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Learning and quality improvement : nursing in the pediatric intensive care unit Mosavian Pour, Mir Kaber 2017

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i  LEARNING AND QUALITY IMPROVEMENT:  NURSING IN THE PEDIATRIC INTENSIVE CARE UNIT by Mir Kaber Mosavian Pour  B.Sc., Shahid Beheshti University of Medical Sciences, 1996 M.Sc., Iran University of Medical Sciences, 2001  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Experimental Medicine)   THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  September 2017   © Mir Kaber Mosavian Pour, 2017   ii  Abstract Maintaining a high quality of care in a Pediatric Intensive Care Unit (PICU) is a constant challenge. Continual 24/7 staffing, ongoing staff turnover, and the constant introduction of new equipment and procedures in a highly technologically-dependent unit requires continuous learning to deliver and improve the quality of children’s care. While all staff consider continuous learning important to maintaining and improving care, learning as quality improvement is made most explicit when new nursing staff are hired and incorporated into the PICU.  In this dissertation, I investigated the process of learning by individuals in the interactive social environment of the PICU to answer the following questions: How does learning occur among the newly hired nurses in the PICU? And, how does learning contribute to quality improvement? In this mixed method inquiry, I employed ethnography, Social Network Analysis and simple descriptive and inferential statistical methods to explore process of learning among the newly hired nurses in Western Canada Hospital.  I found that learning among newly hired nurses happened through face to face interactions in the context of two main activities: Orientation sessions and their Preceptorship. The most significant learning for the newly hired nurses, however, happened during their Preceptorship. Learning in the Preceptorship was social and experiential as they moved from legitimate peripheral participation in the multi-disciplinary and complementary social environment of the PICU into full participation as members of the PICU Community of Practice (CoP). This learning required the transformation and development of their individual and collective identity, as their preceptors, fellow nurses, and other staff employed scaffolding to mentor them through their constantly evolving Zone of Proximal Development (ZPD). Social and experiential learning activities became the basis for continuous quality improvement (CQI).  iii  I conclude that, in the PICU, quality improvement is the tangible manifestation and product of social and experiential learning. Rather than a sequence of corrective actions, in its most effective form, quality of care is improved through scaffolded ongoing learning activities in the authentic setting of a CoP. I recommend the unit to adopt a “learning together” sociocultural approach with scaffolding as key component for successful learning and CQI. iv  Lay summary Learning as quality improvement (QI) is made most explicit when new nursing staff are hired and incorporated into the PICU.  In this research, my goal was to answer: How does learning occur among the newly hired nurses in the Pediatric Intensive Care Unit (PICU)? And, how does learning contribute to QI? In my research, I found that the most significant learning for the newly hired nurses happened during their Preceptorship. Learning in the Preceptorship was experiential and social. Their interaction and the learning they gained led to delivering high quality care. I also found that quality improvement in the PICU is a sociocultural activity and the result of social and experiential learning rather than a sequence of corrective actions. I recommend the unit to adopt a “learning together” sociocultural strategy with scaffolding as key component for successful learning and quality improvement.    v  Preface  This thesis is an original, unpublished and independent intellectual product of the author,  Mir Kaber Mosavian Pour (Mirkaber Mosavianpour). As of the date of this thesis, no part of this research has been published (partially or wholly).  I was the lead researcher of the whole of this research. I was responsible for all areas of research design, data collection, data analysis and the author of the whole manuscript of this thesis.  This research was approved by the University of British Columbia’s Behavioral Research Ethics Board under certificate (H12-03405).  vi  Table of contents  Abstract .......................................................................................................................................... ii Lay summary ................................................................................................................................ iv Preface .............................................................................................................................................v Table of contents .......................................................................................................................... vi List of tables....................................................................................................................................x List of figures ................................................................................................................................ xi List of abbreviations ................................................................................................................... xii Acknowledgements ......................................................................................................................xv Dedication .................................................................................................................................. xvii Chapter 1: Introduction ................................................................................................................1 1.1. Introduction ............................................................................................................................. 1 1.2. Overview background ............................................................................................................. 3 1.3. Rationale ................................................................................................................................. 7 1.4. Statement of the problem ........................................................................................................ 9 1.5. Research question .................................................................................................................. 10 1.6. Research objectives ............................................................................................................... 10 1.7. Organization of thesis ........................................................................................................... 11 Chapter 2: Literature review ......................................................................................................13 2.1. Care in critical care and rise of PICUs .................................................................................. 13 2.2. Quality Improvement ............................................................................................................ 14 2.3. Quality Improvement and learning: a paradigm shift in Quality Improvement .................... 18 2.4. Learning in medicine and nursing ......................................................................................... 19 2.5. Learning in the Pediatric Intensive Care Units ..................................................................... 20 vii  2.6. Various forms of knowledge in nursing ................................................................................ 21 2.7. Learning theories ................................................................................................................... 23 2.8. The Theoretical Framework of the Thesis ............................................................................ 46 Chapter 3: Methodology..............................................................................................................50 3.1. Conceptual orientation .......................................................................................................... 50 3.2. Study design .......................................................................................................................... 50 3.3. Setting ................................................................................................................................... 52 3.4. Participants ............................................................................................................................ 55 3.5. Gaining access ....................................................................................................................... 56 3.6. Timeline ................................................................................................................................ 57 3.7. My stance and reflexivity ...................................................................................................... 57 3.8. Recruitment procedures......................................................................................................... 57 3.9. Data collection ...................................................................................................................... 59 3.10. Data analysis ......................................................................................................................... 66 3.11. Methodological soundness .................................................................................................... 69 Ethnographic Findings: Chapter 4 through Chapter 11 .........................................................71 Chapter 4: Characteristics of the newly hired nurses ..............................................................74 4.1. Educational background of the newly hired nurses ............................................................... 74 4.2. Work experience of the newly hired nurses .......................................................................... 75 4.3. Reasons for working for children .......................................................................................... 75 4.4. Reasons for working for the PICU ........................................................................................ 76 Chapter 5: Orientation sessions ..................................................................................................79 5.1. Description of the Orientation sessions ................................................................................. 79 5.2. Contents of instruction in the Orientation sessions ............................................................... 88 5.3. Specific aspects of teaching in the Orientation session ....................................................... 105 viii  Preceptorship..............................................................................................................................117 Chapter 6: Description of the Preceptorship...........................................................................120 6.1. Preceptorship ....................................................................................................................... 120 6.2. A prototypical 24-hour day of the Preceptorship ................................................................ 121 Chapter 7: Teaching aspect of the Preceptorship ...................................................................133 7.1. Teaching activities during the Preceptorship ...................................................................... 133 7.2. Analytical concepts underlying teaching activities in the Preceptorship ............................ 149 Chapter 8: Learning aspect of the Preceptorship ...................................................................164 8.1. Learning activities in the Preceptorship .............................................................................. 164 8.2. Analytical concepts underlying learning activities in the Preceptorship............................. 180 8.3. Learning outcomes among the newly hired nurses in the Preceptorship ............................ 205 Chapter 9: Social interaction for learning during the Preceptorship ...................................215 9.1. To examine role of interaction in learning .......................................................................... 215 9.2. To examine the newly hired nurses’ informal learning networks ....................................... 220 Chapter 10: Perceptions of the newly hired nurses about learning, quality improvement (QI) and the relationship between learning and QI ................................................................240 10.1. Perceptions of the newly hired nurses about learning ......................................................... 240 10.2. Perceptions about quality improvement and quality of care ............................................... 249 10.3. Perceptions of the newly hired nurses about the relationship between learning and QI ..... 262 Chapter 11: Learning goals of the newly hired nurses in the PICU .....................................271 11.1. Individual learning goals ..................................................................................................... 271 11.2. The Evolution of professional identity during the Preceptorship ........................................ 280 11.3. Shared learning goals .......................................................................................................... 286 Chapter 12: Discussion ..............................................................................................................292 ix  12.1. Learning in the PICU .......................................................................................................... 292 12.2. Adult learning ...................................................................................................................... 294 12.3. Learning and quality improvement ..................................................................................... 324 12.4. Conclusions and recommendations ..................................................................................... 325 12.5. Strengths and limitations ..................................................................................................... 330 12.6. Future research .................................................................................................................... 333 Bibliography ...............................................................................................................................334 Appendices ..................................................................................................................................359 Appendix A: Detailed literature review .............................................................................. 360 A.1.   Evolution of Pediatric Intensive Care Unit (PICU) ................................................................ 360 A.2.   Quality Improvement ............................................................................................................. 365 Appendix B: Interview questions ........................................................................................ 379 Appendix C: Sample PICU Orientation agenda ................................................................ 384 x  List of tables Table 3. 1: Composition of the PICU interprofessional team ....................................................... 54  Table 4. 1: Distribution of the newly hired nurses by their cohort and educational level ............ 74 Table 4. 2: Reasons for working for children and pediatric intensive care .................................. 77  Table 5. 1: Main contents of instruction in the PICU Orientation sessions .................................. 83  Table 11. 1: Comparison of the level of acuity of patients assigned to the newly hired nurses in their previous workplace and WCH PICU.................................................................................. 282 Table 11. 2: Shared and individual learning goals of the newly hired nurses in the PICU during their Preceptorship ...................................................................................................................... 288  xi  List of figures Figure 2. 1: First generation Activity Theory model .................................................................... 42 Figure 2. 2: Second generation of Activity Theory ...................................................................... 43 Figure 2. 3: Third generation Activity Theory.............................................................................. 44  Figure 5. 1: Contents of teaching in the orientation sessions: Interplay between team work, learning and research to deliver quality care .............................................................................................. 93  Figure 9. 1: Individual learning network of the new nurse LACC: NN11 ................................. 221 Figure 9. 2: Collective informal learning network for all three cohorts of the new nurses ........ 231 Figure 10. 1: Sociocultural learning and quality of care at individual and collective level in the PICU  ................................................................................................................................ 269 Figure 10. 2: Sociocultural learning and quality of care at individual and collective level in the PICU (simplified) ....................................................................................................................... 270    xii  List of abbreviations AACN: American Association of Critical Care Nurses ACLS: Advanced Cardiovascular Life Support AR: Action Research AT: Activity Theory BC: British Columbia BiPAP: Bilevel Positive Airway Pressure BPR: Business Process Reengineering BSN: Bachelor of Science in Nursing CHAT: Cultural Historical Activity Theory CME: Continuing Medical Education CNC: Clinical Nurse Coordinators CNE: Clinical Nurse Educator CNS: Clinical Nurse Specialist CoP: Communities of Practice CPAP: Continuous Positive Airway Pressure  CQI: Continuous Quality Improvement CRRT: Continuous Renal Replacement Therapy DMAIC: Define, Measure, Analyze, Improve and Control ECLS: Extracorporeal Cardiac Life Support GDRN: General Duty Registered Nurse ICU: Intensive Care Unit IHI: Institute for Healthcare Improvement xiii  IOM: Institute of Medicine ITL: Intent To Leave LOS: Length Of Stay LPP: Legitimate peripheral participation NHS: National Health System OR: Operation Room OT: Occupational Therapist PALS: Pediatric Advanced Life Support PAR: Participatory Action Research  PBL: Problem-Based Learning PDSA: Plan, Do, Study, Act PHSA: Provincial Health Service Authority PICU PAR: Pediatric Intensive Care Unit Participatory Action Research PICU: Pediatric Intensive Care Unit PM: Program Manager PRO: Personal Responsibility Orientation PT: Physiotherapist QI: Quality Improvement QSL: Quality and safety leader RN: Registered Nurse  RPIW: Rapid Process Improvement Workshop RT: Respiratory Therapists SBAR: Situation, Background, Assessment, Recommendation xiv  SCCM: Society of Critical Care Medicine SDL: Self-Directed Learning SNA: Social Network Analysis SoPK: System of Profound Knowledge SPC: Statistical Process Control SW: Social Worker TCU: Transitional Care Unit TNCC: Trauma Nursing Core Course TPS: Toyota Production System TQM: Total Quality Management UBC: University of British Columbia UK: United Kingdom USA: United States of America VPMA: Vice President of Medical Affairs WCH: Western Canada Hospital ZPD: Zone of Proximal Development    xv  Acknowledgements I would like to extend my special appreciation and thanks to Dr. KS Joseph, a role model who reached out his hand into the darkness, to pull another hand into the light. Without his supports, I would hardly be able to finish this thesis and learn lessons that I learned in his lab.  Special acknowledgement and thanks is due to my committee members, Dr. Jean-Paul Collet, Dr. William McKellin and Dr. Niranjan Kissoon for their time and assistance even at hardship. I truly appreciate all of their guidance and support as I navigated this journey! This research would not have been possible without their impressive support and assistance. A special note of thanks is due to Dr. Jean-Paul Collet, my supervisor, for encouraging my research and for allowing me to grow as a research scientist. His advice on research has been priceless. I also want to thank him for enabling my defense to be an enjoyable moment, and for his brilliant comments and suggestions.  Additional gratitude is offered to Dr. William McKellin, my co-supervisor, who took me out of “Cognition” and showed me the world of “Mind in Society”, “Society in Mind” and then “Society of Mind”. His scaffolding and mentorship is unique, he knows when and how to support you, and gives space for your “self” to grow. His support in submitting this thesis was invaluable. A very special thanks is due to Dr. Niranjan Kissoon, my truly leadership role model, whose door is always open for me anytime I was demotivated. He is a leader who has a clear picture of an immigrant graduate student’s hardship and his hand is always open to take your hand. His support was irreplaceable. I wish to thank many physicians, nurses, allied health and all other staff in the Pediatric Intensive Care Unit (PICU) of the hospital in which I did my research. A note of thanks is also due to the PICU Program Manager and the Clinical Nurse Educators for their continuous support. xvi  Special thanks to Dr. Mohammad Iraj Poureslami for his kind support over this time. I would like to greatly thank Dr. David Kaufman for his kind support and opportunities that he provided in his lab for great experiences in Educational Technology over my studies. I would like to express my great appreciation to my beloved wife Hamideh who spent sleepless nights and was always my support in the moments when all was darkness. Words are not adequate to express how grateful I am to her. She taught me the value of academic achievement and she has always been more excited than I for my academic advancements. Special thanks to my son, Aryan, for all of the sacrifices that he has made for me over years. Aryan, I will never forget that one of those intense days of studying for my Comprehensive Exam, you asked me: “Do I have to do a PhD?” Still, I do not have any clear answer to your question! But, I believe in “My Lord, Increase me in knowledge.” Special thanks to my loved ones whom I have lost them over my studies: my father, my brother, my grandmother and my mother-in-law whose voice is still whispering in my ear: “by the time your doctoral studies are over, I will be gone!”.  I would like to greatly thank my brother-in-law (Kevin) and his lovely kind wife, Fariba, who supported me in many ways over this long journey.  I would like to thank my brother-in-law Parviz and his beloved family (Shahin and Amin), as well as Aziz for their kind support over this time.  I would like to thank, my nephew, Mehran, my sisters, Alavieh and Hamideh for their support for my mother in my absence. A very special thanks to my mother; your prayers for me have sustained me thus far.  xvii  Dedication  Kindly dedicated to:  Hamideh (Helen) Sarmast My beloved wife for her faith, advice and her patience, since she always understood.  &  Aryan Mosavian Pour My loving son for his great deal of patience, determination, and understanding since he always cared.1  Chapter 1: Introduction I’d say every day is a learning opportunity. Things are always changing, especially in intensive care. (New nurse NN25) Um, … learning's sort of the, I would say like the progression of the individual, um, from going from novice to an expert. (New nurse NN11) I think anybody who, who demonstrates, you know, a competency, and a willingness to teach, or even just a competency, such that I can observe them in what they’re doing. Then I would learn something from that situation. So, I mean I’ll watch, you know a new physician, the way they do a procedure. I might learn the right way to do it. And I might also learn how not to do a procedure. And whatever it is, like I take that information forward with me. Um, as far as who I prefer to learn from. Like, you know, like I said anyone who seems like, they know what they’re doing. [chuckle] basically. Or if they don’t know what they’re doing then I, I take that and I internalize that as well. As how, you know as a, reminder for myself, as to how not to practice. Because, you see that as well. (New nurse NN12) I think learning is a key facet of quality improvement.(New nurse NN12)  1.1. Introduction This thesis is about the process of learning by newly hired nurses in the Pediatric Intensive Care Unit (PICU) in Western Canada Hospital. What follows is a study of learning and teaching activities in which the newly hired nurses learn how to deliver good care in the PICU when they start their work in this unit. In short, this research uses mixed methods including ethnography and Social Network Analysis to examine learning to deliver good quality care in a PICU. I present an account of Vygotskian sociocultural learning (1–6), Activity Theory (2,6–15) and Communities of Practice (16–23) in the complex clinical setting of the PICU while I also acknowledge the relevance of individualist perspectives on learning (18,24,25). From this vantage point, I look beyond the more technical aspects of nursing procedures and the institutional 2  orientation that newly hired nurses encounter to explore how they learn, the role that social interactions play in their learning, how they relate learning to quality of care, and their learning goals. I will examine how learning among the newly hired nurses takes place through face-to-face interactions in the context of two main activities: Orientation sessions and Preceptorship. Learning in the Orientation sessions is didactic formal learning that occurs through decontextualized traditional classroom-based instruction, which does not resemble the natural setting of the PICU. It provides them with an introduction to the organizational structure, administrative procedures, and acquaints the nurses with the unit’s approaches to fundamental nursing activities.  The most significant learning for the newly hired nurses, however, happens during their Preceptorship. Learning in the Preceptorship is social and experiential; they move from legitimate peripheral participation in the multi-disciplinary and complementary social environment of the PICU into full participation as members of the PICU Community of Practice. I demonstrate that this learning process requires a progressive transformation and development of nurses’ knowledge and skill while preceptors, fellow nurses, and other members of the PICU employ scaffolding to mentor new staff through their constantly evolving Zone of Proximal Development (ZPD). I maintain that the division of labor and role boundaries are important sociocultural factors influencing their transition through their Preceptorships. These initial months in the PICU serve as a rite of passage during which individuals’ identities are transformed from qualified registered nurses into full-fledged PICU nurses. This transition from novice to expert takes them from their initial roles and functions in the unit into roles that are more complex, and demonstrates the unit’s recognition of their new capacities. This continuous stepwise process is a fundamental aspect of 3  the PICU's progressive social integration of the new staff. Finally, I demonstrate that social and experiential learning activities become the basis for continuous quality improvement (CQI) in the unit.  I conclude that, quality improvement is the tangible manifestation and product of social and experiential learning which happens through scaffolding in a Community of Practice. These continuous, scaffolded social and experiential learning activities in the actual setting of a Community of Practice are the most effective means of improving quality of care, in contrast to other approaches that attempt to improve quality through a series of corrective actions.  Finally, I recommend that the unit to adopt a “learning together” sociocultural approach to learning and continuous quality improvement (CQI) in which scaffolding is the key component. In such an approach to learning and CQI, there is a gradual increase in the complexity of experiential learning in the Community of Practice. That is to say, an ongoing assessment and adaptation of learning to each individual’s and the whole unit’s Zone of Proximal Development leads to the establishment of a culture of continuous quality improvement and reduced resistance to change.   1.2. Overview background 1.2.1. Quality of care at stake The Institute of Medicine (IOM)'s revolutionary twin reports considered poor quality of care as an important preventable cause of mortality and morbidity (26,27).  After IOM’s alarm regarding low quality healthcare (26,27), numerous initiatives developed to improve quality of care using various quality improvement models. These includes strategies developed in the industry such as Total Quality Management (TQM), Business Process Reengineering (BPR), 4  Rapid Cycle Change, Lean thinking, Six Sigma and, the amalgamation of the last two in Lean Six Sigma.  However, the literature shows that unlike progress in quality improvement in various industries, the application of these conventional improvement models in healthcare systems has faced serious barriers. These challenges are related to the unique features of healthcare systems, which include variability of human beings as opposed to industrial machines, the complexities of healthcare systems, the unpredictability of patients’ conditions, the variety of stakeholders in healthcare systems, and the continuous revisions in evidence-based guidelines and new practices. These are compounded by other barriers such as long standing professional standards of practice and inter- and intra-disciplinary tensions (28–36).   1.2.2. Learning and quality of care Quality improvement in the healthcare system involves the ongoing refinement of practice, as a learning philosophy (35), it is a framework for learning aimed at enabling the staff, individually and collectively, to develop intelligent practices and take effective actions (35). The interplay between learning and delivering better care addresses a newer perspective and opens new horizons for quality healthcare delivery. From this perspective, success in delivering better care depends on highly effective learning and constant reflection about practice among people involved in the target practice particularly groups of frontline staff (37,38). The crucial role of learning is woven throughout the fabric of quality improvement philosophies and methodology. In other words, learning is the backbone of delivering better care (37).  Due to continuously evolving character of clinical science, learning and development are perpetual processes in medicine (39) and nursing (40–42). Professional life in these fields is an ongoing learning process in which every person is continuously moving from novice to expert as 5  they enter new areas of practice and encounter new technologies and procedures (43,44). In fact, continuous evolution of medicine (39) and nursing (40) behooves staff working in these teams to engage in lifelong learning (39). This is particularly important in a complex setting such as critical care.  The WCH Pediatric Intensive Care Unit (WCH PICU) is a very complex organization that cares for patients with complex conditions and high acuity. Care is delivered around the clock, seven days a week by a multidisciplinary team that include nurses, physicians, respiratory therapists, dieticians, pharmacists, and other physicians and allied health professionals from outside of the unit. The PICU is a place where any minor mistake in a procedure can have serious consequences from morbidity to death. Consequently, the PICU demands highly competent and professional staff who are able to meet the needs of critically ill patients and adapt to the introduction of new technologies and procedures (39). Additionally, the WCH PICU is part of a university hospital system and an educational site for clinical trainees (such as medical fellows, medical residents, and nursing students). To work and deliver consistent high quality care, the staff of the PICU must continuously learn how to work with other staff as a multidisciplinary Community of Practice. Continuous learning is considered critical to maintaining and improving care (45–48). The learning process is made more explicit when new nursing staff are hired and incorporated into the PICU. The newly hired nurses represent a very interesting population for study because when they are hired they must be fully qualified registered nurses, and often have considerable experience in pediatrics and insensitive care. Therefore, their initial learning and training phase is aimed at engaging them as full member of the unit through a complex initiation process during which the new staff will move from novice to expert through identification of 6  resources and learning the rules of communication and operation. The learning activities designed for them during their first months are intended to provide them with considerable organizational and technical information and professional knowledge necessary to work in a complex social learning environment, and to transform them into members of a multidisciplinary PICU team in which continual learning is necessary to provide quality care. 1.2.3. Complexity of the unit: As stated earlier, the PICU is an extremely complex team-based unit. Each patient poses different challenges that require the contribution of diverse PICU staff including nurses, physicians, respiratory therapists, dieticians, pharmacists, and additional consulting physicians and allied health professionals from outside of the unit. In such a complex, team-based unit, the division of labor and the hierarchy of the professions within the unit contributes to different disciplinary perspectives about the patient and best therapeutic approaches. In this context, “what on the surface appears to be a single central problem of care for the patient is in fact a constantly evolving constellation of problems: it looks different depending on whose point of view we take, and on which point in time we emphasize during the process” (49).   The challenging complexity of the patients and the multidisciplinary perspectives of the staff are further amplified by the complexity of the tools they employ in diagnosing, treating, and monitoring patients. These tools range from highly sophisticated medical equipment including Extra Corporal Life Support (ECLS) systems, to more prosaic monitors and communication media, including beeping pulse oximeters and paper charts. Thus, each of the many multidisciplinary teams that treat patients using these technologies develops its own set of formal and informal rules, and each becomes a Community of Practice 7  devoted to the treatment of a patient. These complex teams and the tools they employ influence the process of interaction, decision-making and re-assessment among the different disciplines which provide quality care for a patient. However, not only do team members create a Community of Practice for each patient, as they work together caring for many patients, the multidisciplinary staff members contribute to the emergence of a collective, unit-level Community of Practice across the PICU.  1.3. Rationale 1.3.1. Prelude to the study: quality improvement activities in the PICU Prior to this study, the PICU had conducted various initiatives to improve quality of care and had become a regional and national leader in developing Quality Improvement (QI) initiatives (50,51). However, the staff of the PICU felt that results of these QI projects have been mixed, and that success was limited (52,53). There were important early successes, most notably a significant reduction in healthcare-associated infections in the PICU. In 2008, when the Provincial Health Service Authority (PHSA) adopted the Lean thinking quality improvement model in an effort to bring efficiencies to the system, the WCH PICU leadership volunteered to be WCH trial unit and four of its members became Lean Leaders. Following this, the PICU team completed impressive 23 Rapid Process Improvement Workshops (RPIWs) over 4 years, but with mixed success.  Only 9 of 23 RPIW projects (approximately 40%) were sustained for one year, whereas the remainder had very limited success due to various individual and contextual barriers (50).  1.3.2. PICU Participatory Action Research (PICU PAR) Among the contextual barriers was the process for developing and implementing QI projects. In discussions with the PICU staff prior to this research, they noted that until 2012, almost 8  all Quality Improvement initiatives in the PICU were top-down, developed by the leaders of the unit, with minimal frontline staff engagement, and pushed down to the bedside for implementation. This, we discovered, was one of the main reasons that QI projects were not welcomed by the frontline staff, and led to very limited adoption and restricted success (50,52).  In 2012, the PICU decided to change its approach and tried to enhance frontline staff engagement and distributed leadership in the development and implementation of quality improvement initiatives. Therefore, under the guidance of the JPC Lab in the WCH Research Institute, a Participatory Action Research and Quality Improvement team was formed with the PICU. This team developed and conducted the PICU Participatory Action Research  (PICU PAR) that ran between 2012 and 2016  in  two phases: phase 1 or PICU PAR 1 (2012-2015) and phase 2 or PICU PAR 2 (2015-2016) (50,51).  The overarching goal of this project was to increase the engagement of frontline staff leadership  in improving practice quality through staff-identified and led change initiatives (50–52). This was a mixed method project that used both qualitative and quantitative methods. Data collection for the PICU PAR1 was conducted from January to October 2013 and was comprised of surveys, semi-structured interviews, social network analysis, and observations.  The PICU PAR 1 identified multiple factors influencing clinical practice that affected the quality of care in the PICU (51). These initial findings inspired this thesis research. Early in our discussion about the PICU PAR project, staff drew a direct relationship between Quality Improvement and Learning. Therefore, first and most important of these findings inspiring the present study was the relationship between Quality Improvement (QI) and learning. Findings of the PICU PAR1 study showed that the staff from various disciplines in the PICU including nurses looked at Quality Improvement as an ongoing learning activity (51,53):  9  P16: ABI_ RN - 16:54: P: [pause] Um, [pause] I think quality improvement is a lot about learning. Um, …Because quality improvement [is] to improve something you have to change what you're doing. Changing what you're doing, means not doing it like you've always done it before. And so there's gonna be new steps involved. So then in learning new steps ..hm.. you have to learn the new steps. And you have to learn the rationale as to why you're changing what you're doing. So, um, [pause] yeah, I, I think it is a little, it's a lot about learning. It's about going out there and looking at what other centers are doing, and what other programs are doing. And, if, if, quality improvement is being measured, then you can see how the improvements are affecting patients. And, the care that they're receiving. And outcomes, and so, that's all learning as well, because you see how things are being done. Um and then we can try it out and, and see how it happens.  In addition, interviews in the first phase of the PAR study (PAR 1) showed that the staff from almost all disciplines in the PICU believed that the knowledge, experiences and information that nurses acquire is crucial for decisions regarding patient care, delivering good care and preventing medical errors by other staff such as physicians, nurses and allied health professionals (52).  1.4. Statement of the problem The PICU PAR findings revealed that members of the PICU considered that learning and the dissemination of knowledge played a crucial role in quality improvement and delivering better care. However, the PICU PAR project did not provide in-depth information about the process of learning among PICU staff. We thought that the process of learning in the PICU would be most explicit and clearly articulated around the experience of introducing newly hired nurses in the PICU. We also needed to investigate various methods of learning that also involved other staff in the PICU. Consequently, I decided to focus on the process of learning among the newly hired nurses, who are fully qualified registered nurses, and may have pediatric and or critical care experience, but have not worked in this unit.  I selected them for the following reasons: (a) 10  Studying new nurses will be helpful in revealing the process of learning that is employed and modeled for a typical PICU nurse over his/ her trajectory of employment in the PICU from the time this nurse enters to the PICU until he/ she is fully integrated into the unit. (b) Focusing on the newly hired nurses’ experience highlights the explicitly identified and institutionalized learning schemas that are identified for new nurses during the Orientation and throughout their Preceptorship.  This focus also captures the learning culture in the PICU as most of the routines of working in the PICU, expectations of/ from the new staff, and values about improving the quality of care in the PICU are made explicit during these periods. (c) In addition, studying process of learning among the newly hired nurses creates an opportunity for prospective investigation of the process of learning among nurses as they interact with their new nursing colleagues and other clinical staff in the unit. This prospective approach, based on observations in situ and interviews is helpful in understanding the learning experience not just of the newly hired nurses involved in the study, but also the experiences of the veteran nurses who had similar experiences when they joined the unit and participated in the Preceptorships and enculturation of more recently hired nurses. This way, I did not need to depend solely on the self-reports of experienced nurses (54).  1.5. Research question In this research, I am going to study the process of learning among the newly hired nurses in the collaborative social environment of clinical setting of the PICU in order to answer the following research question: How does learning occur in the PICU? 1.6. Research objectives Findings of this research will provide insight into (a) understanding of the process of learning in the PICU; (b) the role that interaction with other nurses and other staff play in learning; 11  (c) how this learning process affects the professional identity of newly hired nurses; (d) how learning is conceptualized by both the new nurses and their more experienced counterparts, and (e) how learning contributes to quality improvement and care quality. These findings have the potential to contribute to (a) the evidence regarding learning among advanced critical care nurses, (b) a model of learning and education for nurses based on empirical data, (c) the development of learning strategies for quality improvement initiatives. 1.7. Organization of thesis The focus of this thesis is to assess and describe the process of learning in the PICU and to understand how it is related to quality care. The organization of the thesis is as follows: In this chapter (Chapter 1), I have introduced how staff in the PICU related quality care to learning in our previous research, the importance of exploring process of learning among the newly hired nurses and lack of enough evidence in this regard. I also detailed my research question, aim and specific objectives. In Chapter 2, I present my literature review. In this chapter, I shortly introduce the concept of quality improvement in general and in healthcare, then I describe the role of learning in quality of care. I follow this with a detailed description of literature around learning theories. In so doing, I present a brief literature review about individualistic learning theories. Then, I focus on Vygotskian sociocultural learning theory, Communities of Practice and Activity Theory. Finally, I elaborate on Cultural Historical Activity Theory (CHAT) that is going to form the theoretical framework of this thesis.  12  Chapter 3 focuses on methodology. In this chapter, I re-introduce my conceptual orientation, study design, setting and participants. I also outline my data collection methods, data analysis, as well as methodological soundness. Chapters 4 through 11 present findings of my research. Chapter 4 describes characteristics of the participants. Chapters 5 through 11 describe two teaching and learning opportunities organized by the unit for newly hires nurses to learn how to work in the PICU. Chapter 5 focuses on the Orientation sessions as the first teaching and learning opportunity and Chapters 6 through 11 focus on the Preceptorship as the main learning opportunity for the newly hired nurses. Chapter 6 presents a description of the Preceptorship. Chapter 7 focuses on the teaching aspect of the Preceptorship whereas Chapter 8 focuses on the learning aspect of the Preceptorship. Chapter 9 presents the role of social interaction in learning during the Preceptorship. The focus of Chapter 10 is perceptions of the participants about learning, quality improvement and quality of care, as well as the relationship between these two. This follows by Chapter 11 that focuses on learning goals of the newly hired nurses in the Preceptorship. Finally, I present my discussion in Chapter 12 that includes summary of my main findings, and how they are comparable with related literature. I follow this chapter by drawing some recommendations based on my research findings, strengths and limitations of my research and future directions in research.          13  Chapter 2: Literature review This chapter provides a review of the relevant literature beginning with a very short introduction to ICUs and PCIUs, quality improvement (QI) in industry and in healthcare, and the role of learning in the quality of care (a more detailed literature review about ICUs and QI is included in Appendix A). Then, I present a detailed examination of the literature concerning relevant learning theories that have contributed to my understanding of the process of learning in the PICU. This will include a brief review of the literature about individualistic learning theories and an examination of Vygotskian oriented sociocultural learning theories, including Communities of Practice and Theory Activity Theory.  2.1. Care in critical care and rise of PICUs  The first Pediatric Intensive Care Unit (PICU) was founded by a pediatric anesthesiologist (Goran Hoagland) in Goteborg, Sweden in 1955(55). Twelve years later, in 1967 the first PICU was established in the USA with six beds, each with separate nurses and 24-hour resident physicians and coverage by pediatric anesthesia fellows (56). Thereafter, PICUs started to develop across the USA so that by the mid-1970s they could be found in most hospitals with pediatric residency programs (55,56). Meanwhile, pediatric critical care emerged as a discipline in the 1960s (57) and has evolved over the last 50 years (56).  Intensive care units (ICUs) play important roles in healthcare. Many patients admitted to the hospital receive direct or indirect ICU care during their hospitalization. Characterized by high patient acuity, employment of high technology, high staff-patient ratio (one bed, one nurse and sometimes two nurses for one bed), as well as number of complex care procedures (which are 14  costly), they consequently produce a sizable economic burden (58). According to recent studies, 17.4-39.0% of all hospital costs and 0.56-1% of the gross domestic product in the United States of America (USA) are spent for delivery of care in ICUs (56). I have provided more literature about evolution of PICUs in Appendix A. 2.2. Quality Improvement 2.2.1. Rise of Quality Improvement in industry The Quality Improvement (QI) movement arose in industry in the 20th century. Walter. A. Shewhart, W. Edwards Deming and Joseph M. Juran are considered the pioneers who set the ground woks for the movement. Shewhart introduced the Specification, Production and Inspection cycle (SPI cycle) and also created control charts (59). Deming’s unique contribution in quality improvement was his internationally known “system/ theory of profound knowledge” and “Plan, Do, Study, Act learning cycle (the PDSA cycle)” (59–63) (for more literature about these topics, please refer to Appendix A).  2.2.2. Quality and Quality Improvement in healthcare Quality Improvement in healthcare poses a big challenge and has been a subject of considerable debate in recent years (64,65). Research on medical errors identified tens of thousands of cases of mortality and hundreds of thousands instances of morbidity annually that could have been prevented by improved quality of care (66).  The most significant work in improving quality in healthcare started in the late 1980s in the United States of America (USA) as part of the National Demonstration Project on Quality Improvement in Healthcare, led by Dr. Don Berwick. This led to the establishment in 1991 of the Institute for Healthcare Improvement (IHI), which has become an influential organization in 15  promoting healthcare quality improvement in the USA. The IHI has expanded to other countries such as Canada, England, Scotland, Denmark, Sweden, Singapore, Latin America, New Zealand, Ghana, Malawi, South Africa and the Middle East (67). More recently, the Institute Of Medicine (IOM) identified the low quality healthcare as one of the preventable leading causes of death in the USA (26,27). Through its twin reports “To Err is Human” and “Crossing the Quality Chasm”, the IOM called for healthcare quality improvement and a redesign of  healthcare systems (66,68). The IOM defined quality as “the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (27,69,70). Furthermore, IOM defined quality improvement as bridging the gap between existing and desired levels of quality using special methods and tools (27).  After IOM’s profound warning regarding the low quality healthcare (26,27), various healthcare organizations developed initiatives to improve six aspects of healthcare quality including: safety, effectiveness, efficiency, timeliness, patient-centeredness and equity (66,68,71). In so doing, these organizations recommended various quality improvement approaches to improve the quality of care.  2.2.3. Conventional approaches for Quality Improvement (QI) The most widely recognized models used in development, implementation, and evaluation of quality improvement initiatives include: Total Quality Management (TQM), Business Process Reengineering (BPR), Institute for Healthcare Improvement (IHI) Model for Improvement (also known as Rapid Cycle Change), Lean Thinking, Six Sigma and combined model of Lean Six Sigma (32).   16  TQM is a holistic approach for improving quality through identifying root causes of poor performance. The fundamental element of TQM is its strong emphasis on quality improvement as ongoing activities that mainly focus on internal and external customers’ needs (32,72,73).  This model was increasingly adopted in healthcare systems in the 1990s (32,72). Integration of the central approach of TQM in healthcare systems has not been as successful as expected even though apparently it was widely adopted (28–32,34,74).  The Business Process Reengineering (BPR) focuses on the fundamental organizational issues that contribute to quality (32,75) . Examining and reengineering systemic business processes is core of this approach (32,75). Few healthcare systems have fully implemented BPR. However the British  National Health Service (NHS), conducted two notable 3-year pilot studies in the 1990s, which showed only slight improvements through this approach (32). The Model for Improvement was developed by Langley and his colleagues (76,77)  and was adopted by the Institute for Healthcare Improvement (IHI) (32,76,77). This model is based initially on short iterative cycles and small scale changes (32,76,77) that are then expanded on the basis of reflection and learning (32,76). Unfortunately, this model has received limited peer-reviewed evaluation (32) .  Lean Thinking (also known as the Toyota Production System or TPS) is another variation of Deming’s model of quality improvement (78). This model was developed by Deming while he worked at Toyota in Japan in the 1950s (32,79). Lean Thinking presented a radical alternative to the traditional method of quality improvement for mass production industrial systems (79). It focuses on streamlining the processes to meet expectations of customers (both internal and external) with the least amount of waste in resources such as time and cost (32,79). Lean is an approach that focuses on integrating three aspects: (a) quality-related beliefs and attitudes 17  (philosophy), (b) elimination of waste; in the context of healthcare specifically in hospitals, this means trying to remove duplication in processes and procedures that are not necessary (80) such as multiple records of patient information, patient transfer before readiness of the recipient unit, long waiting time for consultants and physicians and also discharge processes conducive to longer Length Of Stay (LOS) (79). (c) Involvement of the staff that is supported by a management system (80). Through these processes, Lean is following two primary objectives: (a) identifying and specifying value to ultimate customers. This implies that any process and its components should have added value to be considered meaningful (32,80). (b) Analyzing and focusing on value stream in a way that keeps and continues only activities that have added value (80). The Lean method has been used in healthcare systems and has achieved some success in waste reduction (32,80). This approach is more useful in facilitating processes in departments that support clinical activities rather than in mainstream clinical services (32).   Six Sigma is another approach for quality improvement that is based on Shewhart- Deming’s PDSA cycle (32,81). Ideally, improvement activities in Six Sigma are based on a structured approach that is called DMAIC that is an acronym for the  sequence of steps:  Define, Measure, Analyze, Improve and Control (32,38,81). Application of this approach in healthcare has been limited and recent (82). Currently, there is some interest in industry and in healthcare in a hybrid model of Lean and Sigma that is called Lean Six Sigma (32,80,83). The logic behind the integration of Lean and Six Sigma is that Lean is more a holistic approach for controlling the processes without any statistical basis whereas Six Sigma is rich in statistical tools without deep focus on process improvement. Lean and Six Sigma each have strengths; synthetizing these strengths can be helpful in developing and implementing systematic improvement projects in healthcare (80).  18  In summary, the dominant models of quality improvement are all variations of Deming’s theory of profound knowledge and PDSA cycle, and there are considerable similarities in their implementation (32). Objectively, there is no best model, method or approach that is the most effective (32,72). Rather, there is an interplay between the local context and the model that is central to the success or failure of improvement projects (32). As outlined above, research has shown that quality improvement strategies in industry and healthcare systems have made some progress, however healthcare presents unique challenges. These challenges in healthcare include the complexity of the healthcare organizations, complexity of the patients, the variety of stakeholders in these systems, professional practice standards, inter- and intra-disciplinary tensions, and the complexity of care processes (28–35,84–86).   2.3. Quality Improvement and learning: a paradigm shift in Quality Improvement After the first two reports of IOM about the crisis in the quality of healthcare (26,27), a more recent seminal report entitled “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” (84), took a new direction. In their more recent report, the IOM relates quality improvement to learning, and more specifically to continuous learning.  In other words, learning is considered as a crucial aspect of delivering quality care. The IOM believes that healthcare systems should change their orientation to quality improvement from merely detecting errors and identifying variations from standards to develop continuous learning systems. Real quality improvement (and cost reduction), they contend, requires moving to systems in which  learning  emerges from every experience of care delivery (84,87).   This major paradigm shift in quality improvement recognizes that detecting errors and defects in conventional quality improvement strategies has not produced their expected outcomes 19  in healthcare (38,84,87). This focuses attention on quality improvement as a paradigm of ongoing learning (35,37,84,87). I will elaborate on the role of learning in quality care in Chapter 10 of my thesis. 2.4. Learning in medicine and nursing Ongoing changes in clinical science and the continuously evolving technology require ongoing learning and development in medicine (39) and nursing (39,40,88). These demands are addressed by formal Continuing Medical Education (CME) in medicine and variety of types of formal and informal in-service education in nursing (89,90).  Through ongoing learning in the trajectory of their professional careers, clinicians continuously move from novice to expert (43,44). In medicine this learning process is described by Dreyfus and Dreyfus as five steps: novice, advanced beginner, competent, proficient and expert (39,91–93). Learners develop into trainers and trainers go on to be learners in other stages of their professional life; in other words, throughout their professional development in medicine individuals are moving continuously between novice and expert roles. For example, medical students grow into residents who are teaching medical students and are learning from their senior residents and so forth (39). Benner’s studies in nursing have showed that Dreyfus and Dreyfus’s model of novice to expert is generalizable to nursing as well (88): “In my studies, I have found that the [Dreyfus and Dreyfus’s] model can be generalized to nursing. It takes into account increments in skilled performance based upon experience as well as education. It also provides a basis for clinical knowledge development and career progression in clinical nursing.” (88)  For example, the newly hired nurses joining the unit learn from experienced nurses. They are initially grounded, become experienced, and eventually become preceptors for nursing students 20  and other newly hired nurses. At the same time, they learn from more senior nurses, medical trainees and attending physicians and other staff; continuous evolution of medicine (39) and nursing (40,88) requires medical and nursing team to have a lifelong learning (39).  2.5. Learning in the Pediatric Intensive Care Units Pediatric Intensive Care Units (PICUs) have special features that make these units very special places for continuous learning (94). Patients in PICUs are extremely complex with sever illnesses and wide variation in their age (39,95,96). They mostly need complex and multiple treatments (39,97) and quick reaction to the deterioration of their conditions (97).  These features of PICUs create a situation in that any minor mistake in any of the procedures can lead to serious results such as severe morbidity or even mortality. In addition, PICUs are in the forefront of technological and pharmaceutical developments (45,97) and continuous development of medical technology and therapies used in PICUs (39,97).  All these features of PICUs demand clinical staff such as nurses (45) who are: (a) highly knowledgeable, professional, skilled and detail-oriented with strong interpersonal skills (39,45,94,98), (b) continuously learning, empowering themselves and keeping up with progressively evolving knowledge in order to be able to deliver quality care on an ongoing basis to the children cared in PICUs (45,94).  On the other hand, these features of PICUs create a heavy workload and stressful situation that, along with other contextual factors, lead to job turnover among nurses  and consequently a shortage of specialty nurses which may result in  lower quality care (99). In response to these issues, new nurses are continuously hired to work in PICUs. These newly hired nurses join the unit with various levels of competencies that can fit in various levels of the novice to expert model offered by Dreyfus (39,91,92,94) and Benner (88,94). Therefore, in order to deliver expert care, 21  like experienced nurses already working in PICUs, these newly hired nurses need continuous learning.  Ongoing learning among novice as well as experienced nurses working in PICUs has various positive impacts. First, it is widely accepted that high level of knowledge, skills and competence among nursing staff improves quality of care (45,98). Second, research has shown that ongoing learning can improve nursing staff retention in these units (98,100,101). Findings of a national large scale study of 2323 registered nurses among 110 ICUs in the USA showed that ongoing improvement of ICU nurses’ clinical competence and supporting their professional practice in the organization were two important contributing factors in improving retention of ICUs nurses (101). In this study, “perceptions of high nursing competence were associated with reduced likelihood of Intent To Leave (Odds Ratio: 0.61; 95% Confidence Interval: 0.44, 0.83)” (101) among nurses working in these units. Thirdly, findings of another study showed that nurses who are more empowered and highly competent were significantly less likely to leave their current position and their nursing job (100). Furthermore, research has shown that specialty critical care knowledge among critical care nurses has crucial contribution in quality of their interaction with other members of multidisciplinary teams during decision making for patient care in these units (98).   2.6. Various forms of knowledge in nursing Researchers have identified various forms of knowledge in nursing. Two types of knowledge are consistently recognized: knowledge produced by research (evidence based knowledge) and knowledge arising from the experience (experiential knowledge) (102–108). Knowledge based on research is identified  as “science” (102–106) , “knowing that” knowledge (102), “explicit knowledge” (102), “propositional knowledge” (107,108) and “content knowledge” 22  (103). On the other hand, the knowledge emanating from experience is described as intuition-based knowledge, “knowing how” knowledge, “tacit knowledge” (102), “non-propositional knowledge” (107,108),  and “practical knowledge” (103). Carper presented these as four fundamental types of knowledge in nursing that include empirical or scientific knowledge (science of nursing), aesthetic knowledge (art of nursing), personal knowledge (inner experience of nursing) and finally ethical knowledge (the moral component of nursing knowledge) (103–106). Later, this list was expanded by White (1995) by adding sociopolitical knowledge (the context of nursing) as the fifth way of knowing (106). Carper elaborates that none of these ways of knowing can be individually sufficient, rather, all of these types of knowledge are needed for mastery in nursing discipline (104). As another example, Rhyl (102) described two types of knowledge in nursing that includes “knowing how” knowledge and “knowing that” knowledge. Christensen elaborated on this and suggested another categorization of “knowing how, knowing that” knowledge by expanding that “knowing how” knowledge involves three types of knowing: “knowing how,” “knowing why”, “knowing what”. Christensen articulated that “knowing how” includes practical and experiential knowing. “Knowing why” includes empirical and theoretical knowing and “knowing what” encompasses pattern recognition. Then, she carried on that “knowing that” is the action that clinicians perform using their full understanding of the context (103). In other words, she described “knowing that” as the selection of action by the clinician based on clinician’s understanding of the situation. This is only possible via a culmination of “knowing how”, “knowing what” and “knowing why” (103).  These various typologies provide a picture of the range of sources and content that contributes to the areas of knowledge that an effective nurse must learn to develop expertise. They 23  are fundamentally based on two different learning processes - explicit knowledge based on evidence, and knowledge that is acquired through experience during situated practice.  2.7. Learning theories Learning theories in clinical education are categorized in various ways. One popular way is  to group them into two broad categories of individualistic and sociocultural learning theories (25,109). This categorization is helpful since it represents two learning metaphors that are used for describing the learning process, namely the "[knowledge] acquisition" and "participation" metaphors (18,25,110,111).  Acquisition focuses on learning as an individual process and implies that knowledge can be transferred across situations. In this metaphor, learning is considered an individual’s acquisition of knowledge, beliefs, skills, capabilities, competencies, and values. In other words, learning is described as seeking for knowledge by the individual learner, transfer of information to the learner, and reception, accumulation, and reproduction of knowledge by the learner.  In the participation metaphor, on the other hand, learning is not considered a kind of object or  "goods" that can be gained or transferred (18,25,110). "Participation describes collaborative knowledge production as an active process of legitimate engagement in a community of practice" (18). In this metaphor, learning is a process of internalization that transforms socially shared interpersonal experience and knowledge into intrapersonal cognitive understanding; a process that is transformative not transmissive (4,18,25,110,111). In the acquisition metaphor, learning occurs at micro level of the individual while in participation metaphor it happens at macro level (social level) in the interaction of an individual learner with others in their community (24). In the context of nurses learning in the PICU, learning is more than the transfer and acquisition of information; 24  it is also a practice that occurs within the unit as a member of a team, making the social learning model more relevant to explain learning in the PICU.  This distinction between the theoretical approaches is not always totally clear and some aspects of learning can be found in multiple theoretical Orientations. In this thesis I will use this approach and simply categorize learning theories into individualistic and sociocultural learning theories (25). This approach is selected since it will help me explain process of learning among the newly hired nurses considering them individually acquiring knowledge by themselves (individualistic learning theories in line with acquisition metaphor), as well as in the context of social interaction with other PICU staff and other contextual factors that may influence their learning (sociocultural learning theories in line with participation metaphor). 2.7.1. Individualistic learning theories According to individualistic theories of learning, learning happens at individual level even though individuals are interacting dynamically with the environment (18,24,25). Learning theories in clinical education must take into consideration that the learners are adults rather than children. Therefore, among theories belonging to individualistic perspective, first, I will examine different approaches that differentiate adult learning from the larger body of theory that has developed from studies of learning among children. I will then explore three theories that were more relevant to this study and helpful in understanding the process of learning among the newly hired nurses. These theories include self-directed learning, experiential learning and reflection and reflective practice theories.  25  2.7.1.1. Principles of adult learning The nurses involved in this study are also adult learners. Knowles, one of the pioneers in this field framed his approach as “andragogy” to highlight the distinction from pedagogy, which has historically focused on learning by children (112). Knowles focused attention on the adult learner’s self-concept, self-direction, and independence to differentiate adult learners from children (112,113).  Two specific theories of adult learning are relevant to this study of learning among nurses: Knox’s Proficiency Theory, which stresses the life situation of the adults, and Mezirow’s Perspective Transformation theory. There is no single theory that can explain learning among the adult learners.  2.7.1.1.1. Developing proficiency  Knox’s Proficiency theory concentrates on adult learning that develops proficiency and personal growth. This theory focuses on purposeful and systematic learning among adults and also on the process of facilitating learning among adult learners (114,115). In his theory, Knox defines proficiency as “the capability to perform satisfactorily if given the opportunity” (114). Elements of proficiency include knowledge, attitudes and skills (114–116), and most of the adult learning activities include some combination of improvement in these elements (114). Proficiency is the level of competence, adeptness and confidence based on expertise, skill and knowledge resulting from experience and training (114). Fundamental to developing proficiency is the recognition of the gap between current and desired level of proficiency (114,116–118). Regular assessment of this gap is essential in effective facilitation of adult learning. Results of this assessment can be useful in identifying learning needs, developing learning objectives, planning learning activities and developing evaluation plan (114,116,117).  26  Significantly, adult learning from Knox’s perspective is both developmental and transactional.  In other words, it is a dynamic phenomenon influenced by the interaction of various factors. Adult learning is developmental since it happens over time and as part of a change process that includes interrelated developmental changes in the individuals’ performance and personality (114,116). Learning is also transactional in two ways. First, motivation to learn and using learning activities are influenced by contextual factors (114), and  second, change results from purposeful and systematic learning through interaction with other people (116). We will see that this is also consistent with the sociocultural learning theories discussed later in this chapter.  Having a clear understanding of these two features of Knox’s theory is very important in effectively facilitating adult learning.  Furthermore, consideration of the developmental feature of adult learning will help the facilitators to consider adult people’s life cycle and various aspects of their personality (such as self-concept, need for achievement, willingness to risk, openness to new experience and self-directedness) in developing adult learning activities. This will be very helpful in developing learning activities compatible with the adults’ orientation towards change and stability, as well as tailored with their values and interests in various stages of life (114,116,118,119).  Another interesting feature of the theory of proficiency is the differentiation of change from ongoing progress. Knox believes that “merely changing (italic in the original work) the proficiency” is not enough; rather, adults generally try “to improve (italic in the original work)” their proficiencies on an ongoing basis. Therefore, he believes that adult learning is an ongoing process for purposefully improving proficiency (114).   27  2.7.1.1.2. Perspective transformation  Transformation of the learner’s perspectives is the focus of Mezirow’s theoretical approach (119). In this theory, “learning is understood as the process of using a prior interpretation to construe a new or revised interpretation of the meaning of one’s experience in order to guide future action” (Mezirow, 1996: 162 cited in Taylor, 2007; p: 173) (120). In fact, transformative learning involves elaborating, producing and transforming schemes (beliefs, feelings, interpretation and decision) (121) and perspectives (web of schemes that form a larger world view) (119) of the individuals through reflection (119,121–123). Schemes are specific manifestation of perspectives (122). Mezirow’s transformative learning is an individual learning even though transformation may originate from social changes or it may have social consequences (119). This theoretical approach is relevant to this study because we will see in the findings that Orientation and the Preceptorship taken together serve as a rite of passage in which the participants’ identities are changed as they become full members of the PICU.  Mezirow considers reflection as a very fundamental concept in transformative learning theory (120–124). In his theory, reflection includes criticizing schemes acquired during previous stages of life (childhood) and to understand if these schemes are still functional in other stages of life (adulthood) (122).  From Mezirow’s point of view, learning occurs through four venues: modifying or elaborating schemes, acquiring new schemes, transformation of schemes, and transformation of perspectives. Process and content reflection can lead to all four types of learning whereas reflection on the premises can lead to only perspective transformation (122). Mezirow believes that “The most significant behavior changes may be functions of perspective transformation, and such transformation is often an essential precondition for meaningful behavior changes.” (123). 28  Transformative learning is very complex and challenging. Leaving the old non-functional perspective is hard for the learner, and normally the learner has a resistance for letting the old perspective go and moving to the new perspective. Mezirow also believes that adult education should consider perspective transformation as the first priority and develop strategies for achieving this type of learning (123). One of the important strategical considerations for successful transformative learning is reconsideration of the role of educators. In transformative learning, educators take a reformist perspective, in which the educator is a co-learner. The educator should challenge, stimulate, and provoke reflection and critical thinking among the learners. The reformist role for the educator in transformative learning is different from subject-centered perspective in other forms of learning in which the educator has an expert role designing the learning event. It is also different from consumer-centered perspective in which educator is facilitating the learning and has a resource person role (121).  2.7.1.2. Self-directed learning The increasing role of Self-Directed Learning (SDL) in professional development and competence preservation has been acknowledged by various researchers (121,125) . In fact, self-directed learning is a fundamental concept in adult learning and education (126,127). Self-directed learning is even more important for healthcare professionals such as nurses to keep up their knowledge and competence using overwhelming new evidence and adopting updated policies, procedures and guidelines in order to deliver better care (128). For Knowles, self-directed learning is “a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material 29  resources for learning, choosing and implementing appropriate learning strategies and evaluating learning outcomes” (125,128).  As we understand from the definition, in self-directed learning, learners have the control of their learning (121,128). They identify their learning needs, learning objectives, and method of evaluating their learning outcomes.  In other words, learners plan, implement and evaluate their learning (128). Primarily, self-directed learning is considered more as a learner-focused model for achieving learning goals through various steps. Recently, it has been considered more as an interactive model of learning that considers various factors such as environmental learning opportunities, individual characteristics, cognitive processes, contextual factors, and opportunities for validating and confirming collaborative self-directed learning (121).  2.7.1.3. Experiential learning Adult learners experience a wide range of situations that provide learning opportunities. Experiential learning evolved based on the work done by various scientists specially that of Kolb (113,121,129). It was originally called action learning in which there is a great stress on the essential role of reflection in learning and the learner’s own inquisitiveness and action (113). In experiential learning theory, learning is defined as “the process whereby knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience.” (121,130).  According to Kolb’s experiential learning theory, experiential learning involves learning that occurs through concrete experience, reflective observation, abstract conceptualization, and active experimentation. These stages are represented in a cyclic model of learning. To have an effective learning, individuals should first do an activity and actively experience it (concrete 30  experience or do). Concrete experience is grasped through apprehension, through which the learner knows things “instantaneously without the need for rational enquiry or analytic confirmation (Kolb, 1984: 43).” (129). In the second stage (reflective observation or observe), they should consciously reflect on their experiences of the activity. In other words, in this stage, they reflect on what they observed.  In the third stage (abstract conceptualization or thinking), individuals produce new ideas (theories, models, frameworks, hypotheses, concepts or schema) based on their reflection on the previous stage. According to Kolb, individuals produce orders and ideas (theories, models, frameworks, hypotheses, concepts, or schema) through comprehension. In the fourth stage, active experimentation or planning, learners plan and test these ideas in practice in real world and gain more experiences. This leads to the next concrete experience and the cycle caries on. In order to have better learning, individuals need to go through all of these four stages of learning process (121,129,131). They can start from any stage; however, they need to follow each other sequentially as presented (121,129,131).   Kolb also identified four learning environments. These learning environments and their characteristics are as follows: First, affectively oriented environments, where learners respect feelings, believes, and values of the people in the team while they are working with people and actively engaging in a concrete experience in the team. Second, symbolically oriented environments (thinking) in which learners conceptualize their experiences, develop models, frameworks and hypotheses for solving problems or answering questions and use various quantitative [and qualitative] data to test their hypotheses. This phase is related to abstract conceptualization and primary source of information is conceptual. Third, the perceptually oriented environment inspires learners to analyze the data coming from various sources (observing, 31  thinking, and feeling), develop full action plans, make anticipations, and reflect on what has happened. Fourth, behaviorally oriented environments, where leaners select and focus on specific problems or activities and apply their competencies to meet pre-identified objectives. This is related to transforming experience into active experimentation (121). This theory has been used as a tool for effective learning and developing skills among adults in workplaces. 2.7.1.4. Reflection and reflective practice In general, the concept of reflective practice has been globally accepted as a valid and fundamental element of professional development (132). Reflective practice can be defined as “a learning and development process that includes the self-examination of one’s professional practice, including experiences, thoughts, emotions, actions and knowledge that enrich it.” (133).  Continuous learning from experience is a fundamental feature of reflective practice. The present and past experiences of the practitioners help them to interpret theory, which enlightens their actions and understanding. In this way, practitioners test and revise theories of themselves or others through practice and reflection. Through reflective practice, critical thinking and examination, they link theory to practice. Through this process, practitioners reformulate their envisioning of practice, problems, and problem solving. This re-envisioning is part of their learning and change. This is the way that practice helps to revise theory and reflective practice becomes a learning tool in clinical setting (121,133,134). Schön, who is largely responsible for the development of reflective practice model, identified two types of reflection: reflection-in-action and reflection-on-action (121,133–137). Reflection-in-action takes place when the practice is being performed. It includes three activities, namely (a) re-envisioning and reworking the problem using various standpoints, (b) 32  conceptualizing the problem in the already known framework and fitting it in previously learned schemas, and (c) discovering consequences, solutions and implications for future actions (121). Reflection-on-action, on the other hand, is a retrospective approach that is done following practice; it is the process of retrospectively thinking about an event and its contributing factors - what has been learned, and how this learning will be helpful in the person’s next activities. The reflective practice is a cyclic iterative processes (121).  Mezirow refines these distinctions and considers three types of reflection (121–123): (a) content reflection (reflecting on the content of the individuals’ schemes), (b) process reflection (reflecting on the processes through which the individuals have learned them), and (c) premise reflection (reflecting on social context, history and outcomes of the schemes) (121,122). Through reflecting on the content and process of their schemes, individuals change their minds and transform their schemes on a daily basis. On the other hand, reflection on the premises (principles) can lead to transformation in the individuals’ perspectives (122,123). Perspective transformation is very uncommon, but very fundamental and important learning experience. It may happen due to serious events in the individual’s life, or it may be resultant from accumulative changes in the schemes (121–123). Reflective practice has been employed in studies of professional development including teacher education and nursing. 2.7.2. Sociocultural learning theories Researchers in learning and practice change in clinical settings have focused primarily on the individualistic theories of learning (18,24,25,138). This bias towards individualistic theories of learning gives centrality to the isolated individual and limits our understanding of how learning occurs in a social environment such as a complex clinical setting like a multidisciplinary critical 33  care unit (18). Sociocultural theories consider learning a social and cultural phenomenon in which identity, knowledge and membership in the society require one another (138) and individuals are not isolated from a social context and divorced from supporting artifacts (9,138). Proponents of sociocultural learning theories consider the individual as subject to social and historical discourses (4,9,18,24,25,138).  Sociocultural learning theories stress the interdependence of social and individual processes (2,4,18,24,25,138). These theories assume that activities and practices occur in a cultural context, and are mediated by various artifacts. According to these theories, we can gain a clear understanding of human practices and activities if we study them in their sociocultural and historical development (2,4).  Contemporary sociocultural learning theories are largely derived from Vygotsky’s theory of learning and development (1,3,6,139). Though he originally published his research in Russian in the 1920s, his writing did not receive attention in the West until the 1960s when his work was published in English. This spurred the development for two related theoretical approaches, Situated Knowledge, better known as Communities of Practice (16–18,25,140–142),  and Activity Theory (2,6,8,10–13).  Within Activity Theory, Engeström has developed a particular approach, Cultural Historical Activity Theory (CHAT) that is also known as Expansive Learning (7,10,11,24,111,138,143). These social learning theories share a common inspiration—the assumption that learning is a social activity, which will help to explain the learning process among clinicians such as newly hired nurses in the PICU (121).  34  2.7.2.1. Vygotsky’s theory of learning and development Vygotsky and his colleagues Luria and Leontiev systematized sociocultural approaches to learning (2–4). They believed that human activities occur in the cultural contexts, are mediated by tools and signs, and can be best explained considering their historical development (1,3,5,6). The power of this theory lies in its explanation of dynamic interconnection of social and individual processes (3). Two of the most important assumptions of Vygotsky’s learning theory that are more relevant to this study are as follow: 2.7.2.1.1. Social origins of higher mental functions Vygotsky believed that higher mental functions (also called cultural mental functions), such as abstract reasoning, originate from the interaction of the humans in the society and emerge from gradual changes in and transformation of elementary mental processes (5). The key issue here is to clearly understand an individual’s functioning one must gain a clear understanding of the social relationships of an individual (6).  According to Vygotsky, mental functioning appears two times during the development of a person, first at the social, interpersonal  level between a novice and mentor, and later at individual, intrapersonal level (1).  The assumption of the social origin of higher mental processes (functions) is clearly presented in his concept, the  Zone of Proximal Development (ZPD) which he defined as the difference between the actual level of development of an individaul and the potential level of  development that can be determined through guided problem problem solving (1,6).  In other words, the ZPD is the gap between those tasks a person cannot perform independently but can be performed with the help of knowledgable others (peer, instructor, preceptor etc.) (1,3,5,6,139).  Thus,  Vygotsky considers two distinct levels of development, namely actual development and 35  potential develoment. Vygotsky believed that instruction by the mentor should be progressively devloped just beyond the actual level of development rather than at the potential level of development (6). 2.7.2.1.2. Mediation In addition to the relationship between the novice and mentor, Vygosky encorporated mediataion into his learning theory (1,3,6,139). This assumption contends that tools  (technical tools) and also signs such as langauge (psychological tools) mediate between the novice and mentor during the process of developing higher mental processes (1,3,5,6,139). According to John Vera, only by using psychological tools we can internalize knowledge (3). Werestch believes that the assumption of mediation is the only assumption that gives Vygotsky's theory a unique apsect. Mediation provides the link between the interpsychological and intrapsychological functions  (1,5,6). Thus, mentors and the mediating tools are used in an individual’s process of learning and cognition.  2.7.2.2. Communities of Practice (CoPs) Communities of Practice or Situated Learning is a sociocultural learning theory that takes its lead from Vygotsky’s notion that social interaction has an essential role in learning and cognitive development (144–146). The work of Lave, Wenger and others moves the focus from the dyad of the novice and mentor to relationships within a wider social network.  Communities of Practice are ad hoc groups of people who join together in various forms of practice to share their concerns, problems, knowledge, experience and passions which enables them to develop and deepen their knowledge through ongoing interactions to solve their problems (16,17). This theory helps us study progression and movement of individuals from novices who engage in legitimate 36  peripheral participation, into established veterans who are involved in full participation. During this process learning through engagement in these Communities of Practice transforms professional knowledge and identity (16,17,138). Lave and Wenger (18) have explored the process of acquiring legitimate entry to a community of practice and the development of expertise.   2.7.2.2.1. Communities of Practice (CoPs) in healthcare  Theory of Communities of Practice has been widely accepted in healthcare. Researchers believe that Communities of Practice can be ideal learning models for learning, professional development and improvement in healthcare system. Communities of Practice can help healthcare professionals to share their tacit knowledge and experiences, and also discuss best practice in order to avoid mistakes and deliver better care (16,20,22). In fact, some researchers define learning in Communities of Practice as “the ongoing refinement of practices and emerging knowledge, embodied in the specific action of a particular community” (23).  Although Communities of Practice can have a crucial role in the outcome of healthcare system (20), both individuals and organizations must be aware of barriers that can get into the way of learning and professional development in Communities of Practice such as lack of open communication between members (specially between novices and experts), resistance to the transfer of knowledge over the boundaries, lack of consistent membership, lack of trust, as well as lack of organizational supports (16,20).  2.7.2.2.2. Learning in Communities of Practice (CoPs) Learning in Communities of Practice is situated learning through problem solving in which individuals collectively explore situations and seek solutions to problems through interaction with others in social contexts. Learners gravitate to communities where they can benefit from 37  knowledgeable members (16,17,20,43,44,147).  According to Wenger the dominant learning method in workplaces is informal learning via socialization and participation in Communities of Practice (16,148,149). Knowledge produced in Communities of Practice is primarily shared orally through storytelling and narratives within and across disciplinary and geographical boundaries (150,151). 2.7.2.2.3. Legitimate peripheral participation The process of socialization into a Community of Practice and entry into the learning community is described as Legitimate Peripheral participation (LPP). Legitimate peripheral participation explains how a novice and newcomer enters, grows and advances to the center of community to become an expert (16,43,152–154). Studies have found that a good communication between newcomers and established members gives novices a sense of belonging and job satisfaction (155,156). Grealish and others have shown that access to the Communities of Practice has a crucial role in learning among nursing community and in the smooth centripetal transition of the novice and newcomer to an expert in clinical settings (151,155,157).  2.7.2.2.4. Factors affecting learning in Communities of Practice Various factors have been reported to affect learning in Communities of Practice in clinical settings. Most significant for this study is the acceptance by members of the Communities of Practice (151,157,158), assigning responsibilities to newcomers and trusting in their skills (158), high quality interaction and communication between members of the Communities of Practice, mutual relationship between members (155,157) and self-selection by newcomers for participation in the activities of the community all of which are essential in the successful learning in Communities of Practice. 38  2.7.2.3. Activity theory (AT) The most significant progress in extending learning from individual learning to learning in a more dynamic social context can be seen in Activity Theory (18). Vygotsky established foundations of the Activity Theory and most recently Engeström greatly elaborated and developed this theory over time (14,15). Activity Theory (2,6,8–15) is a theoretical framework for studying human practice as developmental processes (12).  In concert with Vygotsky, Activity Theory contends that the human mind comes to exist and develops in the "context of meaningful, goal-oriented, and socially determined interaction" between individuals and their social context (13). Activity Theory expands the social focus of Vygotsky’s learning theory, by moving beyond the dyad of the learner and mentor, to consider the role of the larger sociocultural context in which learning takes place (9,12,13).  2.7.2.4. Assumptions of Activity theory 2.7.2.4.1. Activity: mind in the context Unlike traditional theories of learning based on individuals’ cognitive activity and where learning precedes action, Activity Theory assumes that learning and cognition emerge and exist as a consequence of human interactions within a social milieu; therefore, activity precedes learning (12,13).     2.7.2.4.2. Consciousness in the world In Activity Theory, manifestations of consciousness can be observed in practice. According to this theory "you are what you do" (12). Human consciousness is embedded in a broad activity system surrounding the person so that the individual will internalize any kind of changes in any of 39  their physical, mental or social situations and environment, and will manifest them in their conscious activities (12,13). 2.7.2.4.3. Intentionality  The focus in Activity Theory is on intentional actions that individuals realize them via conscious intentions. Intentions arise from the contradictions between individuals and their sociocultural environment (12,143). After the emergence of the intentions and before their manifestations in the individuals' activities, individuals plan for these intentions even though sometimes these plans and related intentions are not firm and precise, and they are subject to modifications (12).  2.7.2.4.4. Object-orientedness According to the Activity Theory, individuals direct their emergent intentions at objects. “An object (in the sense of ‘objective’) is held by the subject [an individual or a group engaging in the activity] and motivates activity, giving it a specific direction” (9).  In other words, they use their emergent intentions to develop objects (or objectives) for themselves. Objects motivate the subjects and direct their activities to special directions (9). There is a dynamic relationship between object and activities so that any transformation in each of them affects the other one (7,12,143). For example, a nurse who intends to work in a new unit, develops object(ive)s for progress that will motivate his/ her activities and will give special directions to these activities. Any change in the nurse’s object(ives) will affect her activities and vice versa. 2.7.2.4.5. Community: a dialectic context  Activities are affected by their sociocultural context and we can explain an activity system only by addressing the sociocultural context in which this activity occurs (9,12,13). The 40  community affects the functions of the subjects through their formal rules and informal norms (7,12,143). In other words, the community mediates rules and norms that indicate how it functions, believes and supports various activities of the subjects (7,12,143). Various people in the community have various divisions of labor (roles in the community) that defines their tasks (12). Various work communities will have various rules and customs depending on their divisions of labor that mediate their activities (12). For example, activities of the newly hired nurse that we discussed above can be influenced by various sociocultural factors such as other nurses (nursing community), their departmental policies and procedures (formal rules), informal rules (norms of practice) among them and hierarchal system of the clinicians. 2.7.2.4.6. Historical-cultural dimension  Technically speaking, activities are historically evolved. In other words, activities undergo an evolution over the course of time in a culture. This is why Activity Theory believes that tracking and recording the transformation of any situation over the course of time is an essential step to acquire a clear understanding of dynamics of that situation (7,12,143). Practices of healthcare professionals like other higher mental functions are internalized forms of activities that are common in the community that they are working. To better understand these activities, we need to consider their related historical evolution (12). For example, consideration of cultural and historical factors in special unit such as the PICU would be very helpful in better understanding why newly hired nurses are instructed materials that they are and why they are instructed in a way that they be. Another example would be job leave among the newly hired nurses. We will need to consider various cultural and historical factors to understand why some newly hired nurses leave the PICU or why they even quit their job as a nurse.  41  2.7.2.4.7. Tool mediation  Tool mediation is one of the essential assumptions of the Activity Theory according to which artifact, technical tools such as various forms of media and equipment, and signs or psychological tools including language influence and change the nature and character of human activity and affect mental functions of the subjects after internalization (7,9,12,143). Tools and signs shape our experiences (12) and affect the ways that subjects interact with the real world (13). For example, various technical tools (such as various monitoring systems, complex medication administration machines and communication tools) and mental tools (decision making skills, problem solving technics and communication skills) can affect newly hired nurses’ practice. Furthermore, the newly hired nurses’ practices can influence the tools (both technical and mental) that are used in their clinical practice.  2.7.2.5. Activity system Unit of analysis in Activity Theory is the Activity System (9,12,13) which includes the subject or the main participant, object(ive) or goal, mediating tools, types of actions, and operations (9,12,13). A subject is defined as a person or group of people who are involved in the activity. The object of the activity is a physical or mental result that the subject is seeking for and reflects the intent and motivation of the activity (7,9,12,143). Anything that is used in the process of change and transformation are called tools (12,13) composed of physical tools and psychological tools that mediate higher mental functions and is part of activity system. Humans use the physical tools to manipulate the physical objects while they use psychological tools to affect other human beings or themselves (13). There are three generations of activity systems that represent three generations of Activity Theory (7,10–12,18,111,143,159). I will briefly describe 42  these three generations of Activity Theory, with a short focus on the first, which is the simplest to clarify the basic concepts and more on the third generation that is the most fully developed. 2.7.2.6. Three generations of Activity Theory 2.7.2.6.1. First generation of Activity Theory The first generation of the Activity Theory is based on Vygotsky's original concept of mediation and represents how cultural artifacts mediate human actions. This generation is usually depicted as a subject, object, and mediating artifact triad in a triangular diagram (7,10–12,18,111,143,159) (Figure 2.1). The limitation of this generation of Activity Theory is that the unit of analysis is restricted to the individual level (143).    Figure 2. 1: First generation Activity Theory model (Reproduced from Engeström Y., 2001) 2.7.2.6.2. Second generation of Activity Theory Engeström expanded Leontev’s first generation of activity system to represent the social elements of interaction in the activity system (Figure 2. 2). For this purpose, he included Communities of Practice, the division of labor and rules. In this way, the new generation of Activity Theory could help us study activity systems at a social or community level (7,10–Mediation Tool Subject (s) Object(ives) 43  12,18,24,111,143,160). This model made it possible to include the activities of a community of practice , its division of labor, power relations, the distribution of resources among the community members, and the social conventions and rules that govern these relationships (7,10–12,18,24,111,143,160). Limitation of this generation is that unit of analysis is only one activity system (143).  Figure 2. 2: Second generation of Activity Theory                                              (Source: Engeström Y., 2001)  2.7.2.6.3. Third generation of Activity Theory or Cultural Historical Activity Theory (CHAT)  The third-generation Activity Theory, also knowns as Cultural Historical Activity Theory (CHAT), recognizes a network of interacting activity systems. In this generation of Activity Theory, the unit of analysis moves from a single activity system to two or more interacting activity systems (Figure 2.3) (143). CHAT has five main principles that are, in fact, expansion of the assumptions of previous generations of Activity Theory. These assumptions are as follow:  44   Figure 2. 3: Third generation Activity Theory (Source: Engeström Y., 2001) 2.7.2.6.3.1. Mediated nature of activity  All activities are mediated by some cultural means called artifacts. These artifacts are not simply facilitators of mental processes, rather they are fundamentally shaping and changing mental processes. In other words, these artifacts are making and transforming humans (7,10–12,18,24,111,143).  2.7.2.6.3.2. Notion of activity system The idea of activity system as the basic unit of analysis is used by Engeström to stress mutual relationship and strongly interdependent nature of these basic elements (7,10–12,18,111,143). In the third generations of Activity Theory, unit of analysis is minimally composed of two activity systems, as can be seen in Figure 2.3.  45  2.7.2.6.3.3. Object-oriented nature of activity  Like previous generations of Activity Theory, in CHAT also, all practices are inherently object-oriented. In this version, the object creates energy and cohesion, recognizes the emergent, fragmented and evolving dynamics of the system (7,10–12,18,24,111,143).  2.7.2.6.3.4. Historical and contradictory nature of activity  The CHAT model also introduces contradictions (10,11,111,143) which  are sources of tensions and conflicts that produce energy for continuous changes and lead to the expansion of activity systems and their elements (7,10–12,18,111,143). Unlike other theories, CHAT does not look at these contradictions as mistakes or deviations from norm, rather it sees them as an integral part of the activity systems that lead to change and expansion of the activity system and its constituent elements. Contradictions are essential for self-movement and change. The metaphor of expansive learning is used by Engeström to express this process of change and transformation that leads to new patterns of cultural activity (7,11,111,143,159).  2.7.2.6.3.5. Interventionist and developmental nature of studying practice As the contradictions increase, activity systems qualitatively transform over the time because some already established norms and conventions of the community are not supported by those of some people in the community (143). Re-conceptualization of the object(ive) and motive so that it includes a fundamentally vaster horizon of possibilities leads to expansive learning (7,11,111,143,159). Expansive learning starts from small changes and developmentally progresses. In addition to expansive learning, Engestrom introduces the notion of expansive interventions and believes that expansive interventions should go through a series of steps, namely questioning contradictions, modeling new solutions, testing the new solutions, implementing new 46  models and solutions, reflecting on the process, strengthening the new practice and appreciating the effects of new contradictions resulted from new solutions in other parts of the system. Interventions in CHAT are essentially focused on expanding the activity system in hand. These interventions solve some of the problems and contradictions in the system and produce some new contradictions that become the object of new cycle of work (7,11,143,159). 2.8. The Theoretical Framework of the Thesis The Cultural Historical Activity Theory (CHAT) provides a comprehensive framework that can encompass individualistic and sociocultural learning theories.  I will use Engeström’s CHAT framework to describe the process of learning in the PICU. In so doing, the individualistic learning theories such as self-directed learning, experiential learning and reflection and reflective practice fall within the “subject” part of the CHAT. From this perspective, an individual’s (subject in CHAT) intrapersonal learning can be explained using the principles of adult learning theories at individual level as subsequent to the interpersonal interaction of CHAT. The individual subjects learn to improve their proficiency that includes combination of knowledge, attitudes and skills (proficiency theory) within the social process (CHAT). They can also learn through self-directed learning and take the lead of their own learning by taking notes about their needs and using different resources available to them such as internet, policies and procedures, and textbooks. Working in the PICU, the newly hired nurses need to acquire numerous skills and tasks, as well. They learn these skills in different ways; they can learn using textbooks and reading through steps of each skill or task as it happens in self-directed learning. The use of different tools and resources that mediate between the nurses and unseen authors, or between nurses on the unit when these tools are used by colleagues working together exemplify the mediating tools found in the CHAT.  47  Newly hired nurses also need to learn theses skills experientially with hands-on practice and demonstrations that are provided by other colleagues such as preceptors. This is also included in CHAT. In CHAT, individuals learn by participation in the real setting of the unit by accessing opportunities for hands-on practice while observing others while they work and provide demonstrations. By placing experiential learning in the “real setting” with access to “others” CHAT turns experiential learning into situated or “social experiential learning”. In this way, CHAT provides a supportive environment of other colleagues that facilitates the process of experiential learning and hands-on practice in the context of the community (unit).  Reflection and reflective practice can also be embedded in CHAT. At individual level, a person can reflect about his/ her own performance or about the situation and learn how to do the desired task differently. However, in CHAT, through sociocultural learning theories, the process of reflection and reflective process are upgraded and given extra features. In addition to individual reflection on the tasks, the individuals can be encouraged to be reflective by others who may also provide their own reflective comments. This social level of reflection is seen in the error detection systems that can be found in the hospitals (such as the Patient Safety and Learning System-PSLS).  As we can see, the CHAT framework helps us explaining the learners’ learning process at individual level, in the context of a sociocultural environment. In fact, the CHAT, as stated earlier, upgrades all the individualistic leaning theories described previously and adds extra dimensions that take them to a higher level.  Furthermore, CHAT looks at any activity as a goal oriented phenomenon mediated by variety of tools (physical and mental). Understanding learning in a setting like the PICU, with its varied technologies, cannot occur without taking into consideration the significance of mediating 48  tools. This feature hardly can be found in the individualistic learning theories. In fact, the mediating tools help the individuals to internalize what they are learning from the community as they transform interpersonal learning into intrapersonal learning. In any self-directed learning, experiential learning or reflection and reflective practice we can trace the role of mediating tools.  Additionally, the CHAT situates all the experiences in the real situation by adding the situatedness of Communities of Practice into the framework. The learner’s experiences cannot be divorced from the actual setting in which they are to employ their new knowledge. Although simulations are close to the real situation, they still lack the complexity and of the real-life situation especially in the context of the PICU. However, in the CHAT model, this issue is solved by placing the person in the real setting of the unit. Individuals are embedded in the real PICU Communities of Practice and acquire the experience in the context of real PICU.  The CHAT framework also considers the rules (formal and informal) that govern these experiences and practice, as well as division of labor within the community. As we will see, the hierarchical division of labor among disciplines within the PICU must be taken into consideration in explaining learning in the PICU whereas individualistic learning theories lack the ability to account these factors that affect learning.   Other important features that the CHAT adds to the individualistic learning theories include attention to the dynamic interactions among the subjects (learners), their objects, the expected outcomes of their learning, mediating tools, rules, Communities of Practice and division of labor in the teams that provide care for each individual patient. Moreover, individual learning theories fail to consider the interaction among activity systems that arise as staff work together on patient after patient, or when staff work together in groups defined by their discipline. These interactions 49  play important roles in individuals’ learning and practices, which are factors that we cannot find in the individualistic learning theories.  Also lacking in individual learning theories is attention to the contradictions and potential disagreements among participants. In CHAT, interactions can be the sources of contradictions, which can provide the motivation for learning and change. Additionally, the interaction between multiple activity systems facilitates access to the knowledge distributed among the staff belonging to different activity systems, working in different units and different shifts (distributed cognition) that is very important for continuity of care, a feature that can never be found in individualistic learning theories.  To summarize, the Cultural Historical Activity Theory (CHAT) embeds all the individualistic learning theories relevant to this study (such as self-directed learning, experiential learning, reflection and reflective practice), as well as sociocultural learning theories (such as Communities of Practice and distributed cognition) and provides a comprehensive framework that I will use for explaining the learning process in the PICU setting.          50  Chapter 3: Methodology My research was mainly informed by sociocultural learning theories with a special focus on theory of Communities of Practice (16–23) and Engeström’s Cultural Historical Activity Theory (CHAT) (7,10–12,18,143). My purpose was to understand what and how new nurses hired to the PICU learn to deliver care in the context of a complex dynamic unit such as PICU, who they learn from and who learns from them (if any), how they conceptualize learning and quality of care and how they relate learning and quality of care in the context of the PICU. In this chapter, I describe how I conducted my research. For this purpose, first, I elaborate on the conceptual Orientation of the research. Next, I describe study design. Then, I elaborate on the research setting. After that, I describe research participants, process of gaining access and timeline of the study. Then, I describe my stance and reflexivity, and recruitment process. This is followed by a description of data collection and data analysis. Finally, I elaborate on the methodological strengths and limitations of these methods. 3.1. Conceptual orientation As described in Chapter Two, this study was informed by sociocultural learning theories specifically theory of Communities of Practice (16–23) and Activity Theory (7,10–12,18,143) , more specifically Cultural Historical Activity Theory (CHAT). Sociocultural learning theories helped to interpret the beliefs and practices of the newly hired nurses and their learning process.  3.2. Study design This is a prospective study of three cohorts of newly hired nurses in the PICU over the period of 40 months. I used a mixed methods approach (161–163) in which ethnographic 51  observation, semi-structured interviews, and document analysis were supplemented by Social Network Analysis (SNA) (164–168)  which is used to describe the development of informal learning networks of these nurses in the PICU. Social Network Analysis (SNA) (164–168) provided more detailed description of patterns of social interaction and was coupled with descriptive and inferential statistical techniques to further investigate the social networks.  3.2.1. Mixed method Mixed method research enables using both qualitative and quantitative approaches for pragmatic and practical purposes (161–163,169). It enables me to understand the process of learning from different angles through different kinds of data (161,163). Mixed method research is especially helpful in those healthcare researches that focus on knowledge translation, quality improvement and policy changes in the clinical settings (161,169). 3.2.2. Ethnography Ethnography is the description of a specific culture, community, problem or phenomena in context (161,170–172). In other words, ethnographic research investigates the patterns of social interaction, values and assumptions of a group or a subgroup and the ways that the beliefs and practices are transferred to successive generations (161).  In this study, ethnography is concerned with examining the social interaction of the participants, the division of labor, the physical and psychological mediators they employ, and the community rules and norms that contribute to an understanding of the PICU as a Community of Practice and an Activity System  (161). An ethnographic approach may also identify various contradictions that result from two or more communities or cultures’ interaction (161,171,172). Thus, ethnography is the method of choice when designing a study based on sociocultural learning perspectives (4,9,18,24,25,138).  52  3.2.3. Social Network Analysis In addition to ethnographic descriptions of social relationship, patterns of interaction and  their impacts on perceptions and practices of the individuals can also be studied using Social Network Analysis (SNA) (164–168). Social Network Analysis is designed to examine individuals’ relationships and provides a basis for understanding how social connections to others and the division of labor may affect perceptions, behaviors and the way these perceptions and practices diffuse in their community of practice (164–168,173–175). Social network analysis helps my analysis move beyond the participants’ individual attributes to gain better understanding of who newly hired nurses interact with, who they learn from, and who may learn from them. In other words, it provides an analysis that helps to gain a better understanding of nurses’ social learning network within their PICU community. This method fits well with my sociocultural conceptual orientation in this study, as well as with the ethnographic methods I use, both of which try to contextualize individuals in their community of practice. 3.3. Setting This study was conducted in the Pediatric Intensive Care Unit (PICU) of a leading university affiliated Western Canada Hospital (we will call it WCH)1. WCH is the leading teaching and research healthcare facility for the child health (176).  The PICU is a 22-bed unit that provides critical care to children from across the province serving more than 1200 critical care patients on an annual basis. The unit accepts critical patients from variety of specialties including, but not limited to cardiology, surgery, neurology,                                                  1 WCH is a pseudonym to secure the confidentiality. 53  neurosurgery, infectious diseases, respiratory, metabolic, oncology, and home tracheostomy and/or ventilated patients.  About one third of the patients are admitted through the Emergency Department. Most of the critical care visits are related to seasonal injuries or disease processes; respiratory cases are more frequent in the winter or in the beginning of the spring and trauma patients are mostly related to summer. Around 40% of the patient population is related to the cases following cardiac surgery. The PICU admissions and discharges are done on a daily basis, and patient flow includes both planned and unplanned admissions. Furthermore, the PICU houses Transitional Care Unit (TCU) which is a specialized subunit that provides healthcare to chronic, technology dependent pediatric patients such as tracheostomy and Bilevel Positive Airway Pressure (BiPap). It also supports children receiving home care throughout province. Care in the PICU is provided using an interprofessional model. The PICU multidisciplinary care team encompasses various health professionals from variety of disciplines that include physicians, nurses, allied health, support team and other professional staff. Composition of the PICU interprofessional team has been shown in Table 3.1.   54  Table 3. 1: Composition of the PICU interprofessional team Discipline Number of staff subgroups Number of staff Medical group  15-17 Medical director 1 Critical care intensive care physician  6 Clinical assistant 1 Fellows 4 Residents 4-6 Nursing group 98 Program manager 1 Clinical nurse coordinators 4 Clinical nurse coordinator for outreach 1 Clinical nurse leaders (charge nurses) 5 Clinical nurse educators 1 Clinical nurse specialist 1 Clinical resource nurses 3 Quality and safety leader 1 Front line nursing staff 81 Allied health group 19 Respiratory therapists 14 Social worker 1 Physiotherapist 1 Occupational therapist 1 Dietician 1 Pharmacist 1 Other professional staff 4 Spiritual care 1 Ethicist 1 Child life support 1 Music therapist 1 55   3.4. Participants The main participants in this study were the registered nurses hired to work in the PICU. Hiring in the PICU and the WCH more generally occurs in January, May, and October. However, in 2013, instead of May, hospital had July intake. Therefore, for this study, I followed three consecutive cohorts of new nurses hired between July 2013 and October 2014.  I also studied people from whom new nurses learned, which included: instructors of the Orientation sessions, their individual preceptors, other experienced nurses (such as bedside nurses, clinical nurse coordinators, charge nurses, clinical nurse educators and clinical nurse specialists), allied health staff such as respiratory therapists, physiotherapists, perfusionists, pharmacists, attending physicians, as well as administrative staff of the PICU such as clerk. Trainees in many of these disciplines, as well as clinical staff from other services from elsewhere in the hospital were included in observations.  Table 3. 1 (Continued) Discipline Number of staff subgroups Number of staff Other professional staff (Continued) 7 Psychologist 1 Speech language therapist 1 Education- Onsite School 1 Informatics nurse 1 Research & quality coordinator 1 Equipment and supply 1 Infection Control 1 Support staff  12 Care aides, porter aides, unit clerks, housekeeping, receptionists/ assistants  1 Total   155-157 56  3.5. Gaining access In order to gain access to the unit, I obtained permission from stakeholders and gatekeepers (161,177) of the hospital and the PICU, including the  Vice President of Medical Affairs (VPMA) of the hospital, program manager of the PICU, medical director of the unit, as well as facilitators of the educational events in the unit – the Clinical Nurse Educators (CNEs).  Before starting this study, I had previously conducted research in the unit for about 2 years as part of a study of quality improvement Participatory Action Research (PICU PAR) that employed mixed method research (51,53,178). In the PICU PAR study, my co-supervisor and I did the data collection using interviews and naturalistic observations in the unit for about two years. This enabled me to gain access to conduct the present study.  My previous experience in the PICU helped me to establish a trusting relationship with newly hired nurses. The support that I received from the PICU CNEs was very helpful in streamlining the recruitment process. The CNEs included a short introductory session (15 minutes) in the agenda of the Orientation sessions of each cohort of newly hired nurses (in total three sessions for three cohorts). In these sessions, my co-supervisor and I described the scope and purpose of the study, the type of the information I am interested in, confidentiality of information and what was expected from potential participants. In addition, new nurses were given a hard copy of an information package that included information about both PICU PAR 1 and my research project in plain language (I will elaborate on this later). Together these helped me to gain their trust and obtain consent that provided access to them for observation in their Orientation sessions and during their Preceptorships in the unit.  57  3.6. Timeline This research was conducted between September, 2012 and September, 2017. Protocol and ethics approval was acquired from September, 2012 until July, 2013. Data collection (observations, interviews and document examinations) and data analysis, as well as write up was conducted from the end of July, 2013 until November, 2016 on a constant basis.  From November, 2016 until September, 2017, I organized formal thesis that was reviewed by the PhD committee. 3.7. My stance and reflexivity My research question and my perspective in this study was shaped by my background in anesthesia and nursing, which included approximately 10 years of experience of working as a registered nurse in numerous international hospitals’ departments including ICUs. While   clinical knowledge in medicine, nursing, allied health and other disciplines are similar and many skills and capabilities are transferable across clinical settings, there were many differences in technology and clinical policies. Before starting research in the PICU and also during the first phase of the PICU PAR study (Description phase), I had spent two years (May 2011- May 2013) for becoming grounded in the PICU and quality improvement and policy implementation (52,179). Additionally, I orientated myself to various policies and procedures of the PICU.   In this research, my role was as a well-informed outsider who provided the opportunity for the staff to become reflexive practitioners by co-constructing interpretations of their practices in the dynamic setting of the PICU.   3.8. Recruitment procedures I developed an information package that was distributed among new nurses of all three cohorts in their Orientation sessions. This package included one-page summary information about 58  the first phase of the PICU PAR study (“Description” phase) that my study was part of it, as well as the one-page summary of my thesis research. The information package included information about objectives and scope of both studies (the PICU PAR study and my thesis research), what was expected from participants and the fact that participation in the study was totally volunteer. This package was completed with a short oral presentation and question-answer event in which all their questions around the project were answered. Then, newly hired nurses were invited for participation in the study. I repeated the same process for the instructors of the Orientation sessions and invited them for participation before they start their teaching.  In order to recruit preceptors for observations, first, I acquired their names from the educational coordinators of the unit. Then, I approached them in person and used the same process that I had used for inviting the newly hired nurses and their instructors for participation in my research. In order to recruit other staff, patients and their families that were present in the learning-teaching opportunities that I observed during the Preceptorship, information package was also given to these more peripheral participants in this study.  In addition, the package was included in the Friday Practice Update which is the weekly electronic newsletter sent to all PICU staff.  This information package was also included in the charts of all patients admitted to the unit. Patient families were informed about the projects by unit clerks when they were admitted to the unit.  In addition, I approached to the people that I was going to observe (including patient families, patients and the staff) and described both studies and invited them for participation, in the first encounter.  All the invitees agreed to be observed except for one of the new nurses from cohort 1. This nurse agreed to be observed during her initial Orientation but not during her Preceptorship. However, after starting to observe second cohort, she had learned more about the scope of the project and she felt comfortable for observation. All families agreed to be observed.  59  During recruitment for interviews, which the newly hired nurses had been informed about, I provided each person additional information about the nature of the interview questions.  To recruit preceptors and other staff involved in learning-teaching activities of the new nurses to the interviews, I approached them during the observations and gave them additional information about the project.  In total, 54 people participated in one or more of data collection steps (interviews) that was enough to achieve saturation (161,180–183). I studied all people in three consecutive cohorts of new nurses that totally included 13 newly hired nurses. These new nurses were: Cohort 1: 3 newly hired nurses; Cohort 2: 5 newly hired nurses, and Cohort 3: 5 newly hired nurses. I also studied their instructors including preceptors (16 nurses) and other staff from whom new nurses learned during their Orientation sessions or during their Preceptorship in the PICU (25 people). Among the instructors, the preceptors were my main focus, however, I did study other staff as well in order to gain clear understanding of the process of learning among newly hired nurses.  3.9. Data collection As Spradley notes, in doing any ethnographic study (independently or as part of any other design) we can “make cultural inferences from three sources: (1) from what people say; (2) from the way people act; and (3) from the artifacts people use” (184). Therefore, I employed multiple approaches for collecting data to understand perceptions, behaviors and interaction of participants of my study. Therefore, I used both qualitative and quantitative methods for collecting data. I used document examinations, naturalistic observation, semi-structured interviews, informal interviews during observations and network diagrams of the participants for data collection. The documents I examined included the policies and protocols that applied to the PICU, 60  particularly those provided to the newly hired nurses during their Orientation and Preceptorships. Document examination was used to help me learn about learning and teaching activities conducted in the unit for new nurses. Naturalistic observations were conducted during the new nurse’s Orientations, PICU rounds, handovers and the consultations that newly hired nurses held with their preceptors, to learn about participants’ behaviors in the context. Semi-structured interviews were conducted during the newly hired nurse’s work shifts during breaks, or periods in which the Charge nurse was able to arrange for another nurse to cover for them. During the interviews, participants were asked to draw their network diagrams, and this helped me in understanding their learning networks and role of these networks in participants’ learning. During informal interviews during observations, the newly hired nurses provided comments on their understanding of the care activities and their role in them. Moreover, in the informal interviews during observations, the newly hired nurses were asked to assign a score between 1-10 to the patients they looked after in the PICU and their previous workplace. This with the network diagrams formed my quantitative data source.   Application of multiple methods for data collection followed multiple purposes. First, using these methods complemented each other and gave me a better understanding of process of learning among the newly hired nurses joining to the PICU. Observations helped me to watch participants’ behaviors and their interactions in the context of the clinical setting; in other words, it helped me to contextualize their behavior and understand how participants learn in the real situations of the PICU. Interviews helped me to understand their perceptions and beliefs using their own words. Interviews and observations together helped me to compare and contrast the participants’ words and deeds (161). Second, my multi-method data collection helped me establish a partnership with my participants and construct the meaning and interpretation of reality in a 61  cooperative way (co-constructing the meaning) (161,184). It helped me move between participants’ perspectives and my own perspectives (emic and etic perspectives, respectively) (161). Third, this multi-method data collection helped me triangulate the data and improve soundness of my findings (161,169,171,172,184,185).  3.9.1. Naturalistic observation Observations of the Orientation sessions included a total of 60 hours and observation of the Preceptorship period in total encompassed 1980 hours of observations. Orientation sessions for each cohort of newly hired nurses included five days of 8-hour classroom education starting from 8 am until 4pm (5× 8= 40 hours in total). For the first cohort, I observed entire Orientation sessions of all five days of 8-hour education (40 hours). The analysis of the data collected from observation of the first cohort and themes emerging from this analysis were the basis for the observation of the next cohorts. Learning from my observations of the first cohort, therefore, in the second and third cohort, I purposefully (161,183,186) observed those sessions of Orientation classes that (a) would give me more in depth information around things I discovered in the first cohort or (b) would help me discover new dimensions of learning among newly hired nurses during the Orientation sessions. These observations included a total of 20 hours for the second and third cohorts, and were identified in negotiation with unit CNEs.  Observational data during the Preceptorship was collected during an observation for a total of 30 months, which included 3 hours of observation for each day for the first 12 months (1080 hours), 2 hours for each day in the second 12 months (720 hours) and one hour for each day in the last 6 months (180 hours). Observation in the Preceptorship was conducted during various shift times from 0630 until 2100. I observed a few shifts at 2200-2300 with the presence of my co-62  supervisor WM. This distribution of observation helped me include day shifts, evening and night shifts in my observations. Observations in the Preceptorship period were done during week including statutory holidays with a few observations during the weekends.  3.9.1.1. Data collection process for observation I observed new nurses, people whom they interacted with, people whom they learned from or they taught. In the Orientation sessions, I observed interactions between the newly hired nurses and their instructors. In the Preceptorship, I observed their interactions with their preceptors or any other staff or families who they were interacting with for learning or teaching purposes. I shadowed them and observed various events in which the newly hired nurses were present. These events included events such as rounds including morning and evening rounds (cardiac rounds, PICU normal rounds and radiology rounds), various morning and evening handovers such as morning and evening nursing handovers (including central nursing handover and nurse to nurse bedside handover) and patient handovers from operation room (OR). In addition, I observed patient transfers from other units or from outside of the hospital and any other interaction that happened between new nurses and other staff including medical staff (attending physician, fellows, residents and medical students if any), nursing staff (clinical nurse coordinators, charge nurses and other nursing staff), allied health staff (such as physiotherapists and occupational therapists), pharmacists (including pharmacy doctor and their residents or students), clerks and all other staff from the PICU or outside of the PICU who came to the unit for giving care to the patients.  I also observed the setting, patterns of behavior, interaction and communication (161,170,177,184,187–189) in both Orientation sessions and Preceptorship in the PICU. During the observations, I collected data regarding the spatial layout of the place, time, instructors, 63  instructional and learning events, practices, methods, processes, as well as contents of teaching and learning during both Orientation sessions and Preceptorship. In addition, I collected data about engagement level of the staff in learning and teaching events and also various kinds of artifacts (any kind of tool) used in mediating any learning and teaching event. Any time that nature of an interaction was not clear (whether it was a learning-teaching activity or not), I approached to the partners of the interaction and verified and asked them to articulate about the nature of the interaction if it was about learning.  3.9.1.2. Field notes and memo writing For collecting data during the observations, I first took brief and condensed notes in order to be able to follow the pace of the interactions. In the soonest available time (no more than 4 hours), I expanded my field notes. I did not use any special template for taking my notes, rather I tried to collect as rich data as possible.  3.9.2. Interviews  Interviews provided the major source of information for this study. Ethnographic interviews can help us acquire rich sources of deep data that can help us explore participants’ critical insights and understanding, and discover how they construct reality (161,169,172,184,190).  I used semi-structured interviews based on the approach suggested by Spradley (184) and informal short interviews in the form of short conversations during my observations for verification, and elaboration purposes (161,177). All interviews for this research were done by myself.   64  3.9.2.1. Sampling for interviews I used purposeful sampling for the interviews (161,183,186) in order to identify and choose people  who were (a) most knowledgeable or experienced about the process of learning among newly hired nurses, and  (b) available and willing for sharing their knowledge and experiences in this regard (161,183).  I selected all three consecutive cohorts of newly hired nurses. To select people from whom new nurses learned for the interviews, I used purposeful strata specific subgroup sampling method (161,183,186)  because people from whom new nurses learned were heterogeneous, as indicated earlier in the Participants section.  In combination with my field notes, this sampling method helped me maximize diversity of care providers participating in my study and consider their heterogeneity and maximum variation (191). Data and conceptual saturation (defined as no new information or themes or new dimension about a specific topic in three consecutive interviews) (161,180–183) over constant comparison analysis (161,183) was the basis of sample size. Purposeful sampling of the individuals and lengthy observations helped me to achieve saturation in the context of my diverse participants. 3.9.2.2. Data collection process for interviews All the interviews were conducted face to face and by myself and mostly in in two rooms within the PICU. A few interviews were done in the clinical nurse coordinators or the clinical nurse educators’ offices in the unit. These settings provided confidentiality and privacy.  After conducting my initial scheduled interviews with bedside nurses, I realized that it was hard to formally schedule interviews because nurses needed to respond to the changing demands of their patients. There were frequent situations in which patients deteriorated making pre-65  scheduled interviews impractical. Consequently, I decided to spend more time in the PICU to be available to do interviews anytime that the newly hired nurses, preceptors or other interviewees were free and available in the unit. All interviews were guided by the interview questions and prompts that were developed based on the research objectives (Appendix B). The interview questions had three sets of questions: one set for new nurses, one set for preceptors and another set for other staff (161,177). These sets of questions were used as guides for conducting semi-structured interviews and eliciting information from the participants.  Interviews were audio-recorded using a digital voice recorder. Each interview was 45-90 minutes long. Field notes were taken during the interviews in order to record emotions and reactions of the participants to assure completeness of the data regarding context of the interview and for the purpose of appropriate interpretation of the findings. During the interviews, I gave enough time to the participants to describe their perceptions, behaviors, experiences and how they make sense of things. Any ambiguity was clarified by asking for elaboration on their descriptions. At the end of each interview, I asked interviewees if there was anything important that would help me to better understand process of learning among new nurses that I might have not included in my questions. In answering to this question, some interviewees brought up interesting topics such as the conflictual feelings that they had in the beginning of their job in the PICU. I will elaborate on this issue in the findings. 3.9.3. Social Network Analysis Social network analysis (SNA) is a specific approach that provides insights based on  sociometric characteristics of learning networks and Communities of Practice among care 66  providers (16,17,164–168,192). Twelve out of 13 of newly hired nurses provided data for network analysis.  During the interviews, they were asked to draw their own network of social relationships including the people whom they went to when they needed information, consultation, advice or any kind of support for learning and performing any kind of task related to their job in the PICU.  New nurses were asked to include names and positions (roles) of the people within their networks. However, being new in the unit, they often referred to people by their positions rather than by name.   3.10. Data analysis For the analysis of interview recordings and transcripts and other qualitative data I employed techniques from cognitive linguistic discourse analysis (193) to describe the themes and identify information schemas (194). The data was entered into Atlas ti (195) and coded for analysis. Quantitative data analysis in the form of social network data was analyzed using descriptive Social Network Analysis techniques (164–168) and UCINET (196). Patient acuity scores collected during observations was analyzed using simple descriptive and inferential statistical technics.  3.10.1. Qualitative data analysis (analyzing interview data, field notes and documents) 3.10.1.1. Transcribing the interviews, expanding field notes and managing document text Each interview was fully transcribed verbatim (161,169,184) that were edited to remove all the identifiable information. During this process, pseudonyms were assigned for identifiable names in the transcripts. Field notes were expanded from brief field notes the day of each observation in maximum four hours. Furthermore, documents were treated as text, and along with 67  expanded field notes and transcripts were entered into ATLAS ti (195) qualitative data analysis software for analysis.  3.10.1.2. Coding While immersing myself in the data, I identified the portions of discourse that were thematic based on their syntactic structure and the use of information units (194,197,198)  using techniques from cognitive linguistic discourse analysis (193,197,198) to describe the themes and identify information schemas in the interview data (194). I used line by line, stanza by stanza, block by block coding moving between micro and macro parts of speech as recommended in cognitive linguistic discourse analysis literature (193,194,197,198). Normally each small spurt out of which speech is made, is defined by a phonological intonation pattern and carries one salient piece of new information that is focus of attention. Sometimes this is called idea unit, intonation unit or line. Each stanza includes a group of lines about one important event, happening, or state of affairs at one time and place, or it focuses on a specific character. I used the same process for coding the field notes and document texts that I did for the interview transcripts (197,198). I analyzed interview data using constant comparison analysis moving from text to codes and back. Coding was done inductively to give primacy to the data (161,169,184,185,199,200).  After coding, I read and reread codes and compared and contrasted similar codes. Through this process, I iteratively recoded, merged or removed some of the codes. Sometimes, new codes emerged from the data indicating new aspects in the data. This entire process helped me to move to higher level of abstraction and conceptualization and identify categories and sub-categories, themes and schema. This iterative process continued until I was able to make assertions that describe the participants’ reality and perspectives. 68  3.10.1.3. Saturation Data collection and analysis was carried on until the point of data and theoretical saturation. For this purpose, data were collected and analyzed until no new information or themes or new dimension about a specific topic appeared (161,180–183). In other words, I continued data collection, coding, categorization, sorting the codes and categories, as well as comparing and contrasting the codes, categories and sub-categories until no new dimension was discoverable (161,180–183,201).   3.10.2. Quantitative approach 3.10.2.1. Social Network Analysis Social Network Analysis (SNA) was used for identifying informal learning networks within the newly hired nurses and the role of these networks in new nurses’ leaning in the PICU. Network data collected during the interviews were analyzed employing social network analysis techniques (164–168,174,202–206). Network diagrams drawn by new nurses included a mixture of positions/ roles and names. In order to make the data analyzable, I transformed names appearing in the network data into roles, because the majority of nurses used position or role in their diagrams.  This network data was used as the basis for quantitative analysis using social network analysis (SNA) techniques (164–168), using UCINET 6.504 network analysis software (196). Using this software, I calculated measures of centrality including Degree Centrality (the number of links to and from a person or a group of people) and Closeness Centrality (the average distance of a person or a group from all other people in the network) within a network (192,204).  69  Sociograms were generated to depict learning relationships among the participants and organization of these learning networks.  3.10.2.2. Patient acuity scores Other quantitative data included scores that the newly hired nurses gave to the acuity of the patients they looked after in their previous workplaces and in the PICU. This data was collected during the observations and by asking the newly hired nurses what scores they would give to the acuity of the patient they looked after in the PICU and in their previous workplace. They were asked to give a score of 1-10, (10 to be the highest acuity) to the patients they looked after. This non-standardized data was entered into SPSS (207) and analyzed using non-parametric statistical tests to see if the acuity scores of the patients that newly hired nurses cared before and after coming to the PICU had significant difference. Due to small sample size (only 8 out of 13 people), Wilcoxon Signed Rank Test was used.  3.11. Methodological soundness I used various methods in order to establish the trustworthiness or methodological soundness in my research. For this purpose, I used time (lengthy observations), triangulation and thick description (161,162,169,171,172,177,184,185,208,209). I spent a considerable amount of time in the unit before I started data collection for my own research and continued to conduct lengthy observations to provide long term continuity. My lengthy presence in the setting helped in establishing sense of trust resulting in rapport which is a harmonious relationship between researcher and participant with positive feeling in both sides that leads into smooth flow of information and data collection (161,184). Long term observations eliminate oversensitivity and reactivity to isolated incidents.   70  I used triangulation to check my findings of one type of data and methods by reference to another (161,162,169,208,209). Data from observations of Orientation and Preceptorship periods made at a variety of times, coupled with interview data from various groups of the staff, including new nurses, experienced nurses, allied health staff and physicians helped to provide multiple perspectives to confirm my data and interpretations. This qualitative data was also augmented with the analysis of nurses’ social networks.  For researcher triangulation, I involved three other researchers in the process of my research, namely JPC, WM, and NK as my co-supervisor, supervisor and thesis committee member, respectively. For theoretical triangulation, I used both individualistic and sociocultural learning theories as my conceptual Orientations and in each of them, I considered multiple learning theories for explaining findings of my research (161,162,169).  The multiple forms of data employed in this thesis and the methods of analysis have provided a unique perspective on the learning activities of newly hired nurses and the contribution of learning to their ability to provide quality care for their patients.     71  Ethnographic Findings: Chapter 4 through Chapter 11 Overview: Chapters 4 through Chapter 11 In the previous three chapters, I introduced my research topic (Chapter 1), presented literature review and my theoretical framework (Chapter 2), and described my methodology (Chapter 3). The following 8 chapters include an ethnographic description of the PICU based on my research. Chapter 4 describes characteristics of the newly hired nurses participating in this research. Chapters 5 through 11 describe two teaching and learning opportunities that the PICU organized to help the newly hired nurses become grounded and learn how to deliver care in the PICU.  Chapter 4, analyzes and describes characteristics of the participants by focusing on their educational background, work experience, why they liked to work for children needing critical care.  The Orientation sessions which introduce the newly hired nurses to the PICU are described in Chapter 5.  These Orientation sessions are the first teaching and learning opportunities organized for the newly hired nurses.  The first section of this chapter describes prototypical format of Orientation sessions, followed by an elaboration on the teaching activities and tools used for mediating these teaching activities. I end this chapter by exploring the contents of instruction during the Orientation sessions.  Chapters 6 through 11 describe and analyze the Preceptorship which is the second opportunity organized to help the newly hired nurses. Each of these six chapters focuses on a 72  different aspect of the Preceptorship. Chapter 6 provides a brief description of the Preceptorship that includes a definition of Preceptorship and a prototypical 24-hour day of the Preceptorship with particular attention to the activities that were identified by the Clinical Nurse Educators (CNEs) as teaching and learning activities. Chapter 7 describes and analyzes the more structured and directive teaching aspects of the Preceptorship and the particular activities used for teaching the newly hired nurses. This includes events such as rounds, simulations, and short instructional sessions called EduQuicks. Additionally, this chapter examines the instructional equipment used as mediating tools for teaching, including computers, mannequins, and educational videos. In Chapter 7, I also identify analytical concepts derived from teaching and learning theories that helps to explain the teaching activities in the Preceptorship.  Chapters 8-11 examine the less directive learning aspects of the Preceptorship, making use of concepts from Activity Theory and Communities of Practice Theory to structure the presentation. Chapter 8 gives particular attention to the activities identified as learning opportunities such as handovers, rounds and simulations. It will also examine mediating tools that are regularly used as mediating tools in care and learning such as computers, iPads, smart phones, policies and procedures. In addition, in this chapter, I identify analytical concepts derived from learning theories that helps us explain the learning processes occurring during the Preceptorship. The last section of Chapter 8 focuses on learning outcomes of the Preceptorship.  Chapter 9 explores the relationship between social interaction and learning in the Preceptorship by examining the newly hired nurses’ informal learning networks. Chapter 10 describes and analyzes the newly hired nurses’ perceptions of learning, quality of care and the relationship between learning and quality of care. Chapter 11 describes and analyzes learning goals of the newly hired nurses in the Preceptorship. This chapter starts with the participants’ individual 73  learning goals, then focuses on their professional identity, as an important factor in understanding shared learning goals within the PICU, and it ends with an exploration of shared learning goals. 74  Chapter 4: Characteristics of the newly hired nurses Overview The newly hired nurses who are the focus of this study are nurses who were recently employed to work in the PICU. This does not mean nurses that have just graduated from college or university, but that were recently employed by the PICU. This chapter describes the newly hired nurses’ educational background, work experience, and information on why they decided to work in pediatric critical care.  4.1. Educational background of the newly hired nurses This research focuses on the experiences of 13 newly hired nurses who were hired to work in the PICU. It traces their Orientation to the PICU, their Preceptorship in the unit, and their continued learning while at the bedside. Each group of the newly hired nurses in the PICU was considered one cohort. In total, I studied 3 cohorts of newly hired nurses. Cohort 1 included three nurses, cohort 2 included five nurses, and cohort 3 included five nurses. All the newly hired nurses were female.  Educational background of the newly hired nurses has been summarized in Table 4.1. Table 4. 1: Distribution of the newly hired nurses by their cohort and educational level  Diploma in Nursing Bachelor of Science in Nursing Master of Science in Nursing Total  Frequency Percentage Frequency Percentage Frequency Percentage Frequency Percentage Total 1 7.7 11 84.6 1 7.7 13 100  75  4.2. Work experience of the newly hired nurses Majority of the newly hired nurses (12/13) had experience of working in pediatric units and/or pediatric intensive care units. Only one new nurse did not have experience of working in pediatric unit or pediatric intensive care unit. This new nurse, however, had experience working for high acuity patients in adult ICUs.  4.3. Reasons for working for children The newly hired nurses mentioned various reasons for working for children. These reasons fell under three factors: (a) characteristics of the patients (children), (b) characteristics of the work, and (c) characteristics of the staff working for children. The newly hired nurses preferred working with children over adults because they believed that children were resilient and would rebound faster if they got sick. These patients were considered to be innocent and honest and to have different interpretation of pain. They considered children cute, lovely, always happy and people who did not feel bad about themselves.   They also believed that working and caring for children offered a holistic approach that needed considering patients, care providers, as well as families, additional to other aspects of care (such as patient safety). These nurses desired to be supportive and advocate for children, parents and family members, as well as for themselves. They believed that it was easier to be compassionate when working for children, while they felt this was more difficult in adult care. In general, they liked these features of working for children, and they believed that they could find more satisfaction working and caring for children. The newly hired nurses also believed that staff working for children were more friendly.  76  4.4. Reasons for working for the PICU The newly hired nurses liked working in the pediatric intensive care unit (PICU) because of: (a) the characteristics of work in the PICU, and (b) lots of learning opportunities (Table 4.2). Work in this unit was considered challenging by the nurses. The acuity of the patients, complexity of their multi-system failures, their variety, and the fast pace and multidisciplinary, multi-tasking staff were some of the challenges that attracted these nurses with considerable qualifications to the PICU. In addition, the newly hired nurses liked the one-on-one nurse-patient staffing in the PICU. Another feature of work that attracted the newly hired nurses for work in the PICU was the resourcefulness of this unit. They believed that resources and physicians in the PICU were faced with challenges that they met with more resourcefulness compared to other units. In general, they found working in PICU more enjoyable and stimulating. Furthermore, the newly hired nurses believed that the PICU has great amount of learning opportunities for them. P61: Cohort 1_ NN11_ LACC_ RTF.rtf - 61:7 (55:57): I: What do you like most about critical care? P: Um, the acuity, the learning. Uh the fast-paced environment. Um, I really enjoy that about both ICU and emerg[ency department]. Um, I like that kind of challenge. And um, from the learning perspective you get to see tons and tons of things. Um, you're able to have your resources really accessible to you.    77   Table 4. 2: Reasons for working for children and pediatric intensive care  Why working for children Why working in the PICU • Characteristics of the children: Resilient, honest, innocent, have different interpretation of the pain, positive, little, cute, happy, more playful, excited and they do not feel bad for themselves, they are lovely. • Characteristics of work for children: Caring children is a holistic care, it engages families and considers all aspects of care, supportive of parents, family members and children. It is easier to be compassionate with children, it is dynamic, one finds more fun in it.  • Characteristics of the staff working for children: staff are more friendly  • Characteristics of work for PICU: Challenging (acuity of patients, complexity, multi system sickness, more details than other areas, multi-task, variety of patients and fast pace), one-on-one care, available resources, enjoyable and stimulating • Lots of learning opportunities  Summary and interpretation In this study, 3 cohorts including 13 newly hired nurses participated. Almost all of them started their work by nursing for adults before shifting their interest to pediatric patients and then to work in pediatric intensive care unit. Some were interested in working in the PICU due to the challenges and opportunities to learn that characterized work in the PICU. Others liked working in pediatric critical care because they preferred to care for patients whom they characterized as diverse with high levels of acuity.  The nurses in the study gained considerable experience and tacit knowledge from their extensive work in different departments of numerous hospitals ranging from adult care to 78  pediatrics and finally pediatric critical care. This experience enabled them to feel capable of providing care to the most complex patients. Their backgrounds justified their claim to their professional identity as expert nurses. However, this expertise was challenged during their Orientation and Preceptorships as they entered the PICU. The Orientation reviewed basic nursing competencies.  During their Preceptorship, they were assigned patients with simple conditions (I will elaborate on this in Chapter 10) and cared for patients in the TCU, the portion of the unit with more stable with less acute patients. They were also told that they might be re-assigned to general units in the hospital when there were few patients in the PICU.  This would revoke their identity as PICU nurses as they would revert to novice status on units in which the personnel, procedures, and physical organization were unfamiliar. This placement situation is denying the newly hired PICU nurses’ professional identities, and was a source of frustration, that created contradictions and undermined their place in the PICU Community of Practice, and reduced the unit’s coherence as an activity system.    79  Chapter 5:  Orientation sessions Overview In Chapter 4, I described the characteristics of the newly hired nurses participating in this research.  In this chapter, I will describe the Orientation sessions as the first teaching and learning opportunity organized by the PICU to help the newly hired nurses learn how to work in the unit. The first portion of this chapter presents a brief description of the Orientation sessions, the role it plays in introducing the newly hired nurses to the PICU, as well as the prototypical format of the Orientation sessions. The second portion of this chapter explores the contents of instruction in the Orientation sessions. The third section focuses on specific aspects of teaching in the Orientation sessions. This portion of the chapter elaborates on teaching activities in the Orientation sessions. It also employs the analytical concepts derived from teaching and learning theories (Chapter 3) that help me explain teaching activities in the Orientation sessions.  5.1. Description of the Orientation sessions 5.1.1. Orientation sessions Orientation sessions begin on the new nurses’ first day of employment in the PICU. They generally take place outside of the PICU setting in a classroom setting within the hospital.  The purpose of the Orientation sessions is to provide a shared baseline of understandings about technical aspects of nursing practices, learning and development in the PICU, research activities in the unit, work routines and information management in the PICU, quality improvement (QI) within the unit, cultural issues in the PICU, information management, as well as information about support that is available in the PICU. The instruction, which is largely didactic with some 80  discussion, was done by the Clinical Nurse Educators (CNEs) and the leads and staff from allied health professionals in the PICU. There was also additional instruction by staff from other clinical and administrative units of the hospital and the Provincial Health Service Authority (PHSA) concerning hospital and health authority policies and procedures. The content during these sessions varied from more policy and procedural information about the PICU and the hospital, to instruction and discussions about specific nursing activities, such as appropriate responses to codes (such as Code Blue and Code Red) and the use of specialized equipment and the interpretation of their results. Occasionally the newly hired nurses, who had experience in other hospitals introduced information that was new to the CNEs. These sessions also provided the newly hired nurses opportunities to socialize among themselves.  5.1.2. Prototypical format of the Orientation sessions  The prototypical Orientation sessions for each cohort of nurses included five consecutive day-long sessions of classroom teaching, that was distributed over one month. This distribution of Orientation sessions overlapped with the beginning of their Preceptorships. Classes started at 0800 and ended at 1600.  Each class normally included 3-5 newly hired nurses.   5.1.2.1. Session 1 CNEs were responsible for all of the teaching activities during the Orientation. On day 1 of the Orientation sessions, the CNEs welcomed the new nurses, introduced themselves, and went over the entire agenda of five days of Orientation sessions (main topics covered in the agenda can be found in Table 5.1 and full agenda is available in Appendix C). After the newly hired nurses introduced themselves the CNEs delivered some printed educational packages that they had produced. Then, contents of Orientation package were described to the newly hired nurses and the 81  newly hired nurses’ questions about the packages were answered. During the first day, also, the new nurses were introduced to some of the key staff of the PICU beginning with the  Program Manager (PM) , the  Quality and Safety Leader (QSL), Clinical Nurse Coordinators (CNCs), Respiratory Therapists (RTs), Physiotherapists (PTs), Clinical Nurse Specialists (CNSs), Registered Nurse (RNs) from another unit, RNs from the Transitional Care Units (TCU), Research and Quality Coordinator, Human Resource (HR) staff, End of Life Care specialist and Family Centered Care (FCC) staff. They were also introduced to an ergonomics specialist from the Provincial Health Service Authority (PHSA).  The Program manager started her instruction by introducing herself and then using PowerPoint slides, described the expectations of the unit, her role and availability, and offered to provide them with support.  Then, the CNEs instructed the nurses about available resources in the PICU (such as Red Bedside Binder and Team Site) and logistics in the PICU including the location of lockers, Pyxis machine (an automated medication dispensing system) and various kinds of clinical equipment.  This was followed with a comprehensive tour of the PICU in which all the newly hired nurses had their first visit as members of the unit. During this tour, the CNEs showed them the patient rooms and beds, the nursing stations, the patient assignment board, the Tactical Center, the CNEs’ office, the Clinical Nurse Coordinators’ (CNCs') offices and patient family room. They also showed them where the supplies and equipment were stored in the PICU, including the crash cart, spare ventilators and related equipment, lockers, break room, Pyxis machine, Arterial Blood Gas machines, gowns, clean clothes, blankets and blanket warmer. They also were introduced to the High Five bulletin board and the nursing day bulletin board, used for communication among the nursing staff. The tour of the PICU was followed by a tour of the Transitional Care Unit (TCU), 82  adjacent to the PICU. The TCU, known as “back” of the unit among the staff, cares for technologically dependent patients who require chronic care, in contrast to the acute care patients of the PICU.   After lunch, the rest of the printed Orientation package was discussed and explained by the CNEs. Then, Quality and Safety Leader (QSL) made a PowerPoint presentation about Quality Improvement, as well as Patient Safety and Learning System (PSLS) (a system for reporting patient safety issues) and led a discussion of Quality Improvement (QI).  This was followed by a presentation by one of the Clinical Nurse Coordinators (CNC) who are responsible for administering the nursing staff of the PICU. She taught the newly hired nurses about routines, self-scheduling, and the distribution of workloads. The CNC also explained documentation procedures and the paper work in the unit.  After CNC, clinical nurse educators, introduced the professional development pathway (also known as critical care RN professional development pathway or color-coded system). They explained that this color-coded system represented different levels of nursing competency that corresponded to levels of patients’ acuity.  All newly hired nurses in the PICU start from purple, caring for the less acute patients with the potential of advancing through the levels to grey, green and orange and the ability to care for the most acute patients. This final designation also makes them eligible to move into leadership roles such as charge nurse. This is the formal pathway that guides nurses in their professional development by setting learning goals and assessing performance for advancement in the unit. The clinical nurse educators also taught about expectations from the newly hired nurses in the Preceptorship period.  Although teaching in the Orientation sessions was directive and formal, frequently discussions developed among the instructors and learners. Occasionally, during these informal 83  discussions, newly hired nurses taught to the instructors or other new nurses based on their experiences in other units or hospitals. Informal discussions between the CNEs and the new nurses also conveyed informal and unspoken rules of the PICU.  Table 5. 1: Main contents of instruction in the PICU Orientation sessions Session Contents Session 1 • Welcome! • Orientation overview • PICU Welcome and Overview • What/where are my resources? • Coffee • Logistics…to the unit! • Lunch • Quality and Safety in PICU • CNC role & Self scheduling • Professional Development Pathway • Expectations in Preceptorship Session 2 • Check in  • Exam • Ventilation/role of the RT • Coffee • Jet and Oscillation • Lunch • Chest Care • Artificial airways and suctioning • Mock intubation scenario • (emergency drug sheet) • Blood Gas Analysis • Respiratory Failure - Case study Session 3 • ECG Interpretation • Coffee • Principles of Cardiac Output • Hemodynamic Monitoring (IA/CVP) • Lunch • Code Blue in PICU • Odds & Ends 84  Table 5. 1 (Continued) Session Contents Session 4 • Healthy Workplace • Oncology in PICU • Coffee • Lunch • TCU & Tracheostomy Care Session 4 (continued) • Medication Administration • MAR  • Med Admin Case Studies Session 5 • Issues? Questions? Concerns? • Research in the PICU • PAR Study • Human Resources • Coffee • End of Life Care • Lunch • Family Centered Care • Online Annual Certifications on the Learning Hub  5.1.2.2. Session 2 The second day started with an informal written knowledge test about the information given in the previous session and was followed by instruction by a Respiratory Therapist (RT) about ventilation and the role of RTs. The instructor used PowerPoint slides, handouts and real ventilators for teaching this section of the Orientation session. During this session, the nurses gave brief accounts of their experience of working with ventilators. Sometimes, this led to short group discussions and debates among the nurses, the RT and the clinical nurse educators. Sometimes, clinical nurse educators tried to clarify instruction of the instructors by sharing their own experiences and work-related stories. Informally, after lunch, the new nurses discussed their previous work experiences and shared some online nursing resources that they had used. During the afternoon session, a physiotherapist taught about chest care. This instructor used PowerPoint, 85  computer and real objects such as physiotherapy equipment in her presentation and performed some of the technics on the newly hired nurses, who were then asked to try the same technics on each other. This was followed by the CNEs’ explanation of the role of simulations and mock situations such as mock codes as learning and training opportunities.  5.1.2.3. Session 3 The third day began with a presentation by a Clinical Nurse Specialist (CNS) on the Healthy Workplace. The two questions she addressed were: “What are your stressors in your new workplace? What are your approaches for managing these stressors?”  She used question and answer and group discussion methods. She did not use any computer for teaching. She started answering the questions herself and then asked the newly hired nurses to answer the questions, which led to discussions by the new nurses of their concerns and personal approaches they used for managing stressors. They told stories about their stressful experiences and how they dealt with the situations. The CNS said that she was available to talk with the new nurses if they had concerns during their work in the PICU.  This presentation on health in the workplace, was followed by a nurse from oncology, who taught about "Oncology in PICU".  The remainder of the morning was devoted to the CNEs’ presentation about cardiac care and hemodynamic monitoring in the PICU. They used PowerPoint and some handouts during their lecture. Sometimes, questions and answers, short group discussions, short debates and sharing experiences happened, like other classes.  After lunch and some informal socializing, the CNEs instructed the new nurses about Code Blue and some other contents such as technical subjects (including nursing, respiratory therapy and physiotherapy) and learning and development in the unit that I will elaborate on them in the 86  future sections when I am describing contents of instruction in the Orientation sessions. The session continued through the afternoon, with the new nurses adding narrative accounts of their previous experiences as part of the discussion.  At times, the new nurses’ accounts provided information that was new to the CNEs, effectively becoming the CNEs’ instructors.  5.1.2.4. Session 4 Increasingly, the newly hired nurses socialized and came to informally share their professional experiences and personal lives with their new colleagues. Once again, the CNEs led instruction about electrocardiogram (ECG) interpretation. Teaching included a presentation with case studies on ECG, using real ECG strips for the learners to interpret. Sometimes the CNEs asked multiple choice and short answer questions to test the new learners. As in other sessions, this day included both theoretical instruction and some practical shortcuts.  The remainder of the morning was devoted to instruction by the clinical nurse educators teaching about cardiac related topics (Principles of Cardiac Output).  After lunch, a person from Human Resource (HR) department of the hospital spoke to them and provided them with brochures about online access to HR systems including access to their pay stubs, the respectful workplace, and available resources and support. Though the person from HR did not use a computer during her presentation, even when describing how to have online access to paystubs, the clinical nurse educators pulled up related website and showed it to the newly hired nurses.  The instructional session which followed was about Medication Administration. This section was taught by the CNEs themselves. They used PowerPoint slides and handouts to explain medications and provided examples of medication administration errors that had happened in the 87  unit. While teaching, the CNEs frequently commented on the need for safe medication administration and explained expectations of the unit and its attending physicians.  After lecturing about medication administration, nurse educators asked the newly hired nurses to work on some case studies, in which they calculated medication dosages and infusion rates of medications for cases described in the sheets given to them. These activities generated frequent questions and responses for the CNEs and the other nurses.  5.1.2.5. Session 5 Session 5, the last of the day long Orientation sessions began with the CNEs asking the newly hired nurses if they had any questions, issues or concerns about the Orientation sessions or anything else they wanted to discuss. Since the Orientation sessions continued into the beginning of their Preceptorships, they began to discuss some of the issues, such as intimidation that got into their way of learning in the unit. This was followed by a short informal verbal test by the CNEs on topics covered by the instruction during the Orientation sessions. This was continued by a presentation by the Quality and Research Coordinator who described the research activities in the unit. He started his presentation by a short introduction about himself and his role in the unit. He gave a picture of involvement of the PICU in research activities at local, provincial, national and international levels. One of the projects about which the instructor described in his PowerPoint presentation was PICU Participatory Action Research (PICU PAR) and its history, logic and purpose. His talk spurred a considerable number of questions which he answered.   The next instruction was devoted to a presentation by the Family Centered Care (FCC) specialist who spoke about history and evolution of family oriented care and issues regarding End of Life Care.  She used computer, PowerPoint, video clips (about FCC program), examples, 88  personal experiences and stories, as well as practical exercises. Sometimes the amount of information communicated in this teaching session seemed to overwhelm the nurses. There was good learner engagement in the discussions.  At the end of the day, the clinical nurse educators took over and explained online annual certifications using the Provincial Health Service Authority (PHSA) learning hub.  5.2. Contents of instruction in the Orientation sessions In the previous section, I described t the Orientation sessions, their role in introducing newly hired nurses in the unit and prototypical format of the Orientation sessions. In this section, I describe contents of instruction or learning objectives of these Orientation sessions. For this purpose, first, I identify and outline these contents, and then I give more details about each of the contents. During the Orientation sessions, the newly hired nurses were instructed about various topics that can be categorized into the following subjects: (1) technical subjects, (2) learning and development in the unit, (3) research in the PICU, (4) routines of working in the PICU, (5) quality improvement, (6) cultural issues, (7) information management, (8) knowledge of available support. 5.2.1. Technical subjects  Technical subjects were one of the most important topics that the newly hired nurses were instructed during their Orientation sessions. In this regard, the newly hired nurses were taught about three types of technical subjects: (1) nursing, (2) respiratory therapy, and (3) physiotherapy. These will be briefly described in the following sections. 89  5.2.1.1. Nursing technical subjects  Nursing technical subjects were one of the most important contents that the newly hired nurses were instructed in their Orientation sessions. Though the newly hired nurses were experienced and expected to be familiar with these procedures, the Orientation sessions provided an opportunity to explain and practice the assumptions and standard ways of performing these procedures in the PICU. They were instructed in various subjects of nursing science that included following topics: nursing care for patients with respiratory problems (care in respiratory failure, airway care, artificial airway, artificial airway suctioning, tracheostomy care, nursing and intubation, as well as arterial blood gas analysis or ABG), cardiac nursing  (ECG interpretation, essentials of cardiac output, hemodynamic monitoring and IV therapy that included preparing an IV infusion, priming an IV set and using infusion pumps in IV therapy), critical care oncology nursing, hemodialysis, performance of procedures for various types of codes (Code Blue, Code Red) and end of life care.  They were told that they needed to learn and update their knowledge of all of these subjects regardless of the level of care they were going to give in the unit since “it is PICU and you don’t know what will happen to your patient at any moment”. 5.2.1.2. Respiratory Therapy technical subjects The newly hired nurses were instructed about various aspects of respiratory therapy (RT) that included essentials of medical knowledge for RT (such as physiology of respiratory system and pathophysiology of lungs diseases), RT science (such as basics of mechanical ventilation) and RT equipment (including the various ventilators such as Jet Ventilator, Oscillation, Bilevel Positive Airway Pressure (BIPAP), Continuous Positive Airway Pressure (CPAP) and ABG machines. As I will elaborate later, the newly hired nurses were instructed not to do any of the 90  tasks that were in RTs’ scope of practice. The instruction was only to provide them with information that will help them to collaborate with RTs and not to enable them to do tasks that were not in their scope of practice. 5.2.1.3. Physiotherapy technical subjects Similarly, the newly hired nurses were instructed in technical subjects related to physiotherapy (PT) to enable them to work effectively with PTs in the PICU. In this regard, they were taught about topics such as physiology of respiratory system, chest care, chest physiotherapy and some physiotherapy- related equipment. They were encouraged to respect role boundaries and their scope of practice and not to do any of the tasks that fall in the scope of PTs’ practice. 5.2.2. Learning and development  During their Orientation sessions, the newly hired nurses were instructed about subjects related to learning and development in the PICU. In particular, the following themes emerged in the presentations and discussions by instructors: (1) importance of learning for delivering better care, (2) learning as a team work activity, (3) interprofessional learning opportunities, (4) barriers to learning.  5.2.2.1. Importance of learning for delivering better care From the first day of Orientation, the newly hired nurses were instructed that ongoing learning was a crucial aspect of working in the PICU. In particular, they were told that learning from others’ experiences and mistakes was very important for preventing the same mistakes that others did. In this context, they were introduced to the Patient Safety and Learning System (PSLS) as a learning tool, rather than as the system used to report clinical errors:  91  P38: _ Orient_ Obs 1_Session 1__RTF.rtf - 38:37 (42:43); QSL: Instructor: It's all about learning. In the PICU, continuous learning is important and purpose of PSLS is learning. Learn from other’s mistakes. When we read other’s mistakes [and consequences of them] we learn from these and do not commit the same mistake.  The newly hired nurses were also taught that various important Quality Improvement (QI) meetings occurred that were valuable learning opportunities that they should participate in.  5.2.2.2. Learning as a team work activity The CNEs also emphasized that learning in the PICU was a team activity with three important features:  interpersonal, participatory and collaborative action. As demonstrated by the incorporation of presentations by RTs, PTs and others the multidisciplinary aspect of teams was important. Consequently, learning in the PICU happened in teams, with joint participation, interpersonal interactions and collaboration being essential components to learning in the PICU.  P39: Orient_ Obs 2_Session 2_RTF.rtf - 39:15 (28:28): Instructor (Respiratory Therapist): You will see in the unit that we work as team and learn in team. We work collaboratively and learn collaboratively. It’s completely fine to ask [questions] when you need. Double check when you need. RTs can also help you anytime you need and you can help us. Any time you need help, ask us and we will be happy to help.    5.2.2.3. Interprofessional learning opportunities  In the Orientation sessions, morbidity and mortality rounds (patient review) were described as opportunities for interprofessional learning. The newly hired nurses were instructed that in these rounds, cases were presented in the unit with participation of all disciplines involved in their care in order to analyze and learn from these experiences and to deliver better care. They were taught that the purpose of these teaching was merely learning by all disciplines and persons 92  as multidisciplinary learning, not blaming any specific discipline or person. They were considered as change ideas and start points for delivering better care in the unit: P48:  Orient_ Obs 5_ Session 5_  RTF.rtf - 48:31 (74:75): Instructor (QSL): Interprofessional teaching is very important in the unit and unit has great amount of interprofessional teaching and learning. Physicians, residents, fellows, RTs, RNs and everybody in the care are involved in these sessions. Case presentations [pause] [or] morbidity rounds are interprofessional teaching events that happen in the unit and the purpose of interprofessional teaching is only learning [not blaming]. Try to participate in these.  5.2.2.4. Barriers to learning As it was indicated, the Preceptorship had overlap with the Orientating sessions. In this time, the newly hired nurses encountered various barriers to learning in the unit. They shared these barriers with other in the Orientation session. Some of the barriers that newly hired nurses discussed in the Orientation sessions were as follow: individual barriers, such as stress, cultural barriers including intimidation, organizational hierarchies that created barriers related to the different roles of people in a teaching hospital, and barriers related to the quality and quantity of teaching tools. 5.2.3. Learning about research in the PICU The newly hired nurses were instructed about importance of research activities in the PICU and the importance of research and Evidence-Based Medicine (EBM) in delivering better care. Information about current research in the PICU further supported the importance of evidence based practice in the PICU. Together, the presentations and discussions emphasized that working in the PICU incorporated team work, ongoing learning and development with research to deliver quality care in the unit (Figure 5.1).    93            Figure 5. 1: Contents of teaching in the orientation sessions: interplay between team work, learning and research to deliver quality care 5.2.4. Routines of working in the PICU The routines of the PICU was another important topic that were taught to the newly hired nurses during Orientation sessions. In so doing, they were instructed about the following topics: (1) routines of clinical teams, (2) personal routines and preferences, (3) routines and expectations related to the families.  5.2.5. Quality Improvement (QI) Specific instruction about Quality Improvement (QI) was another important topic during the Orientation sessions. The newly hired nurses were taught about following topics regarding QI: (1) theoretical knowledge of QI, (2) good practice, (3) two QI approaches, (4) QI projects in the PICU, (5) patient safety, (6) QI and learning, (7) role of digital mobile devices in QI. Work in the PICU         Team Work Quality Care Ongoing learning and development Research 94  5.2.5.1. Theoretical knowledge of QI The nurses were taught that change is an essential part of personal and professional life. Therefore, the staff need to be open to this ongoing phenomenon. They were even told that even the models used for quality improvement in the unit have changed and the unit was using a participative model for QI at the time.  The nurses were taught about different models of QI with special focus on models used in the PICU. In so doing, they were instructed about quality improvement models such as the Institute of Healthcare Improvement (IHI) model, imPROVE model, Lean methodology, Rapid Process Improvement Workshops (RPIW), audits and curiosity model. They were instructed that these models treated as top-down strategies and were not helpful enough in the PICU. Therefore, the unit started to adopt a participatory model for quality improvement in which projects are developed by frontline staff and supported by the managers.   5.2.5.2. Good practice/ best practice The nurses were taught that good practice/ best practice was considered practice based on evidence coming from research, particularly evidence that supports pediatric: P42: Cohort 2_ Orient_ Obs 5_Day5_Jan 31_2014_RTF.rtf - 42:12(18:18): Instructor: [Good/] Best practice is working based on the evidence that comes from the research. The McMaster University has done a study in which they have seen that only 267 [limited number of] published randomized controlled trials have been done in Pediatric Critical Care. This means that whatever we are doing in the unit for kids is not [kids’] evidence based [i.e.:  based on evidence coming from research on kids].  While instructors were teaching the newly hired nurses about good practice/ best practice, they also taught them about unit policies and procedures as a way of engaging in good practice.  95  5.2.5.3. Two QI approaches The CNEs described two approaches to QI that PICU has experienced recently: top down approach (old approach) and participatory approach (down-to-top approach). They were instructed that in the top-down approach, QI projects were developed by managers and pushed down to bedside in the unit. While in the participatory approach (down-to-top approach), which was a new approach in the PICU, QI projects started by frontline staff and were supported by managers. While the newly hired nurses were told about the two approaches to QI in the PICU, they were also taught about staff attitudes towards these two approaches. Recently the unit had shifted towards a participatory approach as a new way of envisioning Quality Improvement.   5.2.5.4. QI projects in the PICU In the Orientation sessions, the newly hired nurses also were taught about various QI projects implemented in the PICU such as various Rapid Process Improvement Workshops (RPIWs), Friday Practice Update, Purple Sheet and the PICU PAR.  RPIWs were described as workshops in which PICU staff were instructed and mentored to implement changes in the unit at a fast pace in workshops that lasted 3-5 days. Two changes that resulted from this approach were the institution of the Friday Practice Update emailed to staff to inform them about updates of activities and policies in the unit.  The Purple Sheet was a checklist used during rounds to improve quality of care by systematically reporting information about patients and their care. It was developed by a physician in the unit and was very well integrated in the system of rounds. The PICU PAR project was the first participatory initiative for Quality Improvement in the unit. 96  5.2.5.5. Patient safety Patient safety was another important topic related to QI that was part of the Orientation of the nurses. In general, they were taught to pay more attention to patients' safety and prevent any possible harm to patients. In this regard, safe medication administration was one of the important safety issues that they were instructed. They were asked to adhere to guidelines, policies and procedures of safe medication administration in the unit. For this purpose, they were recommended to double check the orders, pay attention to high alert medications, administration of electrolytes, standard infusions, and related documentations.  The newly hired nurses were also taught about “Stop the Line” initiative as a patient safety initiative. This was an initiative based on which if any of the staff felt that tasks were being conducted in a way that were harming or endangering any of the patient(s), they had to ask healthcare team to stop line of the actions under implementation as soon as possible. The newly hired nurses were instructed to adhere to the guidelines related to this initiative. These guidelines encouraged them to be brave and interrupt care processes at any time that they would perceive patients' safety was in danger. They were also instructed about Patient Safety and Learning System (PSLS). This topic seemed more related to learning aspect of Quality Improvement; therefore, it will be described in the next section. 5.2.5.6. QI and learning In the Orientation sessions, the newly hired nurses were taught about learning aspect of QI and patient safety. In this regard, they were instructed that learning was an essential component of any QI related activity such as QI projects (for example RPIWs), QI meetings, patient safety initiatives such as safe medication administration, medical error management and Patient Safety 97  and Learning System (PSLS). They were instructed that this learning was crucial in the PICU and contributed in delivering high quality care.  For example, regarding PSLS they were taught that PSLS was a tool for learning, improving patient safety and quality of care. They were taught that in fact the main purpose of PSLS was learning; PSLS was a system for learning from mistakes and errors and a tool for delivering high quality care: P38: Cohort 2_ Orient_ Obs 1_Day1_Jan 09_2014_RTF.rtf - 38:37(42:43): Instructor: It's all about learning. In the PICU, learning is important and purpose of PSLS is learning. Learning from other’s mistakes. When we read [about] other’s mistakes [and consequences of these mistakes] we learn from these and do not commit the same mistake[s]. .... I read the reports of PSLS. Some people ask me in the unit ‘did you read that report?’ this means ‘give me some feedback [, and I want to learn]’. And I give them some feedback then. As I said, it's all about learning.  5.2.5.7. Role of digital mobile devices in QI In the Orientation sessions, the newly hired nurses were instructed about the role of digital mobile devices such as iPads in QI. In this regard, they were taught that iPads could facilitate process of reporting medical errors to PSLS because they could do PSLS reports using iPads while working in those bedsides that did not have access to desktop computers. P48:  Orient_ Obs 5_ Session 5_ May 29_ 2014_ RTF.rtf - 48:41 (84:85): Instructor: iPads are going to facilitate the PSLS report system. You will do it when you are in the bedside using the iPads. iPads will make it simple and easier. ...In iPads, drop downs are slow, but they are working. 5.2.6. Cultural issues In the Orientation sessions, the newly hired nurses were taught about various cultural aspects of the PICU including the (1) culture of participation, (2) culture of anticipation, (3) siloed care, (4) blame culture, (5) culture of Family Centered Care (FCC). 98  5.2.6.1. Culture of participation In the Orientation, the CNEs discussed the existing culture of team work in the unit and new nurses were encouraged for participating in team work with other disciplines such as RTs. Team work inside RT group and the need for more team work and cooperation for information transfer between nurses and RTs in specific times such as mornings were other things that the newly hired nurses were instructed: P39: Orient_ Obs 2_Session 2_Jan 23_2014_RTF.rtf - 39:16 (29:29): Instructor (RT): We have a good unit now. Before this it was hierarchal, now we have good situation we are working in teams and we share everything. Ask help and give us help or offer us help. I have also helped nurses and they have done it for us. Changing the dipper [they laughed]. Ask us ‘can you help us giving bath to this patient?’ We can help you and take care of the respiratory issues [or other things].  Additionally, the new nurses were encouraged to get involved and participate in various activities in the unit. For example, they were taught to get involved in QI activities, changes in the unit, interprofessional teaching and learning, as well as research activities. They were also encouraged to share their ideas with others the unit. The culture of communication was a major issue within the unit. They were taught that impaired communication was one of the barriers to quality improvement and patient safety in the unit, and therefore, there was a big need for improving communication. Therefore, they were encouraged for participating and engaging in improving communication in the PICU: P48: Cohort 3_Orient_Obs 5_Day 5_May 29_2014_RTF.rtf- 48:16 (53:53): Instructor: Top down approach, [lack of] engagement, [lack of proper] communication and siloes are issues in QI in the unit. Give your voice and ideas. Any time you see and feel [that] you have ideas for improvement you can come to us and openly talk about your ideas.   99  5.2.6.2. Culture of anticipation The newly hired nurses were instructed about culture of anticipation in the unit. They were instructed to anticipate their needs and the work to be done in the unit and adopt anticipation as a normal practice for themselves.  They were also taught that some attending physicians anticipated that the staff would need interdisciplinary skills for working in the new hospital that was under construction at WCH and the PICU was going to move there soon. This was because of the spatial design of the new unit in the new hospital. For this reason, they (attending physicians) recommended the staff to learn various skills from each other in order to be able to deliver high quality care in the new unit in the near future: P46: Cohort 3_Orient_ Obs 3_ Day 3_May 22_2014_RTF.rtf-46:14(16:16): Instructor (RT): We should bundle our care. ... we will learn from each other collaboratively. DR. Z wants RTs learn some works from RNs and vice versa. He is thinking of the new hospital.  5.2.6.3. Siloed care In the Orientation sessions, the newly hired nurses were instructed about culture of siloed care and siloed teams in two forms: direct instruction and indirect instruction. Some instructors (such as instructors of research activities in the unit) directly taught the newly hired nurses that siloed care and siloed teams were issues in the unit that impeded delivering high quality care, therefore, recently the unit started moving towards culture of participation. In order to improve this situation, the newly hired nurses were encouraged to work in teams and participate and help the unit in improving culture of participation.  100  Direct instruction about culture of silo functioning and siloed teams could also be seen when the newly hired nurses were taught about inter-professional teaching in the PICU: P48: Orient_ Obs 5_ Session 5_ RTF.rtf - 48:38 (82:82): The newly hired nurse: Nurses and staff involved in the care are involved in the case presentations in my previous workplace. They are not physician lead; they are led by people involved in the care as team. Instructor: Ours are physician led mostly.  Some instructors such as allied health instructors (for example, RTs) instructed the newly hired nurses in this regard in an indirect form. In so doing, they taught the newly hired nurses that they should adhere to their own role boundaries and restrict their scope of practice to nursing tasks only. In other words, they instructed the newly hired nurses that they should not do any task that was outside of nursing field even though they were taught about tasks and techniques related to allied health in their Orientation sessions or even if they had great amount of knowledge, skills and experience regarding allied health from their previous workplace. The instruction about adherence to role boundaries were very strong inducing the feeling of siloed teams. In other words, the impression was that nursing team and other allied health teams were functioning in silos. The importance of adhering to professional role boundaries was taught when some instructors were teaching about their own specialties, tasks, roles and duties in the unit to the newly hired nurses. In so doing, these instructors emphasized at the newly hired nurses’ scopes of practice and stressed that nurses could not and should not attempt to do those tasks that might seem common between nursing team and the instructors’ specialty. In other words, they taught the newly hired nurses what nursing team were allowed to do and what they were not allowed and should not do:   101  P39: Cohort 2_ Orient_ Obs 2_Day2_Jan 23_2014_RTF.rtf - 39:49 (84:84): Instructor (PT): None of these are prescriptions. Neither of them are nurses’ job. They are for your information and teaching [in the Orientation session]. Nurses only need to be aware of them and ask the PT [strong stress on ask and PT] to do it." [The connotation was like creating a strict boundary around the PT discipline.]  5.2.6.4. Blame culture There were instances in the Orientation sessions where the newly hired nurses were taught that blame culture existed in the unit. When the instructors were teaching about QI and patient safety topics such as safe medication administration, the stories that instructors told indirectly carried a strong message of presence of blame culture in the unit: P32: Cohort 1_ Orient_ Obs 3_Day3_July 23_2013_RTF.rtf - 32:25 (22:23): Instructor: There was a medication error that a kid received an IV medication with a dosage of 10 times normal. [As soon as explaining this, the instructors mentioned that:] It was pharmacists' mistake. It was pharmacist's fault. The nurse had controlled the label [and barcode] and everything was fine on nurse's side [in terms of controlling the dosage], but the medication had been prepared in higher dosage in the pharmacy [level]. The mistake was not caught in the PICU. When the patient [was] moved [to] upstairs, the problem was discovered [by the pharmacist]. The way that it was discovered was that they were discussing to prepare the medication for the patient for the time that patient will be in the unit. One pharmacist tells that we have the medication for this. And then when they were checking the ordered dosage and the dosage of the bottle, they figured out that there was such a mistake so that the kid should have been given 0.1 mg [per kg] while the patient had been given 1 mg [per kg].  5.2.6.5. Culture of Family Centered care (FCC) In the Orientation sessions, the newly hired nurses were instructed about existing culture of family centered care (FCC). In this way, they were first taught about history, evolution, significance, existing culture of FCC in the unit, and ideal model of FCC. Regarding the importance, as an example, they were instructed that due to significance of culture of FCC and in order to establish this culture more than before, hospital had involved families in the project of 102  development of the new hospital. They were instructed that families had great amount of productive input in this project from the beginning, when it was in designing phase. In terms of existing culture of FCC in the hospital, the newly hired nurses were instructed that the existing culture of FCC in the unit was “doing your best to deliver family centered care” and this way they were encouraged to do their best for achieving best possible FCC in the unit. The newly hired nurses were instructed that an ideal model of FCC was not practical and the existing FCC model in the unit was the best possible model of FCC. 5.2.7. Information management Another thing that the newly hired nurses were instructed in the Orientation sessions was information management. In this regard, they were taught about (1) tools used for information transfer and (2) finding information. 5.2.7.1. Tools used for information management In terms of tools used for information management, the newly hired nurses were instructed about patient assignment board and the Purple Sheet. The newly hired nurses were taught that patient assignment board was a glassy board located on the wall between nursing station and the Tactical Center and was used for communicating various information about the patients and staffing to the staff. For example, they were taught that it was a tool showing which patient was assigned to which nurse, which service each patient belonged to, who was clinical nurse coordinator (CNC), who were other staff members, and if there was any patient planned to move in or out of the unit. Therefore, they were taught that they needed to check it in the beginning of each shift to learn about the patient they should look after, their colleagues in that shift and other 103  information that would help them in planning their daily activities. They were instructed that on this board, they could also see some information about the staff working in the next shift.  The Purple Sheet was another information management tool that the newly hired nurses were taught about. They were instructed that this tool was a double sided one-page purple form produced by a physician in the unit. It was created since there was a big variation in presenting information in the rounds that led to loss of great amount of useful information in the rounds. After creation, this tool was used as a systematic way of transferring consistent patient-related information in the point of care in the unit. It was also a checklist for improving continuity of care, quality improvement and learning, and it would be their best friend while working in the unit: P48: Cohort 3_ Orient_ Obs 5_ Day 5_ May 29_ 2014_ RTF.rtf - 48:32 (76:76): Instructor: It [purple sheet] is a tool for presenting accurate and consistent information in the point of care. It started because some people were missing some parts of the information that needed to be presented by them. Each person presents information that they recall. Some people miss some information that are very important for others in patient care. This leads to the point that various parts of important information are lost. To make presentation of relevant information consistent, this tool [purple sheet] was created and used. It is a standard process for presenting information. It is a tool for learning. All the information presented in all rounds are presented in a consistent way using this tool. Everybody in the team are expecting same order of information as [in the purple sheet]. It is a systematic way; it has information and checking what is missing. All the points in the purple sheet are for discussion. The logic behind the points in the purple sheet is discussion, but it is used as a checklist [as well].  P30: Cohort 1_ Orient_Obs 1_Day1_July 16_2013_RTF.rtf - 30:32 (24:24): Instructor: Purple Sheet will be your best friend.   5.2.7.2. Finding information In terms of finding information, the newly hired nurses were taught where and how they could find the information they needed for giving care to their patients (while working in the unit). 104  They were instructed that this would help them to predict what they would need for helping the patients coming to the unit. 5.2.8. Knowledge of available support They newly hired nurses were instructed about the available supports (such the staff around them), resources (such as other people, policies and procedures) and logistics (such as clinical equipment) to them in the unit. They were instructed that they were not left alone in the unit. The unit and all the staff were there to support them. Additionally, they were instructed that there were enough logistics out there in the unit for delivering care in the unit. The newly hired nurses needed to learn where to find them.  Summary and interpretation Thus, during Orientation sessions, the newly hired nurses were informed about Hospital and PICU policies and procedures, as well as learning and development in the unit, research, routines of working in the PICU, quality improvement initiatives in the PICU, the cultural issues in the unit (such as culture of participation, anticipation and culture of Family Centered Care), information management and support that is available to them. Perhaps of more significance, they were instructed in more technical aspects of critical care nursing, respiratory therapy, and physiotherapy by the respective professional who employed more complex teaching strategies. The goals of each instruction were to provide shared understandings of the ways that nursing procedures were performed in the PICU, and to provide the basis for multidisciplinary team work with RTs and PTs. All the instructors emphasized on respecting their role boundaries and scope of practice.  105  During the Orientation sessions, the newly hired nurses were taken back to the basic competencies of nursing. The didactic instruction fit the information transfer model of teaching with limited interaction and engagement. The apparent goal was to make knowledge about basic procedures that was assumed to be tacit, explicit as an assurance of the competencies of the new nurses and assure the CNEs that the new nurses shared a common understanding of procedure that may vary from hospital to hospital.   Some forms of simulations were used in the Orientations, as I will elaborate in the next section, to teach the newly hired nurses specific skills. These limited simulations fell well short of emulating the experience or knowledge that is the product of working in a PICU with real patients. This latter kind of knowledge was acquired in the Preceptorship, which is described in the next section of the thesis. It requires the newly hired nurses to participate in the PICU setting with real patients who are treated by a multidisciplinary team of care providers.    5.3. Specific aspects of teaching in the Orientation session This section looks more closely at specific aspects of teaching during the Orientation session. It explores particular teaching activities that are characteristic of adult education such as experiential teaching, modeling (cognitive and behavioral), and reflection (in and on action). It also examines a more general strategy of scaffolding. This portion of the chapter also considers the role of the instructional tools used for teaching (such as computer, mannequins, teaching videos). Additionally, this section identifies analytical concepts that help us explain teaching activities in the Orientation session. 106  5.3.1. Teaching activities during the Orientation sessions 5.3.1.1. Presentations Presentations were the most frequent teaching activities used for instruction during the Orientation. Presentations were made by the CNEs and staff from other units and administrative units. The objective of these presentations was to prepare the newly hired nurses for work in the unit. This was made explicit by a statement by one of the CNEs at the beginning of the Orientation sessions. The instructors used various tools during their presentations including computers (for PowerPoint slides), video projectors, and the internet and whiteboards for mediating learning among the newly hired nurses. However, not all the instructors used PowerPoint slides in their presentations.  Instructors involved their learners in the process of their presentations at different levels; however, majority of the instructors used high levels of learner involvement in their teaching by asking questions, encouraging the learners to or ask questions and asking them to share their experiences. 5.3.1.2. Simulations Simulations were another teaching activities in the Orientation sessions. The newly hired nurses were the only participants in the simulations. Various forms of simulations were used in the Orientation sessions. These include basic activities in the PICU such as drawing blood from the patient, blood glucose testing, setting up an infusion pumps, setting up a Bilevel Positive Airway Pressure (BIPAP) machine, endotracheal intubation and doing physiotherapy. Before simulations, the process was verbalized and various steps were demonstrated. The purpose of these simulations was to help the newly hired nurses eventually be able to use the simulated techniques and skills in 107  a real-life situation of the PICU.  These simulations, employed various equipment as learning tools.  To simulate drawing blood this included mini bags and a red liquid imitating blood, equipment to represent blood vessels, and syringes.  They also used real infusion pumps during the simulation. To simulate BIPAP machine, they used a functioning BIPAP machine. For intubation, they used a laryngoscope, Endotracheal Tube, a mannequin took the place of a patient and ambo bags functioned as ventilator machine compressor for ventilation.  The newly hired nurses were asked to perform the techniques and experience them in the simulated situation. While practicing these techniques and skills, they were given feedback and asked to reflect on their performance.  The entire process was repeated several times and the more they practiced, the less they needed comments and support from the instructors. At the end, they were able to perform the tasks and techniques without any support from the instructors.  5.3.1.3. Case studies Cases studies were other teaching activity that were used for instructing the newly hired nurses in the Orientation sessions. Detailed descriptions about some cases were given to the newly hired nurses. These description(s) included information about the diagnosis, past medical history, medications, lab results and diagnostics related to the patients. Then, the newly hired nurses were asked to answer questions based on the patient’s situation presented in the cases studies. The tools that were used in these activities were print outs of the cases, and in some situations computer and PowerPoint slides and the video projectors and TV screen used to display the presentations. During the sessions that used case studies, the newly hired nurses were asked questions by the instructors. Additionally, the instructors asked them to reflect on their answers. While reflecting, they taught them more about various aspects of these cases and additional issues related to the cases, such as 108  the relevant pathophysiology, medications, and the type of nursing care that would be appropriate in the PICU. Several times the newly hired nurses started to demonstrate their own knowledge with the instructors that created a mutual teaching and learning atmosphere. 5.3.2. Analytical concepts underlying teaching activities  This section examines the underlying analytical concepts derived from teaching and learning theories such as experiential learning theory (113,121,129), reflection and reflective practice theory (121,133–136). In so doing, I will examine face to face interactions, experiential (hands-on) teaching, modeling (including cognitive and behavioral modeling), articulation, reflection (in and on) practice and scaffolding.  5.3.2.1. Face to face interaction In general, all the teaching activities in the Orientation sessions happened through face to face interactions in a classroom outside of the context of the PICU. This way, the Orientation session missed situatedness of teaching and learning which is an important aspect of learning among the PICU nurses, as I will elaborate later in my findings about the Preceptorship. Through these interactions, instructors presented, described and demonstrated various steps of numerous procedures and asked the newly hired nurses to actively engage in the skills and procedures. They also provided feedback to the newly hired nurses. Most of the instructors involved their learners at high level in the process of their instruction by asking questions, encouraging the learners to ask questions and by asking them to share their own experiences.  5.3.2.2. Experiential teaching The newly hired nurses also were taught through experientially (hands-on) in the simulations, which provided opportunities for active experimentation of various skills (such as 109  drawing blood in simulated situation). This prepared the nurses to use these skills later in real setting. This is significant since nursing (in general and PICU) is a practical profession and is supported by experiential learning theory.   5.3.2.3. Modeling Teaching in the Orientation sessions also happened through Modeling. Two kinds of modeling were used in the Orientation session that included cognitive modeling and behavioral modeling. Cognitive modeling means demonstrating the thinking process and behavioral modeling means demonstrating behavior process. Cognitive modeling was used more frequently than behavioral modeling. In cognitive modeling, instructors described the theory, process and steps of each process, while in behavioral modelling, such as simulation, the instructor’s performance serves as the model.  For example, when the instructors were teaching about calculating medication dosages, or how to use the Pyxis machine, infusion pumps, interpreting Arterial Blood Gas (ABG), Electro Cardiogram (ECG), or how to do self-scheduling, they described the principles behind each of these, how to interpret these tests (if it was a test) and how to perform the procedures. Thus, they verbalized their thinking process about each of these instructional topics. I have copied here a typical example from my field notes that describes an instance of cognitive modeling:  P32: Orient_ Obs 3_Session 3_ 32:43 (25:25): Before starting to do dosage calculations, the instructors reviewed some theory and formula about medication dosage calculation. Theory of medication under instruction were described. Elements of drug calculation formula or sometimes simple math formula were reviewed verbally. They also orally described the steps in using the formula, and then they asked the nurses to use the formula for calculations. The newly hired nurses used calculators for this purpose. Instructors also asked some questions that required short answers. When the newly hired nurses were answering their questions, instructors gave rapid verbal reinforcement feedback such as "correct; good". Meanwhile, more questions and answers happened.   110  Instructors also used behavioral modeling during the simulated situations. In simulations, the instructors demonstrated the process and steps of doing the desired task and the nurse were then asked to perform the same procedure.  For example, in teaching how to draw blood for ABG analysis in the PICU or how to set up a BIPAP machine, they demonstrated various steps of doing ABG sampling or setting up the BIPAP.   In some situations, the two processes of cognitive modeling and behavioral modeling were combined so that, first, the thought process and steps were described. Then, the instructors demonstrated the task by showing the newly hired nurses how the task should be done. Sometimes they described it while doing the procedure. There were also situations in which they did the task practically and description happened right after. 5.3.2.4. Articulation  Articulation was another process through which instruction occurred in the Orientation sessions. This means that learners benefited from the instructor’s stories and experiences and this made the learning more concrete and authentic. It also means that the instructors reinforced concepts already taught or concepts that they were teaching by connecting theory to practice (210). In articulation instructors combined explanations with stories they told about their own experiences. In this way, learners benefitted from concrete examples. Sharing experiences to articulate instruction was not limited to main instructors of the Orientation sessions. The newly hired nurses as well frequently shared their experiences and stories during both the Orientation sessions and informally in conversations outside of Orientation. One example of supporting principles with stories was a story of medication error. In this story, the instructors used story of medication administration error (that had occurred in the unit) as a concrete example to consolidate 111  their theoretical teaching while they were teaching about theory of safe medication administration. One of the CNEs recounted an instance of one of the most common mediation errors, a mistake caused by a misplaced decimal point that resulted in a patient receiving 10 times the prescribed dosage. Fortunately, the patient was not harmed. P32:  Orient_ Obs 3_Session 3_RTF.rtf - 32:25 (22:24): Instructor: There was a medication error that a kid received an IV medication with a dosage of 10 times normal. [As soon as she explained this, the instructors mentioned that:] It was pharmacists' mistake. It was pharmacist's fault. The nurse had controlled the label [and barcode] and everything was fine on nurse's side [dosage wise], but the medication had been prepared in higher dosage in the pharmacy. The mistake was not caught in the PICU. When the patient [was] moved [to] upstairs, the problem was discovered [by the pharmacist]. The way that it was discovered was that they were discussing to prepare the medication for the patient for the time that patient will be in the unit. One pharmacist tells that we have the medication for this. And then when they were checking the ordered dosage and the dosage of the bottle, they figured out that there was such a mistake so that the kid should have been given 0.1 mg [per kg] while the patient had been given 1 mg [per kg].  5.3.2.5. Individual reflection in and on action Instruction by the CNEs in the Orientation sessions encouraged individual reflection. Reflection is “a learning and development process that includes the self-examination of one’s professional practice, including experiences, thoughts, emotions, actions and knowledge that enrich it.” (133). Schön introduced two types of reflection: reflection-in-action and reflection-on-action (121,133,134). Reflection-in-action is a kind of reflection that happens during the time that the practice is being performed. Reflection-on-action, is reflecting on a practice that has been performed and finished (retrospective reflection) (121). Reflections were encouraged by the instructors during simulations and case studies. Two forms of reflection (reflection in action and reflection on action) were identified in the Orientation session. Reflection in action was used when the newly hired nurses were practicing tasks 112  during the simulations or when they were discussing case studies. Reflection on action occurred when the newly hired nurses had finished the activities that they were instructed (such as dosage calculation, setting up a machine and drawing blood). In fact, after simulations, such as setting up the BIPAP machine, participants in the education including the newly hired nurses and the instructors started reflecting on what the newly hired nurses had done, what they could have done and what they learned from it. 5.3.2.6. Scaffolding  During the Orientation, the CNEs and other instructors also employed scaffolding. Scaffolding means temporary assisted guidance using variety of techniques to provide support to help learners progressively move towards understanding and skill levels that is beyond their current abilities and gradually gaining greater independence in the process of their learning (210). Learning objectives during the sessions were progressively increased in complexity and difficulty as the nurses demonstrated their understanding and abilities to master new information. Additionally, instructors of Orientation sessions demonstrated and explained processes to the learners. They also helped them practice the desired skills in the presence of and with the help of the instructors. The more the newly hired nurses learned, the less support they received from their instructors and the more independence they acquired in doing the activities. This continued, until they reached a point where they were able to do the tasks without any help from their instructors. In this way, the instructors helped the new nurses to reach a deeper understanding of the activities. Scaffolding was limited by the short duration of the sessions (1-2) hours. I observed situations in which the transmission of information happened without scaffolding due to time limits of the sessions.  113  A typical example of scaffolding occurred when two of the instructors taught hemodynamic monitoring in the Orientation sessions. They used real equipment and described and demonstrated the process of setting up an IV tube and priming an IV. Then, they asked the newly hired nurses to try to set up an IV tube and prime it. While the nurses were practicing these activities, instructors supported them by providing more verbal information and short practical helps during each part of the process. This way, they provided successive levels of temporary support for the newly hired nurses. In so doing, the instructors helped learners reach higher levels of understanding and mastering the skills and tasks being taught. This continued until the newly hired nurses were able to do the activities independently.  Summary and interpretation The Orientation sessions were the first teaching opportunity organized for the newly hired nurses in the PICU. Teaching in the Orientation sessions happened in a classroom setting outside of the context of the PICU that was about five-minute walk away from the unit. The purpose of these instructional activities was to orientate and help the newly hired nurses get ready for working in the PICU. Various instructors from the PICU, other units of the hospital or from the Provincial Health Services Authority (PHSA) taught things to the newly hired nurses during teaching activities such as presentations, simulations and case studies. Variety of tools were used to mediate instruction in these teaching activities commonly including a computer, TV screen, mannequins, and task-specific clinical equipment such as BIPAP machine and infusion pumps.  Most presentations, the primary type of teaching in the Orientations session, occurred in a traditional classroom format detached from the real and authentic context in which the knowledge and procedures would be practiced. Similarly, interactions in case studies were limited to 114  decontextualized discussions between instructors and the newly hired nurses. Interactions in the simulations, however, were slightly different from presentations and case studies.  Simulations offered situations in which the newly hired nurses had access to the equipment that they would have in the real-life setting. In simulations, instructors (a) provided an environment that respected knowledge, experience, feelings, beliefs and values of the newly hired nurses during their teaching and during the time that learners were in practically doing some skills and activities in the simulations. (b) They provided an environment in which the newly hired nurses could conceptualize their experiences, develop hypotheses for solving various problems presented in the simulations, and answering questions related to their skills and activities in simulated situations. (c) They provided an environment in which the newly hired nurses could observe the skills and activities that were being performed in the simulated situation, reflect about it, reflection on the activity, and modify and improve their skills and activities. (d) Simulations also provided an environment in which the newly hired nurses could select and focus on specific problems, skills or activities to test and develop their competencies, as well as experiment in the simulated situations.  While the newly hired nurses were encouraged to reflect on their learning and experiences, I did not explore their reflections in depth nor did I discuss with them the role of reflection and reflective practice in their learning. I have relied on their accounts of reflection during more general interviews and observations.  In providing such a supportive environment for helping the newly hired nurses in their experimentation in the classroom and simulated settings, instructors used various forms of scaffolding. They: (a) showed the process and sequence of various skills and activities (behavioral modeling), (b) described and verbalized their way of thinking and the logic behind it (cognitive 115  modeling), (c) sometimes they added more details into their instruction whenever necessary. In so doing, they used their own experiences and stories, asked for the learners’ experiences and stories, brought examples, and sometimes added more detailed theory regarding the subject to their instruction (articulation). This way, instructors helped the newly hired nurses progressively improve their skills and activities and finally be able to do the instructed skills and activities with minimal supervision in a simulated situation. Gradually, the instructors faded away and the newly hired nurses did their skills and activities independently.  Scaffolding, however, was limited by the amount of interaction that nurses could have over time. This was clear in the Orientation sessions in which instructors were trying to transfer great amounts of information to the newly hired nurses in short and focused instructional session of 1-2 hours. The clinical nurse educators, however, had ongoing interaction with newly hired nurses over the entire Orientation sessions which offered the opportunity to answer questions and augment in the instructional sessions which provided a form of scaffolding.  Even though simulations were the most interactive teaching activities, they were focused on skills that were done on a simulated patient in a simulated context that hardly resembled the real-life context of the busy, complex setting of the PICU.  Instruction in the Orientation sessions was dominated by didactic teaching, mainly in the form of presentations, that took place in decontextualized classroom settings. These sessions provided opportunities for the instructors to transfer explicit or evidence-based knowledge from nursing and other related disciplines such as respiratory therapy and physiotherapy to the newly hired nurses. However, this instruction simplified the tasks by extracting the activity from the complexity of the actual PICU setting. Lack of access to real setting with patients and team members simplified teaching some facts and skills but it also deprived them of the situated learning 116  that could occur in the PICU. They did not learn the full spectrum of tacit knowledge that is very important in jobs such as nursing in critical care. The simplified setting also limited their access to the real mediating tools used for the tasks. More importantly, these classes also limited the interactions between the staff, and the dynamics of the social hierarchies which could influence their activities and learning. In short, the simulations of the Orientation sessions, offered activity systems composed by the learning subjects, their objectives, the mediating artifacts, the roles, division of labor, and the rules, that were pale imitations of the activity systems they would encounter when working in the PICU. Thus, although some simulations in the Orientation classes provided opportunities for experiential learning environments as characterized by Kolb in experiential learning theory, these simulations themselves lacked the true complexity of the PICU.  In conclusion, learning in the Orientation sessions is dominated by didactic teaching consistent with the learning as knowledge acquisition metaphor and the individualistic learning theories such as proficiency theory, experiential learning theory and reflection and reflective practice, which are reflected in this mode of instruction. The Orientation sessions, though they do include simulations, are missing important elements that contribute to effective learning such as situatedness and social interaction. Even in the simulations, where there are limited instances of scaffolding, the instructors do not determine each learner’s Zone of Proximal development and develop scaffolding to suit their needs. Scaffolding requires the time and depth of interaction that is not found in the Orientation sessions, but does occur during the Preceptorship.  117  Preceptorship Overview of the Preceptorship In the previous chapter (Chapter 5), I described and analyzed the presentations and learning that occurred in the Orientation sessions as the first learning opportunity for the newly hired nurses in the PICU. In so doing, I described the prototypical format of Orientation sessions, contents of instruction, as well as activities and tools that were used for teaching newly hired nurses in the Orientation sessions.  In the following six chapters (Chapter 6 through Chapter 11), I describe and analyze the Preceptorship which is the second opportunity organized to help the newly hired nurses learn how to work in the PICU. This is a prelude and a necessary pathway to their work as an independent PICU nurse during which they will receive in depth learning about specialized PICU tasks such as Extracorporeal Life Support Program (ECLS). Findings about learning in the Preceptorship are presented in six chapters (Chapter 6 through 11) each of which elaborates on different aspects of learning activities within the Preceptorship. I have used different theoretical components of Activity Theory and Communities of Practice for organizing these chapters since as I will elaborate in the Discussion (Chapter 12) these are two major sociocultural learning theories that are explaining findings of this research.  Chapter 6 gives a thick description of the Preceptorship that includes a definition of Preceptorship and a prototypical 24-hour day of the Preceptorship with particular attention to the activities that were identified as teaching and learning activities among the newly hired nurses. 118  This description helps the reader gain a clear idea about the real and authentic context of the PICU setting and will be very helpful in understanding rest of the findings.  Chapters 7 and 8 explore various activities focused on teaching the newly hired nurses and learning among them. These activities are core elements about learning in Preceptorship and having a clear idea about these activities help us better understand how learning happens among the newly hired nurses in the PICU. Chapter 7 describes and analyzes the teaching aspect of the Preceptorship and the specific activities with the objective of teaching the newly hired nurses and facilitating their learning in the Preceptorship. These activities include rounds, simulations and short educational events (called EduQuicks). It also describes the instructional tools (such as computer, mannequins, educational videos), which are used for mediating and facilitating teaching. In addition, this chapter identifies underlying analytical concepts (such as modeling, reflection in practice, reflection on practice, articulation) explaining teaching activities happening in the Preceptorship. This helps us better understand how social and experiential learning theories explain teaching activities used for facilitating learning among the newly hired nurses. Chapter 8 analyzes the learning activities within the Preceptorship, giving particular attention to the activities identified as learning opportunities (such as simulations, handovers, overhearing other colleagues’ discussions) by the newly hired nurses. This chapter also describes tools used for mediating and facilitating learning (such as computer, iPad, smart phones, policies and procedures). Using various learning theories (such as experiential learning, Communities of Practice and Activity Theory), this chapter also identifies underlying analytical concepts that help us explain learning activities in the Preceptorship. In addition, by describing what the newly hired nurses learn, this chapter describes and analyzes learning outcomes among the newly hired nurses during the Preceptorship.  119  Chapter 9 explores the relationship between social interaction and learning in the Preceptorship and helps us understand how learning happens in