Table Of ContentMutual Development through Authentic
Relationships: Adventures, Journeys and
Appreciative Stories of Service User
Engagement in Student Nurse Education
by
Julie Dix
A thesis submitted in partial fulfilment for the requirements for the degree of
Doctor of Philosophy at the University of Central Lancashire
January 2016
Mutual Development through Authentic Relationships:
Adventures, Journeys and Appreciative Stories of
Service User Engagement in Student Nurse Education
STUDENT DECLARATION FORM
I declare that while registered as a candidate for the research degree, I have not been a
registered candidate or enrolled student for another award of the University or other
academic or professional institution
I declare that no material contained in the thesis has been used in any other submission for
an academic award and is solely my own work
Signature of Candidate
Type of Award: PhD
School of Health
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Abstract
Current educational guidelines require clear evidence of the involvement of service users
across the nursing curriculum, but give no real direction as to how to achieve this, or clarity
about what would constitute successful engagement. There is a limited body of literature
that specifically addresses service user engagement in the classroom and this literature is
largely evaluative in nature, small scale, single site, often atheoretical and many do not
include service user perspectives. The studies present evidence of the value of service user
engagement, albeit not in great breadth or depth, but fail to critically examine the actual
processes and practices that contribute to the perceived success of service user
engagement in the classroom. This study seeks to develop and strengthen the current
understanding of service user involvement in nurse education and the way in which it is
enacted in the classroom setting. In this study, the term ‘service user’ encompasses people,
carers and families with experience of healthcare who are involved in teaching sessions
with pre-registration nursing students for the purposes of sharing their life experiences.
A participatory, Appreciative Inquiry approach was taken, using a series of appreciative
workshops (n=8), observations of teaching (n=5) and interviews (n=3). These approaches
ensured that there were opportunities for the participants to generate and share their
stories and experiences of service user engagement. This participatory appreciative
approach also ensured that all voices within the study were respected and that ethical
considerations were attended to with high levels of sensitivity. These approaches also
facilitated the critical consideration of the interactions, dialogues and relationships that
occur between pre-registration nursing students, service users and lecturers. Data were
analysed using a thematic narrative approach drawing on the principles of socio-
narratology and considering three key components: setting, character and plot.
Three themes were identified: the first ‘real world as opposed to what?’ focuses on setting;
the second ‘students, service users, lecturers - there is a togetherness about it all’
addresses the characters within the classroom; and the third ‘involving service users has
helped me grow as a student nurse’ considers issues related to plot. The overarching meta-
theme, ‘mutual development through authentic relationships’, encompasses the idea that
service user engagement is more than merely an action carried out by service users (sharing
life experiences) for the benefit of students in their development as compassionate nurses.
Instead, service user engagement is a complex and mutual set of interactions and
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relationships between service users, students and lecturers. These interactions and
relationships occur within a distinct setting, are grounded in authenticity (where
authenticity is interpreted as something which is real, genuine or true), and influence the
development of shared narratives of service user oriented practice.
The core contribution to knowledge from this study is summarised within a model of best
practice for service user engagement that is built from the findings and based within
contemporary theoretical thinking on service user engagement. The model presents a map
of the journeys of students, service users and lecturers and the ideal classroom conditions
for successful service user engagement. It also reveals the processes and practices that
occur in classrooms and the profound, positive impact of service user engagement, such as
nourishing the emotional lives of student nurses in a way that consolidates compassion.
Recommendations for practice, policy and research are presented.
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Table of Contents
Abstract 2
List of Tables and Figures 8
Abbreviations 9
Acknowledgements 10
1 Introduction and Background 11
1.1 Introduction 11
1.2 The Context of Service User Engagement 11
1.3 Terminology 15
1.4 Healthcare Education Policy 15
1.5 Pre-registration Nursing Programme Outcomes 17
1.6 Space, Place and Sense of Self 20
1.7 Aims of the Current Study 22
1.8 Chapter Summary 22
2 Literature Review 24
2.1 Introduction 24
2.2 Review Methods 24
2.2.1 Design 24
2.2.2 Search Strategy 25
2.2.3 Overview of Papers included in Full Text Evaluation 26
2.2.4 Final Selection of Papers 28
2.3 Results 34
2.3.1 The Student Point of View 34
2.3.2 The Service User Point of View 43
2.3.3 The Staff Point of View 46
2.3.4 Interconnectedness 47
2.4 Limitations in the Context and Scope of the Literature 48
2.4.1 Rationale for the Current Study 49
2.5 Chapter Summary 50
3 Methodology and Methods 52
3.1 Introduction 52
3.2 Methodology 52
3.3 Appreciative Inquiry 53
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3.3.1 What is Appreciative Inquiry? 53
3.3.2 The Appreciative Inquiry 4-D Cycle 55
3.3.3 The Appreciative Method 56
3.3.4 Criticisms and Limitations 56
3.4 An Overview of the Appreciative Inquiry Approach Used in the Study 57
3.5 Context, Ethics and Recruitment 57
3.5.1 An Overview of the Research Context 57
3.5.2 Access, Ethics, Informed Consent and Governance 57
3.5.3 Participants: Target Population and Recruitment 59
3.6 Using Appreciative Inquiry, Being Flexible and Collecting the Data 61
3.6.1 Phase One: Workshops & Graffiti Wall 65
3.6.2 Phase Two: Workshops & Observations 69
3.6.3 Phase Three: Workshops 72
3.6.4 Phase Four: Workshops, Interviews & Survey 73
3.7 Chapter Summary 76
4 Data Analysis 77
4.1 Introduction 77
4.2 The Preparation of the Data 77
4.3 A Journey to Identifying an Appropriate Analytic Approach 78
4.3.1 The Initial Approach: Thematic Analysis 78
4.3.2 Narrative Analysis 78
4.4 Thematic Narrative Analysis and Being Iterative 80
4.5 Developing the Themes: Narrative and Journey 81
4.5.1 Theme 1 - Setting: Real world as opposed to what? 84
4.5.2 Theme 2 - Character: Students, service users, lecturers - there is a
togetherness about it all 85
4.5.3 Theme 3 - Plot: Involving service users has helped me grow as a student
nurse 85
4.6 The Meta-Theme: Mutual Development through Authentic Relationships 86
4.7 Reporting the Findings 86
4.8 Chapter Summary 87
5 Setting: “Real world as opposed to what?” 89
5.1 Introduction 89
5.2 University vs. Real Life 90
5.3 A Safe World 95
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5.4 A Practical World 101
5.5 Chapter Summary 105
5.6 A Closing Narrative: Stepping into Another World 106
6 Character: “Students, service user, lecturers - there is a togetherness about it all” 108
6.1 Introduction 108
6.2 Interacting Together 109
6.3 Asking Questions 114
6.4 Being Real 117
6.5 Balancing Power 123
6.6 Chapter Summary 126
6.7 A Closing Narrative: Building Authentic Relationships 128
7 Plot: “Involving service users has helped me grow as a student nurse” 130
7.1 Introduction 130
7.2 Personal Gain 131
7.3 Reflection 137
7.4 Implications for Practice 141
7.5 Temporal Aspects 144
7.6 Chapter Summary 146
7.7 A Closing Narrative: Reflecting on Experiences 147
8 Discussion 149
8.1 Introduction 149
8.2 The Beginning of the Journey and the Call to Adventure 151
8.3 The Adventure 154
8.3.1 Setting and Our Sense of Self 157
8.3.2 The Impact of Self on Interactions 162
8.4 The Return Home and Continuation of the Journey 170
8.5 Mutual Development through Authentic Relationships: A Model of Best Practice
177
8.6 A Reflexive Account of the Researcher’s Journey 180
8.7 Limitations 182
8.7.1 Data Collection and Recording 182
8.7.2 Recruitment 182
8.7.3 Scale 183
8.7.4 Method 183
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8.8 Implications and Recommendations 184
8.8.1 Implications for Classroom Practice 184
8.8.2 Implications for Policy 185
8.8.3 Recommendations for Future Research 186
8.9 Conclusions 188
9 References 190
10 Appendices 209
10.1 Appendix 1: Confirmation of Ethics Approval 210
10.2 Appendix 2: Information Sheets and Consent Forms - Students 212
10.2.1 Information Sheet: Appreciative Workshops 212
10.2.2 Consent Form: Appreciative Workshops 216
10.2.3 Information Sheet: Observations 217
10.2.4 Consent Form: Observations 220
10.2.5 Consent Form: Interviews 221
10.3 Appendix 3: Information Sheets and Consent Forms - Service Users 222
10.3.1 Information Sheet: Appreciative Workshops 222
10.3.2 Consent Form: Appreciative Workshops 226
10.3.3 Information Sheet: Observations 227
10.3.4 Consent Form: Observations 230
10.4 Appendix 4: Information Sheets and Consent Forms - Lecturers 231
10.4.1 Information Sheet: Appreciative Workshops 231
10.4.2 Consent Form: Appreciative Workshops 235
10.4.3 Information Sheet: Observations 236
10.4.4 Consent Form: Observations 239
10.5 Appendix 5: Phase Two Data Collection Observation Coding Sheet 240
10.6 Appendix 6: Phase Four Data Collection Survey 242
10.7 Appendix 7: Example of an Iteration of Data Analysis 249
10.8 Appendix 8: An Overview of the Three Novels Chosen To Illustrate the Findings
250
10.8.1 The Chronicles of Thomas Covenant: The Unbeliever, Stephen R
Donaldson 250
10.8.2 Lord of the Rings, JRR Tolkien 250
10.8.3 Earthsea, Ursula K. Le Guin 251
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List of Tables and Figures
Table 1-1 Standards taken from the NMC Standards for Pre-Registration Nursing Education,
2010, p59-82 16
Table 2-1 Inclusion and Exclusion Criteria 25
Table 2-2 Papers Not Included in Review, but Referenced Elsewhere in this Thesis 29
Table 2-3 An Overview of the Fourteen Papers Meeting the Criteria for Inclusion in the Final
Review 30
Table 3-1 Participant Data 63
Table 3-2 Positive Aspects - Phase One Workshops 68
Table 3-3 Themes - Phase Two Workshop 69
Table 3-4 Statements and their Responses - Phase Four Survey 75
Figure 2.1 Flow Chart of Literature Search 26
Figure 2.2 Sources Identified in the Integrative Literature Review, by year of publication
(Note: the data for 2015 only includes January) 27
Figure 3.1 A Diagrammatic Representation of the Process of Data Collection 64
Figure 4.1 The Process of Data Analysis 79
Figure 4.2 The Meta-Theme, Themes and Sub-Themes 84
Figure 5.1 Theme and Sub-Themes for the Narrative Element of Setting 90
Figure 6.1 Theme and Sub-Themes for the Narrative Element of Character 109
Figure 7.1 Theme and Sub-Themes for the Narrative Element of Plot 131
Figure 8.1 The Beginning of the Journey and the Call to Adventure 153
Figure 8.2 The Adventure 155
Figure 8.3 The Return Home and the Continuation of the Journey 172
Figure 8.4 Mutual Development through Authentic Relationships: a model of best practice
179
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