Within the UK the quality of care delivered in some hospitals, nursing homes and caring facilities has been the subject of significant enquiry, challenge and concern in recent years. There was need for a change in the culture of patient and client care. Traditionally a change in culture is seen as moving from an organizational head through to the organization and in this case through to front-line care. This hasn’t necessarily achieved the desired effect and impact in terms of quality of care within the UK. Historically, certainly nurses have acted more as recipients of change, rather than agents of change.

This paper suggests that schools of nursing and medicine with robust core values and a more consistently enacted culture of care are better able and more likely to transfer this to nursing and medical students within their professional socialization. In addition, and rather than the newly qualified nurse or doctor being absorbed into existing cultures of care delivery (which are not necessarily always reflecting high qualities of care), schools of nursing and medicine could better facilitate the development of more `agency’ within students and better equipping the students on qualification and stepping into practice, with a role and function as potential agents of change. Effective leadership within schools of nursing and medicine can both translate to quality and consistency, and enactment of organizational core values and working culture. The working culture of schools is intrinsic to developing students as agents of change.

Keywords: Agents of change; Medical; Nursing students

The environment in which nursing and medical students are educated could significantly impact on their development and professional socialization. In addition, schools of nursing and medicine help form in students a sense of self-efficacy and their professional assertiveness. Significantly, schools of nursing and medicine could perhaps more effectively encourage train and facilitate students as agents of change; particularly relevant in their early stages of qualification and practice within the health service. This discussion paper addresses the idea of organizational core values organizational culture and its transference to and through educators to students, with significant potential for impact on their professional approach to care and practice and contribution towards the building a more effective and proactive health service, rather than a reactive service effectively managing disease. Importantly, the paper explores the role of leadership within schools and the extension of agency through teaching and lecturing staff to students.

All effective organisations should have established and should work to core values [1,2]. Pendleton and King [3] define core values as ‘deeply held views that act as guiding principles for individuals and organizations’, they both shape the organization and its objectives and inform those within the organization and those engaged with the organization and reflect in relations within the organization. Intrinsic to schools of nursing and medical education is the need to both establish and work to the schools core values; mirrowedin the organizations performance and `intrinsic’ manifestations of the organizations integrity [4]. Collins and Porras [5] argue that robust core values translate to quality of practice, quality of performance and to quality of product delivery; often evidenced in the quality of product/service and of long-term success [6]. Core values, demonstrate both strength and vision translated through to levels of commitment and motivation within the organization. An organization that is both substantially guided and has significant leadership reflects in vision and the establishment and an adherence to core values [3,4] and help towards constructing greater connectivity, inclusiveness, collectiveness, personal agency and greater organizational collegiality [1,7].

Without clearly defined and worked to core values, this can reflect in organizational/staff confusion, incongruence and perceptions of shallowness or lack of organizational integrity [4,8]. Limited commitment on the part of staff is sometimes reflective of core values being interpreted as ' platitudes ' and in practice not effectively ‘honored’ or ‘upheld’ [4] .Significant within schools of nursing and medicine should be evidence of collegiality; commitment to a common professional purpose, in which power is effectively and appropriately shared in an atmosphere of mutuality and support [9,10]. These qualities are markers of what is sometimes referred to as `communities of learning’ or learning organizations [1,11,12]. Within such organizations/schools there would be greater evidence of an interconnectedness, effective agency and the valuing of individuals contribution to decision-making, with evident examples of transformational styles of leadership [1,13]. Agency within this context is defined as appropriate and relative independence, capacity, capability and freedom and acknowledged contribution [7].

Stevenson et al. [14] addresses the need to improve the experience of medical students within education in order to `enhance the professional and caring qualities of doctors’. Stevenson [14] suggests `that good role modeling could be of primary importance in the medical school environment’ and educators should `embody the values and behaviors that are desired of students and new doctors ‘‘ Freshwater & Stickley [15] focus upon the issue of emotional intelligence, its transformational role and centrality `at the heart of learning to care ‘ and as core principles within a nursing curriculum; with students reflecting a mirror image of their school of training and education.

Organizational culture has been significantly researched in recent years [1,2,7] and translates from an organizations core values. `An organization’s mission, vision, and philosophy both shape and reflect organizational culture ‘reflective in behaviors and organizational action and interaction [7]. Arguably the organizational culture of a school of nursing or medicine has an intrinsic effect upon a student’s professional socialization.

Models of organizational culture include:

1. A functional model.
2. A social action/symbolic interaction model of organizational culture.

Functionalist might view organizational culture as representing a managerialistorientated perspective, focusing on consensus and improving performance, significantly reflecting the role/impact of senior management; a corporate culture that can be potentially engineered. Functional models of organizational culture may manifest disproportionate features of role and task focuse [1]. By way of some contrast, social interactionists (critically orientated analysis) focuses on particular and specific social interaction and power relationships; a model in which individuals can potentially play a more significant role in shaping, developing and contributing to the change of organizational culture [16,17]. Learning organizations might demonstrate more qualities of social interaction and effective agency of staff [1], or in this case of schools of nursing and medicine, of students. Within the context of health care Yoder-Wise [7] suggests that true organizational culture is manifest in the immediate lived experiences of staff and patients. In earlier Canadian qualitative study with hospital nurses, Laschinger [18] suggests their perception was that their roles and agency were not respected by the hospital management, with perceived lack of concern, consultation, and involvement in decision-making or quality information giving. The study perhaps highlights the impact of a negative lived experience of organizational culture. Barr & Dowding [2] suggest that the UK National Health Service (NHS) is significantly a role culture. Roll cultures may manifest as hierarchical structures, relatively inflexible, departmental silos and historically suppression of individuality and agency [2]. Organizations marked by role culture are less likely to encourage and facilitate agency within the change process.

A range of literature presents the intrinsic importance of organizational culture and core values reflecting significant degrees of congruence [7,16], including within the education of health care professionals. Shared identity and perspectives are important to an organization’s cultural congruence and in the absence of that there is risk of cultural dissonance [1]. Cultural congruence or shared perspectives and identity are important within organisations and Waddington [19] discusses role socialisation of medical students as a reflection of their medical school. A less role focused and more person focused organisation is probably more likely to promote and facilitate agency and in developing potential agents of change. Wendland & Bandawe [20] also noted the important effect that the schools of medicine can have upon the professional socialization of medical students. Again Brosnan & Turner [21] also suggest the important impact that medical school culture can have in socialising students the `role of medical schools as powerful institutions; the socialisation process that medical students undergo during their period in training’ as ` representation of medical-school culture‘. Vaidyanathan [22] discusses the importance of and the need to effectively communicate a professional culture in medicine through medical schools; medical schools as a significant conduit to students socialisation, particularly and importantly ethical and idealistic values. Shinyashiki et al. [23] in a Brazilian study suggests that the `identity’ of the nursing student significantly reflects the socializing experience of their education, particularly the development of their professional identity. Khouri [24] emphasises the very important function of those educating nursing students as `role models’ both teaching to but also reflecting holism and a qualitative approach to care. Clements et al. [25] address and reinforce the important function of `commitment’ in the formation of a nursing students professional identity; again reflecting against their educators. Loke et al. [26] emphasise the essential core of professional nursing as caring, which particularly includes the formation of attitudes to `expressive caring’; in the absence of a high quality to nursing care the nurse would be professionally obliged to influence/effect more positive change in professional culture [27]. In reviewing the literature Baldwin et al. [28] identify the importance of role models within undergraduate nursing education and the particular impact of nursing academics in the development of the student’s professional identity. Again significant to the development and enactment of both organizational core values and the working culture within organizations (including and particularly schools of nursing and medicine), is the quality of leadership and the degree to which this reflects upon the students development and professional socialization.

Effective leadership is crucial to enacting organisational core values and organisational culture [1,2,7] and to the effective education of nursing and medical students. Nursing and medical students are being educated and trained to function effectively within the clinical domain. The NMC [27] suggest that in turn the quality of leadership is central to the effective delivery and quality of care.

The establishment of an effective practical and visionary organisational culture sits within the role of leadership [1,29]. Importantly, the role of leader is to clearly demonstrate and ensure adherence to the enactment of core values within the Department organisation. Mismatch or in congruence between the professed values and enacted policy and lived experience presentation translates to organisational, cynicism, and the motivation and that organisational culture is poorly or ineffectively internalised [1,30]. Effective leadership could perhaps be marked by the ability to help create and maintain harmony and levels of motivation within the organisation or school; key characteristics of `emotional intelligence’

Curtis et al. [31] argue that effective leadership is integral to developing, engaging and sustaining a more positive professional culture within nursing. Importantly they suggest that leadership qualities are intrinsic/essential to schools of nursing and should be clearly delivered within the nursing curriculum `nursing leadership should, therefore, begin at the earliest stages of basic nursing education and training ‘. Sometimes, perhaps, the roles and qualities of management and leadership can be presented as interchangeable, or juxtaposed. Importantly the authors argue, that rather than merely training nursing students as effective managers of care (working to existing policy practice and culture), the focus should be more upon leadership as change agent `a leader innovates, inspires, guides, and challenges’ [31] rather more reflective of transformational styles of leadership [1,16,32]. Importantly, leadership should both reflect the qualities and skills as an agent of change, but importantly should seek to promote and facilitate change agency that within the organization. The focus within schools of nursing and medicine could perhaps be more on engaging the skills and qualities within students. Students as potential agents of change within health care practice.

There is pressing need for some significant change within UK healthcare and an older professional centred role and culture is being increasingly challenged [2,33].

A change agent in health care, might present as one who significantly challenges the existing status quo, but has regard to the practical reality of health care providers and organizations of delivery. The change agent would neither be comfortable with nor complacent about existing systems and quality of delivery. Change agency would focus less on criticism and focus more on critical analysis-and particularly on the benefits of change [34].

Kay et al. [35] within a UK study outline an approach to both greater student participation in teaching and learning methods within University, but practically developing and facilitating their role in leadership and as agents of change. Hobbie [36] within the context of US Pediatric oncology notes the process of change is inevitable and perhaps accelerating within health care. Hobbie [36] suggests that nurses, both familiar with systems and with significant clinical expertise, are sometimes best placed to facilitate as change agents, rather than as merely recipients of change. Similarly Kerridge [37] argues that there is a pressing need for nurses not merely to participate in change but to take the lead in managing change and translate this to quality of care. Rather than focusing on change leadership within the formal management structure, the emphasis should be more upon health care workers as change agent. Importantly, Kerridge argues that the majority of people have the potential to lead change, but perhaps lack the `confidence’, knowledge and awareness/insight to change. These are skills the author argues, can be nurtured and facilitated. Allied Health Care Professionals Group Scotland [38] suggest a role for allied health care professionals, which is certainly not merely reactive or simply engaged in the delivery of care, but more significantly involved in the innovation and development of care. Kiehi & Wink [39] acknowledge that whilst acute placements are significant learning opportunities for developing care skills, and addressing complex illness and disease processes, relatively few clinical placement experiences facilitate the student’s development as critical thinkers and change agents. Kiehi & Wink [39] suggest, however, the importance of developing school based educative programmes and facilitating students as independent thinkers and change agents. Ortner [40] discusses the results of a programme of training and facilitating nurses as advocates and change agents in environmental health. The study group included student nurses. Ortner [40] suggests that principles of environmental health advocacy should be significant parts of leadership courses in nursing and should be included within undergraduate nursing education, equipping potential future nurses, as agents of change [40].

Rather than the newly qualified nurse or doctor being absorbed within and having to adapt to existing cultures of care in clinical practice, there is perhaps more potential for the newly qualified `set of eyes ‘ to perform as effective change agents, although this cannot be achieved without appropriate and structured programs developing agency within schools of teaching and learning.

Larsen et al. [41] in a small qualitative study in a UK University suggest the value in facilitating the development of students as change agents. The authors note that universities should in their own rights be agents for change within society and communities, reflecting on universities as learning communities. However, the authors argue that (even more so than the University institution) students may be the most significant agency for change-if properly empowered. Goodwin & Heymann [42] within the context of US public health call for students to be educated and trained as agents of social change within health care and impacting on local communities. Hole et al. [43] in a qualitative Norwegian study from within a Masters level programme suggest that students as health care professionals could be facilitated to develop analytical competencies/ skills and application as change agents within clinical settings. The authors underline the importance of learning organizations and the importance of support from leadership. Doung et al. [44] discuss and evaluates an approach within the US to developing medical student’s skills as innovators and agents of change, using a structured educational and training program. Couros [45] in addressing an innovative approach to higher education suggests less focus on compliance and an `industrial ‘model of education and more in developing positive assurance and agency in students. Couros outlines approaches to developing an impetus and motivation for change and innovation within students, significantly reflective on the quality of their relationships within the school [45] in.

Dunne & Zander [34] discuss approaches in teaching and learning for students in higher education to develop skills and abilities as change agents and to drive organizational change. They argue that in order to develop students potential as agents of change, within higher education they need to be more intrinsically involved as co-producers/shapers, active participants and facilitating positive role engagement. Significantly, this role is a reflection of and developed within their higher education institution, as learning communities. Rather than being a customer or consumer the student becomes increasingly the collaborator and co-producer in their educative experience, with less focus on institution driven, and more focus on student driven agendas. Dunne and Zander argue that whilst the students having a voice is important, this `may remain a passive experience in comparison to been given the opportunity to drive and lead change initiatives’ [34].

Successful and effective organisations delivering a quality of product are organisations more often marked by the quality and consistency of organisational core values and their transference through to and enactment of an effective, consistent and engaging organisational culture [1,2,4,5]. These are reflective of high performing organisations [1,4,7]. Schools of nursing and medicine should be marked by the quality of their school core values, their teaching and learning culture; percolating down through/mirrored in the teaching and lecturing staff and impacting on and helping to professionally socialise nursing and medical students. In the absence of substantial and enacted core values and collective culture, organisations, and those employed within them manifest degrees of dissonance, cynicism, resistance and this translates to quality in the delivery of product. In the case of schools of nursing and medicine, this impacts negatively on teaching, learning and the professional socialisation of students [23,25-27]. Transformational styles of leadership [1,2,7,28,31] are important and perhaps intrinsic to schools of nursing and medicine in helping to develop, establish and translate core values, a culture of care and the professional socialisation of students. Organisations and particularly schools of nursing and medicine, which manifest less role culture and are more closely engaged as learning organisations [13], are perhaps better able to engage the student qualities in developing their professional socialisation.

There continues to be evident problems within the UK health service in terms of the culture of care, or rather examples where there are significant deficits within care delivery [33]. There is urgency in the need for agency in change within the UK health service. Traditionally the process of change would be delivered through the hierarchy of an organisational structure, and particularly where the organisation manifests a role culture [2]. In some cases this change is evidently not happening, or is slow to embed at the clinical face. Perhaps historically, many newly qualified nurses and doctors have become embedded within and absorbed existing clinical care cultures. Alternatively, fresh to qualification as health care professionals and with qualities of effective and constructive critical appraisal, newly qualified health care professionals could engage more effectively as agents for change, with potentially positive impact on frontline care delivery [39,42]. Frontline nurses could and should be more effective agents of change [36]. In order to develop such a role, it would be necessary for schools of nursing and medicine to more effectively gear teaching and learning to developing student agency and particularly to facilitate and equip them as agents of change within practice [39].

There are some emerging and very positive examples of developing higher education students as agents of change [35,41-45] and this should become more consistently embedded within schools of nursing and medicine. Importantly, agency sits within and is reflective of positive substantial and enacted core values and organisational culture [8]. Perhaps even more importantly schools of nursing should reflect high qualities of leadership, leadership that is significantly engaged to both extending agency to staff and student educators and importantly transferring that empowerment to students as potential agents of change within health care delivery.