmatic approach to understanding some of the components of socialisation, bringing these together to give insight into the overall picture of the process, and identify what effective and promising interventions are available.

The report consists of set of a rapid evidence reviews examining interventions that support the ‘positive’ and / or mitigate the ‘negative’ socialisation of nurses.

Structure and methodology

The report begins by contextualising the review question, and describes what is meant by ‘professional socialisation’. These are broken down into three key areas: socialisation of teams; socialisation through formal education mechanisms (such as mentoring or preceptorship programmes); and impact of organisational factors (including organisational culture).

A rapid evidence appraisal approach was taken to review the available literature, and searches were carried out for each of the key areas identified above. Literature searches were carried out on CINAHL, BNI and Medline databases from 2006 to present. The section on impact of organisational factors draws on commissioned work by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPICentre) who carried out a ‘review of reviews’ examining the relationship between organisational culture and professional socialisation (Newman and O’Keefe, 2013). The EPPI Centre report is in Appendix 1.

Appendix 2 presents the findings of a narrative synthesis considering emerging literature on the role of social media and social learning tools in the context of nurse socialisation.

Overall, the research identified was of low quality, with little robust research indicating effective approaches to socialisation. Some research does suggest a link between inter-professional and multi-disciplinary team training and aspects of socialisation. One of the difficulties of carrying out research in this area is, as the appended EPPI Centre report explains, a lack of clarity or consensus around the concept of socialisation. Further exploration of this area may benefit from considering component parts of the socialisation process, rather than tackling the concept as a ‘whole’. That said, drawing together some of the components of socialisation does reveal an emerging picture of where mechanisms for change may lie, and these are presented here through the three key areas under consideration.

  1. WHAT IS MEANT BY PROFESSIONAL SOCIALISATION?

One purpose of this review is examine definitions of what is referred to as ‘professional socialisation’.

A general definition may be a useful starting point. The Encyclopaedia Britannica defines socialisation as the process by which a human being beginning at infancy acquires the habits, beliefs, and accumulated knowledge of society through education and training for adult status.[1] A useful definition from the nursing context is provided by Mackintosh (2006), who describes socialisation as the process by which individuals take on the characteristics, attitudes and values of a given profession.

While the process of socialisation clearly has a strong learning component, formal education is not the only route successful learning. Informal on the job learning may account for the majority of the learning that takes place in practice (Cross, 2003; Jennings, 2010). Cross (2003) described suggests approximately 20% of learning is formal (such as classes, workshops and online events), while the remaining 80% of learning is informal (such as observing others, asking the person in the next cubicle, calling the help desk, trial-and-error, coaches, mentors and simply working with people in the know). Although the focus and investment of organisations may be centred on formal learning, it may be that informal learning is of equal if not more interest and importance.

In the context of nursing, socialisation (or professional socialisation) begins upon entry into the nursing education program and continues with entry into the workforce (Weis, 2002; Wolf, 2007). There are numerous definitions of socialisation within nursing literature, but the most currentfollows a concept analysis undertaken by Dinmohammadi et al (2013). Their concept of nurse socialisation has four critical attributes: learning, interaction, development and adaptation. The precedents of these attributes are comprehensive orientation and educational programs; competent role models; and adequate field experience.

Dinmohammadi et al (2013) suggest that professional socialisation is the consequence of both educational programs and professional environments, leading to positive and negative outcomes. Desired outcomes are the acquisition of a professional identity, ability to cope with professional roles, professional and organisational commitment, and thus improvement in the quality of care. Undesired outcomes may be the consequence of improper management of initial professional experiences, and include low motivation and productivity, demoralization, and decreased care of patients. Negative forms of socialisation can also cause other undesired consequences, such as frequent turnover, continuance of ritualised practice and bureaucratic views, role ambiguities, lack of critical thinking, repeated dismissal requests, increased attrition, and gradual desensitisation about humanistic patients needs.

Socialisation may have both positive and negative consequences. Given this, there is clearly benefit in understanding the factors that can influence professional socialisation in a nursing context in order to maximize the desired outcomes of socialisation and minimize the unintended or negative ones.

Our analysis of these discussions indicates that socialisation is a complex topic and not one that lends itself to understanding through a single definition. For the purpose of this report, we have consideredthree facets of socialisation drawn from the literature described above:

  • socialisation of teams, including inter-disciplinary team working and training;
  • socialisation through formal education mechanisms, particularly mentoring and preceptorship;
  • impact of organisational factors, including cultural and leadership factors.
  1. SOCIALISATION THROUGH TEAMS

A rapid evidence review carried out for this report explored learning interventions that supported ‘positive’ socialisation as an outcome, with a focus on inter-professional and multi-disciplinary team training.

A search of CINAHL, BNI and Medline databases from 2006 to present was carried out to identify learning interventions that supported ‘positive’ socialisation as an outcome. Findings indicate the importance inter-professional working, together with multi-disciplinary team training as important in supporting the ‘positive’ socialisation of nurses, both in being integrated into a team (feeling ‘part’ of a team) and in subsequently in working effectively as a team.

There are some promising indications that inter-professional collaboration interventions can improve health care processes and outcomes (Zwarenstein et al., 2009). A key recommendation from the Willis Commission (2012) emphasises the need to socialise health care professionals into interprofessional teams:

“Interprofessional learning must play a key role in continuing professional development. Training professionals in teams must also have a much stronger focus in preregistration nursing education.”

(Willis Commission, 2012, p.38)

The review looked at outcomes of team training across different disciplines. Numerous organisations, including The Joint Commission and the Institute of Medicine in the US, have recommended team training as an effective approach to reducing medical errors (Institute of Medicine , 2001; Joint Commission, 2004; Kohn et al., 2000). Studies of the benefits of interprofessional learning interventions aimed at practice based changes are likely to employ process measures (such as: safety reporting, documentation of discharge decisions) or outcome measures (such as: length of stay, mortality) (Neily et al., 2010). Other complex industries, in which high risk has to be managed with extreme care (including the aviation industry) have used concepts of crew resource management to support safety and quality (Salas et al., 1995, Salas et al., 2001). Generally, the process of collaboration and its link to health care outcomes has not been systematically examined (Goldman et al., 2009). This review identifies studies that have reported improvements in process measures and/or in outcome measures in healthcare to highlight the potential of team training in improving the safety of a process and ultimately the impact of team training in a ‘hard’ outcome such as mortality.

There are some studies that link team training to such beneficial outcomes. A recent US study of a piloted team training initiative in an outpatient oncology setting (Bunnell et al., 2013) used a train-the-trainer model to achieve a reduction in the incidence of missing orders for unlinked visits[2] from 30% to 2%. 92% of breast cancer staff completed the training. Prevention of errors was supported by self reported improvements in efficacy and safety of care by over 70% by providers, infusion nurses and support staff. There was a likely positive effect on team dynamics, such as more respectful behaviour and improved relationship among team members. Patient satisfaction scores also improved. To achieve improvements in processes such as preventing missing orders for unlinked visits, a steering committee identified weaknesses in the process of writing orders, and added a control to it. The pharmacist on the committee noted that preparatory planning occurred in the pharmacy two days prior to visits. Using this opportunity to note the absence of orders, the pharmacist agreed to send reminder emails to the appropriate clinicians. This improved the process assuring a shared mental model and situational awareness for team members, which ultimately led to an improvement in the process measure (% of missing orders for unlinked visits).

In another US study Neily et al. (2010)analyzed surgical mortality for facilities that received a team training programcompared with those that had not yet received it. The study used crew management theory of aviation adapted for a healthcare context (Musson and Helmreich, 2004). The result was striking, with 74 facilities in the training program experiencing an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P = .01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P = .59).

While these studies suggest the promise of teamwork training in improving safety and quality of health care, they don’t indicate a direct link to positive socialisation, but rather that an effective team is a more beneficial environment into which to be socialised. Building collaborative teams may also have an additional, indirect impact in daily work for the team members. A recent study based in neonatal intensive care reported the development of a workshop based on Team STEPPS to introduce new team-based practices (Brodsky et al., 2013). Staff satisfaction was rated higher after the training, with responses suggesting staff had greater job fulfilment. This indicates added value to team training through supporting engagement of teams (Thomas and Galla, 2013) and therefore staff.

Adopting effective and appropriate approaches to team training need to be considered, and are perhaps the topic of a further review. Achieving improvements though team training is not an isolated, one-size –fits-all solution to safety and quality (Salas and Rosen, 2013). Discrepancy between expectations and goals and actual participation should be accounted for when planning team training for students. In a study of interprofessional training wards for health and social care students, the choice of setting and learning situations appeared to be crucial to the learning that occurred (Lidskog et al., 2009).

The definitions explored above suggest that attitudes and values within a team are an important component of socialisation. Several studies explored how interprofessional education (IPE) can influence the attitudes of health care students towards team working. A Japanese study measured how lecture style and training style within IPE affected views of other professionals, suggesting that the introduction of IPE early in the curricula could prevent stereotyped perceptions, and change attitudes of students at an early stage (Hayashi et al., 2012). A Swedish follow-up study shows results that suggest that interprofessional training in undergraduate students education provides lasting impressions that may promote teamwork in their future professional life (Hylin et al., 2007).

Half day and one day placement models of interprofessional learning amongst students had positive effects in students understanding of team working and collaborative practice (Anderson et al., 2006, Törnkvist and Hegefjärd, 2008). A UK study also shows positive results of IPE that includes facilitators and trained service users, which gave students the chance to learn and apply the principles of teamwork in putting service users at the centre of the care process (Cooper and Spencer-Dawe, 2006). A Canadian study did not find evidence of IPE curriculum at influencing attitudes of undergraduate students towards teamwork, although students were satisfied with it (Curran et al., 2010).

In general, the evidence seems promising of the positive effect of team training, with a higher potential if introduced early in the curricula through undergraduate IPE experiences. Students receiving IPE prepares them for the social nature of their future work within interdisciplinary teams.

However, in general findings are limited. There is a lack of research examining longer term impact of IPE. Buniiss et al (2012) observe, teamwork training should not only be valued by the extent to which it may be linked to immediate quality improvements (including the introduction of an electronic workflow system into their practice processes in this particular study), but also through understanding iterative change over time (Bunniss et al., 2012). An additional piece of information that would be informative for decision makers and is usually disregarded in studies of health care education, is the cost of the intervention on top of the benefits they provide (Mazmanian, 2009). Having the evidence to assess the value for money of training and educational interventions would provide with the right arena for more informed decisions.