Three themes emerged from the nurse descriptions of experiences with their workplaces as learning environments, namely “participation in the work community”, “to engage in interpersonal relations”, and “accessing important knowledge resources”. The interpretation of nurse descriptions led to an understanding that nurse experiences of learning environments were connected to the opportunities that work provided nurses as they developed a personal engagement in learning. Representative passages that were illustrative of this shared understanding are presented below.
Participation in the Work Community
The interviewees emphasised that their work communities were structured around patients, diagnoses, tasks, and routines. The nurses found participation in their respective work communities to be an important part of gaining insight into the expected work activities and learning opportunities in their workplaces.
The nurses working in surgical and medical wards described their communities as consisting of other registered nurses, nurses with additional training, physicians, enrolled nurses, and other health professionals. The work community functioned as a team; sharing areas of competence and special knowledge among team members was related to the team’s responsibilities towards individual patients and groups of patients. One of the nurses working in a surgery ward believed:
Even if we work independently, we are still a team, with each of us learning from one another. (9).
Another nurse working in a surgery ward described how she experienced cooperation between nurses and physicians:
We have many physicians we have to relate to. We go the round with them every day (…) Most of them are clever listening to us. If there are any problems, they listen to our opinions, because we are the one who watch the patients all the time (…) We don’t actually question the treatment, but are a bit critical anyway. (4).
According to the nurse working there, the rehabilitation ward was a community characterised by its interdisciplinary nature and a holistic view of each patient, who usually stays in the ward for one to three months. The nurse described herself as a coordinator for other professionals involved in the rehabilitation process:
From the time the patient is admitted we have the responsibility for everything that happens with the patient (…) In interdisciplinary work it becomes very visible who is doing their job properly (…) The responsibility as a nurse becomes very visible. (5).
For the nurses working in nursing homes, communities consisted of few nurses; most of their co-workers were enrolled nurses and welfare workers. The nurses bear the responsibility for entire units of patients, and a physician visits the nursing home once a week or less. One of the nurses reported how she experienced her work community:
It is so different from the hospital. There you always have many people around you, physicians and…It is much lonelier here, and we don’t have the opportunity to talk so much with colleagues and other nurses. We have a meeting one hour every week and of course if something special occurs. However, there are not so many professional discussions. (8).
Although the nurse in home nursing care described her work in terms of being alone with the patient, she emphasised that she worked in a community of other nurses and enrolled nurses. The community care office functioned as a meeting point. The nurse used the telephone to discuss issues with other nurses and to confirm her assessments of patient care. Each patient had a family doctor, and the nurse had the responsibility to contact the physician when needed. The nurse explained:
We are alone with the patient in his or her home, so if for instance there are serious wounds developing critically, then you have to take the responsibility for the assessment (…) So we are dependent on the patient’s doctor to call him/her and talk to him/her, and they are dependent of trusting us. It is quite different than in hospitals and nursing homes (…) A family doctor is often difficult to get a hold of… Very often they are nowhere near a phone when you need them. (6).
These various descriptions of nurse experiences in different workplaces show the importance of including nursing roles and responsibilities in specific work communities when discussing the learning environments of nurses. Their descriptions also show how the nurses’ understandings of their professional development connect to various relationships in their work communities. The next section describes how the nurses experienced these relationships and examines how nurses describe their learning in the context of having to manage workplace responsibilities.
To Engage in Interpersonal Relations
The interviewees highlighted the importance of benefiting from learning opportunities gained through relationships with their colleagues. First and foremost, the nurses emphasised that a good relationship with peers was important to feel confident in particular situations. They stated that they engaged in interpersonal relations both to prepare for performance and to obtain a confirmation of actions. Some of the interviewees mentioned having a formal mentor among more established nurses, but most of them expressed how they actively sought support in their work community. They noted that there were certain colleagues whom they trusted more or with whom they had better relations. Thus, the nurses chose their mentors and role models according to personal qualities and competence. The nurse working in a rehabilitation ward spoke about her selection:
Actually, I went looking at others discreetly and thought about whom I could ask and whom I thought was good at this and that. In a way, I chose my role models. People are good at different things. I picked up the best from each of them. (5).
The importance of the community of colleagues was discussed in the focus groups. The nurses emphasised the importance of receiving feedback and comments from colleagues both when work was done well and when mistakes were made. They discussed how a supportive culture can influence the continuous improvement of nursing practise in their workplaces and make them better at their jobs. However, the nurses expressed that they needed time to discuss and reflect upon their work with colleagues in group settings and that there should be more time set aside for professional meetings. Unfortunately, whether such arrangements actually existed seemed to depend on the workforce situation. In focus group 1, the interviewer asked why advice from the more experienced colleagues was so important. Two of the nurses working in surgery wards explained:
They have got more experience. They have tried out different procedures and know what functions well or not, or what others before them have tried out. (3).
But of course you should always be open for other possibilities than listening to those who have been there for a long time (…) Things change, and they can be obstinate about the way things have always been done. It does not have to be that way. However, you have your own persons to discuss with. (4).
The interviewer then asked if they chose the co-workers they wanted to consult. One of the nurses working in a nursing home answered:
Maybe you ask those who are thoughtful and that you know will view things from different sides rather than those who are very obstinate and think they know what are the right things to do. (2).
In a similar discussion in focus group 2, the nurses agreed that whether they needed to confer with other nurses depended on the complexity of the situation as well as their own knowledge and experiences. The nurse working in nursing home care stated:
For instance, when it comes to procedures for healing wounds, you may feel that you can trust you know how to do it because you can try out different procedures. However, in other occasions, the consequences of what you’re doing can be much more serious, and then it is important to have someone to ask among your colleagues. You can get confirmation about what to do. (6).
These statements illustrate how and when the nurses sought guidance as well as how they initiated discussions with their peers to expand their knowledge. The interviewees emphasised that they needed work experience not only to learn what to do in the context of complex patient care but also how to cooperate with co-workers. Accordingly, the nurses also had to learn to deal with disagreements in their work communities. A nurse working in a nursing home told the following story:
I think it can be difficult when I as a nurse have the professional responsibility, and when there are enrolled nurses with long experience and they have very strong opinions. It was one situation, a patient was struggling with mucus, and the enrolled nurse said that we had to help the patient absorb it, and I knew that it would just be worse if we did that. But I think it’s difficult to say “No I don’t want to do it”. I have to stand for it and do the right things, and it’s not so easy…I would feel dreadful if I did anything wrong, because I’m the one who is responsible (…) You should do the best for the patient, but you also want to satisfy others. You don’t want to have dissatisfied colleagues. (8).
The nurses highlighted their responsibility for patient care while also explaining that they found it important to sustain the working climate. The experiences of nurses reported in this section underline their desire to be active in their learning. However, the work environment and social relations also affect this learning. Thus, the next section moves away from these concerns regarding how nurses both utilise and adapt to interpersonal relations to deal with how the nurses actively choose different knowledge resources accessible in their workplaces.
Accessing Important Knowledge Resources
The nurses referred to several knowledge resources that they understood to be important in their workplaces. They also explained that figuring out how to access these resources was part of the learning experience. The constant need for learning was emphasized by the nurses, and they had several strategies for managing these challenges. The nurse working in a medical ward shared the following:
I do not have knowledge about everything. Even if we have special areas, there is every possible kind of disease, and it is complicated and complex. It often happens that there are things I haven’t come across before or know anything about, but then I can ask somebody or I can read. I constantly have to do that, and I think I will always have to do that in this job. I will never be so professionally confident that I know everything. I don’t think so (…). And, of course there are things you don’t feel so confident doing, but you do it anyway, and well, then you learn it. (10).
Despite their varying workplaces, all of the nurses in this study expressed a need for various kinds of specialist knowledge to meet challenges and respond to complexity in patient care. The interviewees emphasised how their workplaces provided important sources of specialist knowledge through other nurses with special training. In nursing homes, for instance, one or two nurses are given the opportunity to participate in courses to expand their knowledge in a particular field. This is done in place of training all nurses in special fields related to basic patient care. One of the nurses described the role of these nurses as contact persons:
Some contacts are specially trained for hearing, eyesight, hygiene and wound healing. Apart from that, we receive extra training in wounds and wound products, and then there are the hygiene contacts who receive their training from hygiene nurses. (2).
Nurses with formal education beyond basic qualifications (e.g. nurses with further education in hygiene, cancer, or pain treatment) were also important knowledge resources. A nurse working in a surgical ward spoke about the utility of these knowledge resources when making decisions about patient care:
We have a nurse who is specially trained in cancer. We can ask her and discuss with her what should be tried during pain treatment so that we can suggest a treatment to the physician that day, instead of delaying it for another day. (4).
Physicians were another important source of specialist knowledge. The structure of the workplace influences the ability of nurses to get to know the physicians involved in patient care. However, most of the nurses expressed their access to physician knowledge as dependent upon their ability to overcome the authority of the physicians. The home care nurse described this during a discussion in focus group 2:
It is a threshold to cross to call the physician. You just do not make a phone call for everything. It has to be pretty serious. First, you talk to a colleague or look up the relevant literature or something, and then maybe you call the physician. (6).
The medical ward nurse noted that physicians were always present on the ward. Despite this, however, she emphasised that obtaining access to their knowledge required overcoming a fear of their authority:
I decided early that I should not be afraid of them (…) I have no qualms about calling them. However, it depends on the person. Some you can ask about everything, and ask if they can teach you anything. After all, we cooperate often with the physicians. (10).
Some of the nurses working in nursing homes emphasised their use of Internet resources to find research and knowledge applicable to their work. They explained how their workplaces made knowledge-seeking a routine part of work. A nursing home nurse explained her need to stay current:
The things where we are independent—it is occasionally those that I need to read up on or keep myself updated on. (2).
The nurse from the rehabilitation ward expressed her systematic use of an electronic documentation system containing information on patients:
We have access to the assessments made by all the people included in the team treating the patient. Then I can get useful information, and it is not always necessary to go talk to them (i.e. the physicians or physiotherapists). (5).
The nurses working in the surgical and medical wards explained that they seldom used Internet resources due to lack of time or lack of access to these resources. Instead, they emphasised their constant need for access to updated manuals or books. They expressed that they were generally able to use these resources to find the knowledge that they needed, including, for example, information on the procedures ordinarily performed in the ward.
The findings reported in this section show how the nurses needed to access knowledge to handle various work activities. In addition, these findings show how the multiple sources of knowledge related to the characteristics of the work community and the responsibilities in the different workplaces represented in this study.
The above three sections illuminate how nurses experienced their work in terms of learning. This study particularly focused on demonstrating that nurses need further learning when entering a variety of specialised workplaces after graduation from a general nursing education programme. The reports from the nurses underline the notion that learning in these environments is related to multiple facets of workplace experience, such as how the nurses were invited to participate in work activities; in which activities they were expected to participate; how they engaged in interpersonal relations with colleagues; and how they accessed knowledge resources to confirm, create, or develop their practical and professional knowledge. Their reports elucidate the interdependence between the intentional actions of individuals and their workplace practises. This understanding of work as a learning environment with respect to nursing practice is further discussed in the next section.