The Department of Health and Social Care (DHSC) (2013) mandate to Health Education England (HEE) highlights the importance of establishing and maintaining training structures to enable workforce development within the NHS. This ensures future sustainability of a workforce with the right knowledge, skills and behaviours, and in the right numbers, required for delivery of high-quality patient care (DHSC, 2013). A vital part of the NHS in all countries of the UK are the district nursing and community services (Queen's Nursing Institute (QNI), 2019). There are insufficient numbers of suitably qualified district nurses in the UK to meet the complex and burgeoning needs of district nursing services. To meet the demands seen within the community teams, undertaking the Specialist Practitioner Qualification in District Nursing (SPQDN) is advocated to support the delivery of quality-based leadership, and maintenance of high-quality patient care (Nursing and Midwifery Council (NMC), 2001; QNI, 2014; 2015). However, despite this, the QNI (2019) reported that education within community teams is often postponed when teams lack the workforce to enable training to take place and be fully supported. Alongside these organisational challenges, there are also personal complexities associated with undertaking this qualification that need to be addressed, particularly around professional identity. Nurses who undertake the SPQDN programmes must make a transition into higher education, which requires an identity shift, not only in terms of practice but also in cultural disposition and character (Tobbell et al, 2010). SPQDN students move from one life path as a professional registrant to another as a post-graduate student. This transition requires a revision in individual roles and responsibilities and an acknowledgment that external commitments can also play a part in their future success (O'Brien et al, 2009; Baxter Magolda, 2014). Howard and Davies (2013) argued that the social and cognitive risks of participating in higher education are often greater for mature non-traditional learners who may have positioned themselves as having a non-learner identity; thus, the transition towards a learner identity and embracing a change in their perceived self-concept and efficacy can often be difficult to negotiate. Attrition rates, for example, are higher among mature learners, which could be linked to the difficulties that some students have in returning to a learner identity (Kenner and Weinerman, 2011).
The terms adult learner, mature student and non-traditional learner have been used interchangeably throughout the literature. Chen (2017) defined a non-traditional learner as someone aged over 25 years who has responsibilities, such as caring for dependents, and having a non-traditional educational trajectory, such as seeking further career progression later in life. Chapman (2015) suggested that mature students are over 21 years at the start of their programme of learning, while Merriam and Bierema (2014) combined the terms ‘non-traditional’ and ‘mature’ into the term ‘adult learner’, describing them as ‘those whose age, social roles, or self-perception, define them as adults’. As the terms are mutually compatible, the term ‘non-traditional’ or ‘mature’ student will be used in this article.
Baxter and Britton (2001) argued that, although empowering, learning can also be disruptive, and there are other risks faced by mature learners returning to higher education that affect an individual's identity, including external commitments, such as personal and professional relationships and domestic responsibilities (Baxter and Britton, 2001). Carr-Chellman and Levitan (2016) suggested that, when new educational experiences are discovered, adults take on new identities, but argued that the synergy between identity and learning has been under-theorised. However, one way in which mature non-traditional learners can negotiate the conflicting roles and identities is through the narration of their life stories, which helps students to construct meaning and make sense of the challenges faced (Marsman, 2014).
Aim
The aim of this research is to examine to what extent an individual's identity influences the learning experience of non-traditional students undertaking the SPQDN.
Methodology
This is a small qualitative study using a narrative inquiry approach. The three participants were purposefully selected and asked to recall their experiences 1 year after undertaking the SPQDN programme. They were individually interviewed, at a location of their choosing, using a template comprising seven guiding questions (Box 1).
Box 1.Guiding questionsQ1. What made you decide to return to education and undertake the SPQ?Q2. How did you, as a non-traditional student having had a professional identity as an experienced community nurse, negotiate the challenges around entering higher education and becoming a learner?Q3. How did this transition into education make you feel as a person and as a professional?Q4. Please describe both positive and negative experiences of becoming a student SPQDNQ5. What helped at university and what did not help?Q6. What helped in practice and what did not help?Q7. Is a sense of belonging integral to the overall success of the non-traditional student when undertaking the SPQDN?Can you now share freely your experience of being an SPQDN student in your own words? Your story, your narrative, free from interruption
The participants gave informed consent knowing that their participation was voluntary and in line with approval given for the study by the University of Buckingham's ethics committee. The interviews were audio-recorded and transcribed verbatim prior to analysis, which was guided by a narrative inquiry approach.
Following the audio-recording, each participant was given a set of six reflective questions (Box 2) to capture any information that may not have been elicited within the storytelling session, and consent was given to access reflective accounts kept during the SPQDN programme. Member-checking took place after transcription, allowing the participants time to correct any factual errors and clarify meaning, which increased the overall validity and credibility of the study (Creswell, 2014).
Box 2.Six reflective questions1. Did you find it difficult to make the transition between professional and student identities?2. Did becoming a student take away from the feeling of being a professional practitioner?3. Please reflect upon whether using the term student impacted on how you or others viewed you professionally4. Please reflect upon ways in which you negotiated the expectations and tensions between two communities of practice (ie, learning in a classroom and in a new practice area)5. Please reflect upon whether you consider your identity as integral to your success6. Please can you share extracts of your personal reflective journal that you feel highlight the journey that you undertook as a student undertaking the SPQ
Findings
N Vivo code, an interpretive process that uses direct quotes in the participants' own voice, was used to analyse each narrative (Clandinin and Connelly, 2000; Saldana, 2013).
Three key themes were identified:
- Academic self-doubt
- Student identity challenges
- Past learning experiences.
The participant stories and reflections have been presented as vignettes. All names have been changed to ensure that confidentiality is maintained (NMC, 2018).
Alice's story
‘My journey this past year has been a rollercoaster.’
Transitioning from a professional identity towards that of a learner identity was quite difficult for Alice. She found that the term ‘student’ did not sit well with patients, and they did not understand that she had been a registered general nurse for 12 years. This made Alice start to question her own ability, and she began to feel as if she had to prove her worth as a qualified nurse. Alice began to question whether she was taking the right path for her career and began to ask herself: ‘Am I right to do this course?’, ‘Do I know my stuff?’
Alice had been identified earlier in her life as having dyslexia and was finding it difficult to negotiate the complexities of essay writing. She reflected: ‘It was my academic side that was making me feel I wasn't worthy’.
Entering a new team as a student was also challenging, and Alice had to get to know new members of staff, something she found difficult as some saw her as ‘just a student’ while others thought she should know everything. Alice reflected:
‘Some people had the perception that I knew stuff, so you had one lot of people thinking I didn't know enough and then another perception that, well ‘you are a district nurse student, so you know it all’. ‘
As well as that, it was really difficult because some people from outside of the profession thought that you didn't know enough, which made me feel incompetent.’
Alice also felt overwhelmed during this time, and moving towards a positive learning identity seemed an impossible task.
‘I felt overwhelmed. I went home thinking I don't know anything. Most days throughout the course until after my consolidation period finished I thought “What am I doing?” “Who am I?”, “Where am I?”, “What have I got to do today?”, and it was trying to balance everything, and as soon as you got the balance right it flipped again, and it was really hard.’
Alice reported that these feelings affected her sense of belonging, and she stated:
‘When you don't belong, you feel you don't belong anywhere, you question everything from professional and academic to personal.’
However, despite these challenges, Alice felt that she had grown professionally and personally, and, by the end, of the year, she could see a difference in both her professional and learning identity.
‘I worked harder than I ever have.’
‘My team of supporters, whether it was family, friends, work colleagues, mentors or lecturers, and, at times, my patients, gave me the strength and the belief that I can do it.’
‘Someone said I have changed so much since the course, I have become more knowledgeable, and most importantly more confident in how I approach a task, manage people and look after patients. I feel this is down to knowing who I am and who I want to be and that's the best district nurse I can be’.
Belinda's story
‘I just felt like a novice again.’
Belinda's story is one that challenges the use of language and stereotyping. Belinda had always wanted to be a district nurse, and undertaking the SPQDN was both a personal and professional goal.
Belinda reflected:
‘I have always wanted to be a district nurse. That was my goal. That was my goal when I went into community nursing. I felt proud, to be honest, that I had got on the course, and I was proud to be there and that I had got through the interview, and I was aiming for my goal, and I felt really proud of myself.’
Belinda was a competent community staff nurse and had been qualified for over 7 years. However, despite being a confident practitioner, Belinda had reservations about her ability on the SPQDN programme and acknowledged that she was concerned about some of the challenges that lay ahead, as it had been many years since she had done any studying.
‘The challenges were time and believing that I could do it and whether I could write an academic assignment again. It really worried me more than anything. More than the practical, it was the academic side that worried me. I was frightened of failing.’
Once on the programme, Belinda began to question her identity as a qualified nurse, too, despite her initial confidence in this area.
‘I found it difficult to transition between professional and student identities. I felt that all my knowledge as a community staff nurse had been taken away, and I felt that I had reverted to a student nurse again! Learning from scratch.’
‘Being labelled as student had an impact on how I felt, especially when I visited patients and was introduced as a student district nurse, and patients then automatically assume that you are a student nurse; after all, they do see more student nurses than student district nurses. I always had to explain to them that I am a qualified nurse and that I am doing further training to become a district nurse.’
Belinda saw her identity as integral to success and felt that being labelled as a student had a negative connotation, undervaluing her professional status and her skills that had been developed over the past 7 years. She said:
‘If you are constantly introduced as a student, it kind of feels like you are being undermined. I just felt like a novice again.’
Belinda was also concerned about being a mature student and felt that this impacted her identity.
‘I enjoyed learning in the classroom as I love to learn and gain more knowledge. I was very anxious about the assignments, though, as I thought I would not be able to achieve good grades or even pass the course, so I suppose I was fearful of failure. I also thought I would be the bottom of the class as I believe I was one of the oldest students’.
Alongside being anxious about completing the assignments, Belinda also had responsibilities as a carer, which put extra pressure on her emotionally.
‘My mother was also taken very ill on the day that I did the nurse prescribing exam. I tried very hard to put her out of my mind during the exam because there was nothing I could do at that time as she lived 4–5 hours away. Also, I knew that she would have wanted me to focus on the exam.’
Despite these external challenges, Belinda successfully completed the course and acknowledges the positive impact that the SPQ programme had on her.
‘I really enjoyed the course. I have the knowledge now, and that's given me confidence’.
Caroline's story
‘I seem to have started a caterpillar and emerged a butterfly, ready to spread my wings.’
Caroline felt ready for the challenge of higher education and the prospect of becoming a student again and found that learning in a university setting alongside practice was manageable and enjoyed her experience as a learner.
‘I actually enjoyed my experience in the university. In fact, yeah, that was probably the best bit.’
However, Caroline did have some anxieties around her learning.
‘I thought, am I too old? I was apprehensive, was everyone going to be younger than me?’
‘I felt quite academically backwards. I felt that I needed a lot of support with that.’
‘I thought, why am I doing this? It wasn't so much coming to university or even going out to patients, it was suddenly the enormity of it.’
Despite this self-doubt, Caroline found that her experience on the SPQDN programme had also had a positive impact on her identity outside of the course.
‘I am more confident, and I am able to stand up and speak to people, and doing the course has made me a better person.’
‘The learning experience was intense. But once you have set your mind to it, having two days in university and two days in practice was good, as you needed a break from each other, so that what you were learning in university you could try out in practice. That helped me move forward with my learning; once you get your head into the learning process, then it has no bounds’.
Caroline embraced the learning experience despite her initial concerns around academic ability and reflected that she has emerged from the experience with a new found confidence and professional identity:
‘Well, I seem to have started a caterpillar and emerged a butterfly, ready to spread my wings, within a new chapter of my life. Ready to embrace new experiences and gain further knowledge. It has been an emotional, stressful, tiring and very rewarding year. I have learnt so much, clinically and academically, and now feel ready to face my next challenge as a district nurse.’
Discussion
Although there were common themes, specifically, academic self-doubt, past learning experiences and concerns around being labelled as a student, each narrative was unique in terms of the extent that these elements influenced the learning experience. No interview question asked directly about their academic ability and yet all participants voiced their concerns in this area, albeit from different perspectives.
Alice doubted her ability as she had experienced difficulties in the past with dyslexia. Pollak (2005) argued that individuals with dyslexia often lack confidence when entering higher education, as they focus on their deficiencies, which has the potential to affect their identity. Rees et al (2000) also confirmed that identity as a competent learner is influenced by past learning experiences. However, the negative perception by others of an individual's identity in terms of academic difficulties detracts from the positive appreciation of the non-literacy aspects of having dyslexia, such as other ways of thinking and learning (Herrington and Hunter-Carsch, 2001).
‘I felt that essays were defining me and telling me my capability, not what I could do professionally, and I am a doer, so what you see out in practice, I can do, but if you ask me to write it down, I will crumble’.
(Alice)
Belinda had parental carer responsibilities, and both Belinda and Caroline doubted their ability due to their age. These findings are consistent with the evidence from the wider literature that mature students must negotiate conflicting roles and domestic responsibilities alongside their learning commitments (Baxter and Britton, 2001; Marsman, 2014), requiring a paradigm change (Watson, 2009; Arvaja, 2018). Belinda voices the challenges of negotiating this changing paradigm by stating:
‘Being labelled a student, you feel that you are a novice again, which, I suppose, I was a novice in terms of becoming a district nurse. I was not a novice as a community staff nurse, and I felt confident within myself that I am a professional practitioner. I always had to explain to patients that I am a qualified nurse and that I am doing further training to be a district nurse.’
Belinda's story highlights the feelings around being viewed as a student, and the stereotype that students do not have much experience affected her self-concept. This is supported by Becker's (1963) labelling theory, which asserts that construction of an individual's identity is based around the perception that society places on them. Gates (2010) argued that a label influences the perception of other attributes that may be present within the student, while Magnano et al (2014) suggested that the relationship between an individuals perceived self-efficacy and academic performance is directly related, suggesting that how individuals view themselves has an influence on the learning experience. A professional identify is formed through personal attributes and membership of certain groups (Arvaja et al, 2018), and all three participants in this study were transitioning towards becoming specialist practitioners and away from community staff nurses.
Benner (1982), in her seminal work on nurses transitioning from novice to expert, argued that acquiring expertise does not just happen purely from practising over time, or from length of service; it is the refinement of formalising theory through being immersed in complex clinical practice, moving from novice, to advanced beginner, towards competency and proficiency within a role before becoming an expert. Thus, undertaking the SPQDN, which is 50% theory and 50% practice, offered Alice, Belinda and Caroline the opportunity to advance towards specialist practitioner status and reconstruct their professional identities.
Limitations
As the researcher holds the SPQDN qualification and has experienced the programme from a personal and professional standpoint, researcher bias must be considered. To counter this, as far as possible, all judgement was suspended during the interviews, and continual reflection on the meaning and interpretation of each narrative was carried out (Merriam, 2009). Member checking the raw data and final narratives was also carried out to limit any bias (Creswell, 2014). Acknowledgement is also given to the small sample size.
Conclusion
This small study offers an appreciation of the challenges of re-entering higher education for non-traditional students undertaking the SPQDN, an important consideration given the insufficient numbers of suitably qualified district nurses in the UK and the declining trajectory of nurses applying for the SPQDN programme. Accessing and embracing the support offered by lecturers and the wider university support systems, alongside practice supervisors and assessors, is an important step to take throughout the programme. Engaging with other SPQDN students to create a sense of belonging and to establish a peer support network is also recommended.
Despite the challenges that each student faced, all participants reflected on the positive outcome that undertaking the SPQDN programme had on their personal and professional identities. As Caroline reflected:
‘Would I do it again? Yes, I have learnt so much.’
KEY POINTS
- Transitioning from a professional identity towards a learner identity can be challenging for some students in the Specialist Practitioner Qualification in District Nursing (SPQDN)
- Past learning experiences can impact on identity and confidence. Help and support should be sought from lecturers and practice supervisors and assessors at the start of the SPQDN programme
- The learning experience on the SPQDN programme had a positive impact on the personal and professional identity of all three participants in this study
- Having a sense of belonging in university and clinical practice is an important element in the learning experience while on the SPQDN programme
CPD REFLECTIVE QUESTIONS
- Have you ever found it difficult to make a transition between professional and student identities? If so, what support did you find to be beneficial?
- Can you think of ways in which a sense of belonging can be created for nurses undertaking the Specialist Practitioner Qualification when entering a new team?
- Reflect on how SPQDN students are introduced to patients and the team. How can valued past experiences as a registrant be conveyed?