Learning in practice : enrolled nurse medication administration

University of Technology Sydney. Faculty of Arts and Social Sciences.This study contributes to knowledge in the field of nurses’ practices and learning. Specifically, it answers questions regarding medication administration in acute care. The main research question was: What and how do enrolled nurses learn when administering medications in an acute care setting? To provide further focus, two subsidiary questions were asked. The first addressed what socio-material assemblages enable enrolled nurses to deal with knowledge challenges in administering medications, and what learning emerges through practices associated with those assemblages. The second subsidiary research question focused on what rhythms enable enrolled nurses’ learning to emerge when administering medications, and what learning emerges through the practices associated with those rhythms. In 2004, medication administration was added to the role and scope of practice for enrolled nurses in Australia. Medication administration is both a complex and high-risk practice, with medication errors identified as some of the most common in health care. Because acute care health practice is so challenging, and the possible risk of medication error is high, a greater understanding of enrolled nurses’ learning in practice when administering medications is important. The evolving nature of practice and the unpredictability of acute care means that nurse’s learning cannot be determined in advance. Therefore, the purpose of this thesis was to examine enrolled nurses’ learning in practice as they carry out medication administration to patients in their care. A qualitative naturalistic methodology was used to generate data through non-participant observation and semi-structured interviews. Fieldwork was conducted in a hospital in New South Wales (NSW), spread across 10 wards and units from medical, surgical and speciality placement areas in a single hospital. Fifteen enrolled nurses were observed while administering medications and interviewed about their practices and learning. A further 16 registered nurses who interacted with these enrolled nurses during any aspect of the medication administration process were also interviewed. The concept of emergence provided this study’s overarching framework. By embracing the concept of emergence, researchers have provided a different approach to examining workplace learning. Learning is understood as emerging from the ongoing and unpredictable interactions that occur in continually changing contexts. These interactions between human and non-human elements are shaped by and change in response to the emerging nature of work, meaning they cannot be wholly predetermined or specified in advance. Because circumstances change each time, new possibilities and improvisations continue to be created. A conceptual framework comprising concepts from a practice-based approach and rhythmanalysis was used. The study found that during each medication administration activity, different socio-material assemblages, bodily performances and knowledge-sharing practices between the registered nurse and the enrolled nurse enabled the latter to learn through practice. Aesthetic judgements were found to be an important feature of this learning, which highlights the significant role of the body and materiality—aspects that have been previously overlooked in conceptualising enrolled nurse medication administration. Rhythms affect how nurses access others and how and what they learn from others. In this study, learning was also found to be rhythmic. The enrolled nurses learnt about rhythms and how to do things in a rhythmic way—a way that fitted with rhythms of the ward, patients and administering medications. Recurring patterns, relationships between individuals and material assemblages were key for enabling enrolled nurses to learn from others and to learn by doing. In practice, nurses responded to changes in patients’ clinical conditions by changing their pace. Medication administration was a frequently repeated activity, performed many times in a shift. However, each time the enrolled nurse undertook this process, varying demands and requirements created a need to learn. Concepts from rhythmanalysis enabled the data analysis to become attuned to these relationships between repetition and difference. This professional doctorate makes a novel contribution to knowledge and practice in the discipline of nursing, adding significantly to what is known about enrolled nurses’ learning and medication administration. A conceptual framework consisting of a practice-based approach and rhythmanalysis formed the basis of the study’s original and distinctive approach