Nurse Education in Practice (2005) 5, 198–208

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

Supporting learning in practice in the EBLcurriculum: pre-registration students’ accessto learning resources in the placement setting

Graham Walton a,*, Ann Smith b, Pat Gannon-Leary c, Anne Middleton d

a Library, Northumbria University, Coach Lane Campus, Newcastle-upon-Tyne, NE7 7XA, UKb School Health, Community and Education, Northumbria University, Coach Lane Campus,Newcastle-upon-Tyne, NE7 7XA, UKc Centre for Social and Business Informatics, Institute of Policy and Practice, Claremont Bridge,University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, NE1 7RU, UKd Library, Northumbria University, Coach Lane Campus, Newcastle-upon-Tyne, NE7 7XA, UK

Accepted 19 October 2004

Summary This paper explores access to learning resources for nursing studentswhen on placement. It also examines, in parallel, the impact of the move to enquirybased learning has on learning resources use by nursing students. The increased timespent learning in the clinical setting means that a deeper understanding of the use oflearning resources by nursing students is necessary. A questionnaire survey was com-pleted by 247 nursing students at Northumbria University around their use of learn-ing resources on placement. This corresponded with focus groups being run withUniversity and NHS providers of learning resources to establish the impact of enquirybased learning. It was found that effective collaboration between different stake-holders was especially important. Nursing students are also becoming increasinglysophisticated in their use of electronic learning resources. The nature of supportfor effective learning resources use by nursing students whilst on placement inthe NHS has also been identified as key. The work has shown that it is very difficultto establish the impact of enquiry based learning on learning resources, as there areso many other variables.

�c 2004 Elsevier Ltd. All rights reserved.

KEYWORDSEnquiry-based learning;Problem-based

learning;EBL;PBL;Learning support;Learning resources

1d

471-5953/$ - see front matter �c 2004 Elsevier Ltd. All rights reseroi:10.1016/j.nepr.2004.10.003

* Corresponding author.E-mail address: graham.walton@unn.ac.uk.

Introduction

Nursing pre-registration education has neverstayed still for very long. Changes have taken place

ved.

Supporting learning in practice in the EBL curriculum 199

at the organisational level, in learning and teachingapproaches and also in technology now used. Muchvalue can be gained from evaluating the impact ofthese changes and then using these insights to in-form future developments. One area that has beenexposed to these changes has been the nature anduse made of learning resources and libraries by pre-registration nursing students. The purpose of thisstudy was to explore how the increased time spenton clinical placement and the move to enquiry-based learning (EBL) has influenced learning re-sources and library use by pre-registration nursingstudents at Northumbria University.

In September 2001, Northumbria Universityintroduced EBL as a core learning/teaching strat-egy for all pre-registration nursing programmes.Concurrently, the ‘Making a difference’ (Depart-ment of Health, 1999a) curriculum was introducedfor the same programmes. One feature of the lat-ter was the increased amount of learning timespent by nursing students in the clinical setting.The introduction of the EBL strategy coupled withthe lengthening of time on placement representeda fundamental change affecting students, staff andlearning resources. It was seen as crucial that aca-demic, clinical and library staff work together,both supporting practice learning, and in the devel-opment/monitoring of the curriculum. A joint eval-uation strategy was therefore established at anearly stage to enable clear assessment, not onlyof the impact on students’ learning and progres-sion, but also of the resources needed to supportthem.

In order to establish use of learning resources onplacement a questionnaire was distributed to pre-registration nursing students (Middleton et al.,2002). A related parallel study took place examin-ing students’ perceptions of learning by means ofEBL, academic staffs’ perceptions of using EBLand the nature of interactions occurring withinEBL group sessions. The focus of the discussionfor this paper is on the impact both of increasedtime on clinical placement and EBL on libraries/learning resources.

Context

The pre-registration nursing courses at Northum-bria University are undertaken at Diploma, Ad-vanced Diploma and Degree levels within all fourbranches of practice; Adult Nursing, Mental HealthNursing, Learning Disabilities Nursing and Chil-dren’s Nursing. There is a large student nurse pop-ulation with intakes of two cohorts per year each

with 300–350 students. A key feature of the under-graduate curriculum is the recognition of thedynamic interface between theory and practiceand the value of learning from sustained clinicalexperience necessitating the need to work collabo-ratively with local NHS trusts and other health careprovider organisations. EBL was introduced asmeans of promoting skills needed for effectivepractice and life long learning. The University Li-brary provides a wide range of print and electroniclearning resources as well as a significant range ofservices to support learners.

Review of the literature

A literature review shows a dearth of studiesexploring the use made of learning resources spe-cifically by health students on clinical practice,with the exception of Leeds University’s (2002)study on the learning resources’ needs of place-ment students. This is a major gap as health stu-dents are spending an increasing amount of timelearning in practice. There are few studies on theimpacts of specific nursing curriculum practicedevelopments on libraries and learning resourcesalthough a national survey was conducted (Gan-non-Leary et al., 2003) of UK university libraries’adaptation of services to meet the needs of ‘Mak-ing a difference’.

Libraries are seen to be crucial in supportingboth pre-registration health student learning andhealth professionals undertaking continuing profes-sional development. An over view of the roles li-braries have in health student learning has beenprovided by Peacock et al. (2004). Library servicesare ’the bedrock’ of education and training(Department of Health, 1999b), and increasedemphasis on continual, self-directed learning posesa considerable challenge to NHS libraries: ‘‘libraryand IT strategies should provide a framework forensuring equal access for all staff groups to thelearning resources which support work basedlearning’’.

A significant body of knowledge has developedaround the impact of EBL or problem-based learn-ing (PBL) on the use of libraries and learning re-sources. Impact has been identified in four mainareas: library usage, library resources, libraryspace and the role of library staff providing ser-vices to health care students (Mackenzie, 2000).It is suggested that PBL students make greateruse of the library and its services, from the verybeginning of their studies and use a wider rangeof resources than students following a traditional

200 G. Walton et al.

curriculum. Their visits are more frequent andlonger since they use the library both for studyand as a meeting place. (Fitzgerald, 1996; Rankin,1996; Saarinen-Rahiika and Binkley, 1998; Blum-berg, 2000; Booth, 2000). They may therefore re-quire group study areas as well as individual studyspace. Problems associated with noise levels andconsumption of food and drink can arise from groupworking (Fitzgerald, 1996).

There are also indications that PBL studentsmake more extensive use of electronic databases,periodicals, short loan materials, photocopiersand audiovisual materials. Increased usage of peri-odicals and books results in concomitant increasesin levels of shelving and numbers of interlibraryloan requests (Fitzgerald, 1996). It is highly signif-icant that all the studies have focussed on theexperience within the education institution. Nonehave explored use of learning resources on practiceplacement.

Methodology

Two approaches were used to inform this paper,the underpinning theoretical perspective of whichis that evaluation should be holistic, developmen-tal and user-centred, part of an improvement pro-cess. By incorporating both quantitative andqualitative approaches it was hoped that datawould be generated which are as rigorous and gen-eralisable as the scale of the investigation allows,and also give weight to user perspectives.

To explore the impact of EBL on libraries andlearning resources, two separate focus groups wereheld. One was with University library staff specifi-cally involved with supporting nursing students andthe other was with a group of NHS librarians in thesame geographical area. The same interview scriptswere used with each group and comprised questionsabout changes in usage of their services by nursingstudents over the past five years. The focus groupswere recorded and then transcribed by the re-searcher with the results being thematised. Thekey themes were agreed upon by synthesising theinterpretations of the transcripts by members ofthe research team so that consensus was assured.

To investigate students’ use of libraries andlearning resources on NHS placement, a question-naire was developed for pre-registration healthstudents (midwifery, nursing, occupational therapyand physiotherapy) to complete, although only theresults from the nursing students will be consideredhere. Funding for this part of the study wasobtained from the NHS Northern Workforce Devel-

opment Confederation. The questionnaires werepiloted before distribution with a group of nursingstudents, who would not be included in the finalsurvey, as they would be away on placement andsome revisions were carried out to shorten thecompletion time.

The revised questionnaire (see Appendix A) wasdistributed over a two-week period to a sampleof pre-registration students in the classroom whenin the University. It was anticipated that this wouldresult in a higher response rate than a postal sur-vey. Through this approach completed question-naires were returned from 15% (247) of the totalpopulation of pre-registration nursing students atthe University. The questions were a combinationof fixed and literal responses to gain a mix of qual-itative and quantitative data. The respondentswere requested to complete the questionnairebased on their experiences during their ‘‘last clin-ical placement’’.

Results

When exploring the data from focus groups and thequestionnaires the following key broad areasemerged: collaboration, information technology,support in the NHS and the impact of EBL. Thethemes emerging from the focus groups are collab-oration, information technology, support andimpact of EBL.

Collaboration

The importance of collaboration between NHS andhigher education sectors is illustrated by the factthat 92% of the pre-registration nursing studentssaid that access to learning resources was either‘important’ or ‘very important’ to their studieswhen on placement. With learning resources’ ac-cess being so important, there has to be qualityprovision, which can only be achieved by effectivecollaboration. The NHS librarians were quite vocalabout their relationship with the University andthe library because they felt the former had notappreciated the ongoing use students would con-tinue to make of Trust libraries after the transferinto the University. A study published in 1997 (Ca-pel, Banwell and Walton) indicated that the trans-fer of nursing education from the NHS into highereducation had implications on learning resourcesprovision.

The questionnaire showed that 78% of nursingstudents on clinical placement used the University

Supporting learning in practice in the EBL curriculum 201

libraries and 42% used NHS libraries. Further evi-dence was provided on the importance of collabo-ration when 27% of the students reporteddifficulties in accessing learning resources onplacement. These problems revolved around theplacement venue being remote from the Univer-sity, libraries having inadequate opening hoursand limitations in computer access. More effectivecollaborative practice can help address thesedifficulties.

Information technology

In respect of IT, the more mature students tendedto have more problems with this than did the youn-ger students. The majority of the nursing studentswere mature and, in some cases, had never useda word processor before. The younger students,once they were given their passwords, were ablejust to ‘‘go away and get on’’ but the library hadfound a need to run workshops for small groups.36% of the students reported that they had accessto a networked computer on placement and 47%indicated that they did not. Nursing students wereforced to use IT because of facilities such as virtuallearning platforms (VLE) and the fact that a greatdeal of university communication was via email.The implications of needing to access the Univer-sity VLE coupled with limitations in access onplacement meant that 30% of students on place-ment accessed the software either back in the Uni-versity or from home.

The questionnaire results that show that pre-registration students use a sophisticated range oflearning material, both print (books and journals)and electronic (database, e-journals and Internet).For example, when asked about use of electroniclearning material just from home, 40% used e-jour-nals, 37% used database and 67% used the Internet.The point of need often seemed to come whennursing students were on placement.

Support in NHS

While discussing loan periods of library materialwith NHS staff it became apparent that there wasa wide variation in resources available to nursingstudents on placement. Some sites allowed refer-ence only access:

They can look at books, they can copy the journalsbut they do not have access to electronic resourcesunless they are post-reg. staff who work for theTrust and are doing a course. [NHS librarian focusgroup participant]

Others had borrowing rights while they wereon placement but once the placement finishedtheir library entitlement lapsed. Items were avail-able for standard loan or ‘short loan’ if thelength of the placement was shorter than theloan period of the book. As focus group memberscommented,

There are lots [of inequities]. Some allow borrow-ing, some allow interlibrary loans, some allowInternet access and some do not.

[NHS librarian focus group participant]

it is very much dependent on local Internet proce-dures and whether they get access to these elec-tronic resources. [NHS librarian focus groupparticipant]

The student survey endorsed these perceptionswhere it was shown nursing students would havevariable placement access to learning resources,depending on location. 64% of students on place-ment in the acute sector had access to library/learning resources. This was in contrast to studentsin the community and residential care sectorswhere access was available to only 19% and 15%of students, respectively.

The questionnaire survey produced some inter-esting findings on support for students in the NHS.A high proportion of students indicated that theynever accessed personal support for learning re-sources when on placement. They were askedwhich of these groups they used for support forlearning resources: academic staff, library/IT staffand NHS mentor. When they did look for supportfor learning resources, they would go primarily totheir NHS mentor.

Impact of EBL

Although results from the student questionnairecannot be used to establish the full impact ofEBL it can be concluded that access to learning re-sources when on placement is equally as importantfor these students as when they are in the Univer-sity. In respect of liaison with academic staff, theUniversity library focus group members felt thatthey historically had a good relationship with themalthough now they were ‘‘further apart. . . we arepart of a bigger organisation’’ [University libraryfocus group member]. The information specialistfelt they had built up this relationship over a lotof years of hard work and there was a ‘‘willingnessto work together, to integrate learning resourcesinto the curriculum’’. The NHS Library focus groupmembers had varying experiences. In one case,

202 G. Walton et al.

because they were dealing with a specialistarea, they had achieved good contact. In othercases, academic links were weak or non-existent.In consequence, the NHS librarians felt they didnot know what was going on in teaching andlearning.

Table 1 Collaboration perspectives

Collaboration University library staff

Access More use of library for reseaVisit (virtually)

Visit physically, usage intens‘free’ dayMore support given in electro

Disaggregating nursingstudents from other users

Students in other disciplines

Unless nurses come to desk wquery, cannot identify

Equality of service Trend to customer focus andpreparation of customer carestatementMuch support info on library

Table 2 IT perspectives

IT University library staff

Use of electronic resources More mature students exproblemsNeed to run workshops fgroupsLibrary helpsheets usefu

Getting to grips with pas

Use of blackboard

Need to know about Pptpresentation workLibrary staff skills needs

Journals Academics pressing use oelectronic journalsStudent preference for h

Photocopying Heavily used

Interlibrary loans Heavily used by final yea

Discussion

The work explored here is significant in that itexamines in detail the use pre-registration studentsmake of learning resources on clinical placement.Very little published work exists which has a similar

NHS library staff

rch Libraries limit access in some casesVisit physically but may be accessrestrictions

ive on Visit to library may not be possiblebecause of distance of placement

nic form

visit too Access provided across the Trust, cannot tellwho is a pre-registration nurse on placement

ith

Inequities depending where placement is

website Students feel unsupported by Univ. while onplacementAccess restrictions may disadvantage some

NHS library staff

periencing Need off campus access

or small Students not making full use ofe-resources available

l Point of need coming when onplacement – time when needrefresher

swords Use of full text journals, the hereand now, students can access, NHSstaff cannot – hard to supportOnus on student to get to grips withIT

for Unfamiliarity with blackboard.Limited access – hard to supportNHS staff skills needs

f Less vandalism of hard copyjournals

ard copy Happy to sit with a box of journalsrather than try to find full-textsonline

Heavy usage – source of income

rs Some offered ILL but did notpromote

Table 3 Support perspectives

Support University library staff NHS library staff

Library entitlements,loan periods etc.

Short loan little used Wide variation – some haveorrowing rights, some do notInternet access negotiated by some for studentsCessation of borrowing rights becauseof problems of chasing overdues, etc.

Enquiries received Using IT, accessing websites, passwords More statistical informationRight keywords to use for searches

Usage patterns Layout changed to accommodategroup work

No suitable study areas for groupwork – use common room

Supporting learning in practice in the EBL curriculum 203

focus. Since this study was completed, elementsbeen replicated in three other geographical areasof the UK. This indicates the increasing awarenessabout the need for evidence on the various facetsof placement learning. In this study, 92% pre-regis-tration nursing students attached high importanceto being able to access learning resources on clini-cal placement. Data from the focus groups showsthe centrality of collaboration in providing theseresources.

Another key finding from this study is that it isimpossible to disaggregate all the issues and devel-opments to establish the precise impact on

Table 4 Impact of EBL perspectives

Impact of EBL University library staff

Liaison with academicstaff

Good relationship built up over yea

Clued up on learning and teachingCurriculum planning a joint activit

Input into informationskills

Variable and dependent on persona

Staff awareness sessions every 6 wPersonal information and Communskills unit (assessed) offered by lib

EBL Some knowledge

Impact on resources because studeresource-basedResponsibility for own research

Read around topics, more on managroup dynamics etc not just nursinStudents stimulated, there is a buzGroup workGroups inspire confidenceCoping with noise from groupsExtra night opening for late night a

libraries and learning resources of the move toEBL in the health curriculum. There are so manyvariables that isolating EBL impacts through themethodology used in this study did not prove prac-tical. This is illustrated in Tables 1–4 which sum-marises all the issues around EBL identified byboth university and library staff. The nursing stu-dent (along with other students) is faced with aworld where more and more information is avail-able. The NHS Core Content (http://www.nelh.nhs.uk/home_use.asp) has been negotiated and givesNHS staff (and university students in NHS) accessto a wide range of electronic learning resources.

NHS library staff

rs Variable experiences

trends PPF as main contact but some invisibley Unaware of what is going on in learning

and teachingHalf day at Uni offered and taken upby some

lity of tutor One working with PPF on trainingneeds analysis

eeks Information received in ad hoc formicationrary

Some knowledge because of half-dayUniv. event

nt-centred, Impact on group work

Study time written into timetables,library inundated

gement,g

Noise disturbing other customers

z

ccess

204 G. Walton et al.

Many health organisations have their own websites, which contain material that can be used forlearning. No standard software has come throughfor accessing databases or e-journals so studentsare confronted with further variance. This complexsituation reinforces the importance of collabora-tion. Nursing academics (including those with vitallinks into clinical areas such as Practice PlacementFacilitators), higher education librarians and NHSlibrarians all must work together to ensure EBL issuccessful.

Conclusion

Systematic pooling of knowledge related to curric-ulum development and changing learning strategiesis essential and has the potential for both enhanc-ing quality and providing a focus for research.

There is a need to ensure students have the req-uisite information and information skills to beeffective in EBL. This is being addressed by learning

resources workshops, including small group ses-sions held for those in need of top-up IT training.

There also has to be close work to make the vastrange of information/learning resources availablein print and electronically easier to use and moreaccessible. New technologies such as pda’s andtablets coupled with wireless technology increasethe potential for quick access to learning resourceswherever the student may be. Learning resourcesmay need to consider the possibility of lending suchtechnologies to students on placement to ensureequity of access.

This study has shown that many changes are hap-pening, which will influence where and how nursingstudents learn. Future services have to be devel-oped and modified to reflect these changes. Fur-ther studies are therefore crucial to allowintelligence and findings to be established thatcan be used to develop ‘informed’ learning re-sources for the nurse student of the future.

Appendix A. Appendix questionnaire

Supporting learning in practice in the EBL curriculum 205

206 G. Walton et al.

Supporting learning in practice in the EBL curriculum 207

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