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The path to positive learning

Good-quality placements enhance student nurses’ understanding of illness in the community. Amy Noakes highlights how all parties can build beneficial learning opportunities.

Community placements provide valuable learning experiences by enabling students to gain an insight into the background to health status. The government is also currently emphasising – in Transforming primary care (Department of Health, 2014) and Five year forward view (NHS England, 2014) – the transfer of patient care away from the acute setting and closer to home, aiming for hospitals to be more available in providing specialised and acute care. This denotes a need for student nurses to be further prepared in caring for patients out of the hospital setting. 

The Willis Commission (2012) identified the difficulties in obtaining good-quality community placements for student nurses, yet pre-registration nursing commissioning numbers have expanded. This makes clear the need to ensure the drive for greater capacity of community placements is balanced with adequate support for student nurses’ learning needs. This article aims to provide consideration of preparation and support for students and mentors within the community setting, enhancing this valuable student learning experience.  

 

What constitutes a community placement?

The NMC (2010) considers a community placement to constitute time spent learning and experiencing care provided outside the acute hospital setting. Temple (2013) has highlighted the difficulties of defining what constitutes a community nursing practice setting. This is due to rapid changes in community nursing, as well as the need to expand student placements to a greater variety of settings due to capacity issues. Temple therefore indicates that the only aspect that categorised a placement as ‘community’ was a setting that does not encompass a prolonged inpatient hospital stay. This highlights that the community setting is moving away from the traditional image of solely community nurses such as health visitors or district nurses, and transferring to an out-of-hospital experience. A community placement could therefore encompass the following environments:

  • Hospice care
  • pecialist services such as neonatal or Macmillan nurses
  • Respite centres
  • Care homes
  • General practice
  • Health visiting
  • Community children’s nursing teams
  • Children’s centres
  • School nursing
  • Outpatient services
  • Pre-assessment services
  • Continuing care services
  • Virtual hospital services
  • Day surgery settings
  • Community hospitals
  • Walk-in centres
  • Minor injury units.

With such a variety of placements being provided within the community, it is important students are able to adapt to these environments, while also being fully equipped for the experience.  

 

Why are good-quality community experiences important for students?

The NMC (2010) standards for pre-registration nursing education identify the need for practice placements to provide diverse learning opportunities within a multitude of health and social care environments, including the community. This was supported by the Willis Commission’s Raising the bar review (2015), where the need for community placements to occur throughout nurse training was emphasised. 

Health Education England, higher education institutions and the NMC have been collaboratively trying to meet the recommendations of the Willis review to improve pre-registration nursing education and encourage positive practical learning environments. This includes a proposal regaling changes to the structure of nursing education programmes and mentorship. It is therefore recognised that innovative methods of mentoring students in the community must be employed to provide good learning opportunities and support students in completing their nurse training (Perrin and Scott, 2016). 

Technological enhancements have enabled patients to live longer; however, this has meant more patients are living with co-morbidities, requiring complex care interventions (RCN, 2014). Students need to have greater awareness of this as nurses possess a fundamental role in coordinating care pathways post-discharge and implementing the reform to encourage care at home. Community placements also provide valuable student learning opportunities because of the ability to gain understanding of services available outside of the acute setting, in addition to recognising how policy and guidelines are implemented within this environment. Students are also able to gain a multitude
of transferable skills, including communication, teamwork and some comprehension of the concept of health promotion and lifespan development.

It is hoped that by providing more community placements, the stereotypical image of nurses working within the hospital-based setting could be changed. It is also envisaged that this will increase the workforce within this environment, particularly as an NHS census showed a 10.7% (29,689) increase (to 307,692) in the qualified nursing workforce within the community between 2003 and 2013 (Health and Social Care Information Centre, 2014). A survey by the RCN (2012) showed that nurses in the community felt reduced capacity and increased caseloads applied additional pressure on nursing teams. This survey revealed that 86% of the 2219 participants thought patients were discharged from hospital more quickly than before, and 92% considered that staff were dealing with more complex health needs. Encouraging good-quality student placements could help reduce this deficit and fully equip students to work within a transformational environment, enhancing confidence to apply for community positions post-qualifications. 

 

What are the support requirements within community placements?

When stress and anxiety are reduced for both the mentor and student, practice environments become more beneficial to learning (Miller, 2014). It is therefore necessary to ensure that support needs within placement are considered. Factors affecting student enjoyment of placement are multifaceted in respect of the placement environment, the student, the mentor and link lecturer (university representative who acts as a connection between the university and placement). Suggestions of ways to provide support and enhance student enjoyment are presented below.

Placement environment

The breadth of experience available within the practice learning environment has been recognised as a possible impact to student learning (Emanuel and Pryce-Miller, 2013). This can be aided by a thorough initial interview, with a discussion between the student and mentor regarding their aims for the placement setting, appropriate objectives and identifying how these will be reached. 

Student inclusion within the placement area can impact their enjoyment and ability to learn; for example, a space to sit within the office environment and access to computers can enhance students’ feelings of purpose (Papp et al, 2003). An environment that is unstructured and not inclusive can lead to students feeling unsupported, which impacts on their learning. 

There is a need for community health providers to support both the mentor and student as it has been shown that mentors who feel their workload is excessive experience greater difficulty in supporting students (Kenyon and Peckover, 2007). This can potentially impact on the quality of their placement. Therefore, adequate time should be made available to ensure the mentoring role can be undertaken thoroughly.

 

The mentor

The mentor’s knowledge and how this is imparted can greatly affect students’ learning: those who possess a positive attitude towards students are considered to provide better placements (RCN, 2009). This is particularly important within the community because students could be working solely with the same individual for the majority of their placement. There is a need for mentors to be supportive via encouraging teaching and involvement within the placement. 

Mentors should endeavour to facilitate learning by explaining aspects clearly, encouraging reflection and questioning, and organising a variety of experiences related to the placement (Foster, 2015). Students have reported that they enjoy a participatory role as much as possible, rather than an observational role (Tattam, 1991). However, there may be difficulties for practice areas in which the nurse’s role chiefly revolves around communicating with patients/clients, rather than practical skills, and so post-visit reflections should be encouraged. 

Willis (2015) identifies student feedback as key to ensuring a positive and high-quality learning environment. It is therefore crucial that mentors review the feedback provided to them via students, and an action plan for improvement is constructed, as necessary, to ensure continual improvements.

 

The student

The students’ approach to the placement can influence their enjoyment and ability to learn. The placement needs to be perceived as relevant to the student to enhance their learning. Student preparation for practice sessions within university can assist not only in respect of placement expectations, but also in relating the relevance of the placements to themselves. Thus it is encouraged that students should arrive at the placement with a positive attitude, ready to learn and gain a greater view of the context of health. Wilson (2015) points out that, to make the most out of a placement, it is important to recognise that every patient experience is valuable; due to the speciality of a community placement, this could be the sole opportunity to work with this client group, and therefore motivation and ability to reflect are paramount. 

A professional attitude to placement, according to the NMC guidance on conduct for students (2012), should be maintained throughout. Students should treat others with dignity and honesty, and collaborate to promote the wellbeing of clients/patients, in addition to providing a high standard of care within their limitations. Students’ personal preparation for practice, by reviewing current literature in respect of the placement, can also emphasise the placement relevance to individual nursing knowledge.

 

The university

Students and mentors consider the link lecturer role a key communication conduit between practice and university. The role is harder to deliver within the community because of the dispersed locality of placements. It is therefore necessary that the link lecturer is easily contactable by and readily available to provide support (Foster et al, 2015). Also, regular visits to practice learning environments enable visualisation of support for both students and mentors. Sessions for students to reflect on their experience at the placement midpoint enable the learning undertaken to be related to theory, in addition to providing the ability to detect early any issues within placement.

Support to mentors by providing yearly updates within practice areas and timely educational audits aims to ensure the quality of practice learning environments. It also enables good links with the practice areas, so any organisational changes that could impact student learning could be identified and resolved.

 

Conclusions

A collaborative approach is required to ensure good-quality community placements. When this is provided, students can gain a good overview and learning experience regarding community services, with an aim of encouraging students’ enthusiasm to want to work within this environment. However, not all students can have a desire to work within the community post-registration. It is hoped that these students will still gain good understanding of services available out of the acute setting to enable a smooth transition for patients when discharged from hospital.

The community placement is a valuable experience in which students can acquire a breadth of knowledge. Continued consideration of the supportive needs for students is required by all professionals working within the community and the university to enable a positive learning experience. 

  • What is your experience of the evolving multi-option approach to what ‘community’ – and therefore community nursing – means? What are the advantages of the new approach, and of the previous divide between acute hospital-based nursing and community nursing? Let us know at aviva@communitypractitioner.co.uk
  • Amy Noakes is senior lecturer in the Department of Children’s Nursing, School of Health and Social Care, at London South Bank University

Key points

  • The community placement has transitioned from the traditional view of occurring solely with a health visitor or district nurse. It now encompasses learning within a variety of out-of-hospital environments.
  • A community placement provides a valuable learning experience for pre-registration nurses to gain understanding of patients’ needs in the community in addition to lifespan development.
  • There is a need for trusts, mentors, universities and students to work collaboratively to ensure a positive and supportive learning experience during a community placement. 

References

Department of Health. (2014) Transforming primary care: safe, proactive, personalised care for those who need it. See: housinglin.org.uk/_assets/Resources/Housing/Policy_documents/Transforming_primary_care.pdf (accessed 15 September 2017).

Emanuel V, Pryce-Miller M. (2013) Creating supportive environments for students. Nursing Times 109(37): 18-20.

Foster H, Ooms A, Marks-Maran D. (2015) Nursing students’ expectations and experiences of mentorship. Nurse Education Today 35(1): 18-24.

Health and Social Care Information Centre. (2014) NHS workforce: summary of staff in the NHS: results from September 2013 census. See: content.digital.nhs.uk/catalogue/PUB13724/nhs-staf-2003-2013-over-rep.pdf (accessed 22 September 2017).

Kenyon L, Peckover S. (2008) ‘A juggling act’: an analysis of the impact of providing clinical placements for pre-registration students on the organisation of community nursing and health visiting work. Nurse Education Today 28(1): 202-9. 

Miller SL. (2014) Assisting students to prepare for a clinical practice placement. Nursing Standard 29(15): 51-9.

NMC. (2012) Guidance on professional conduct: for nursing and midwifery students. See: bit.ly/2hlV7nr (accessed 22 September 2017).

NMC. (2010) Standards for pre-registration nursing education. See: nmc.org.uk/standards/additional-standards/standards-for-pre-registration-nursing-education (accessed 15 September 2017).

NHS England (2014) Five year forward view. See: england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed 15 September 2017).

Papp I, Markkanen M, von Bonsdorff M. (2003) Clinical environment as a learning environment: student nurses’ perceptions concerning clinical learning experiences. Nurse Education Today 23(4): 262-7. 

Perrin L, Scott S. (2016) Health visitors have much to offer pre-registration child branch student nurses. Community Practitioner 89(5): 44-7.

RCN. (2014) Moving care to the community: an international perspective. See: my.rcn.org.uk/__data/assets/pdf_file/0006/523068/12.13_Moving_care_to_the_community_an_international_perspective.pdf (accessed 22 September 2017).

RCN. (2012) The community nursing workforce in England. See: https://my.rcn.org.uk/__data/assets/pdf_file/0003/450525/09.12_The_Community_Nursing_Workforce_in_England.pdf (accessed 22 September 2017).

RCN. (2009) Guidance for mentors of nursing students and midwives. See: my.rcn.org.uk/__data/assets/pdf_file/0008/78677/002797.pdf (accessed 15 September 2017). 

Tattam A. (1991) Growing pains. Nursing Times 87(51): 17.

Temple J. (2013) What constitutes a community placement? Nursing Times 109(37): 16-7.

Willis Commission. (2015) Raising the bar. Shape of caring: a review of the future education and training of registered nurses and care assistants. See: hee.nhs.uk/sites/default/files/documents/2348-Shape-of-caring-review-FINAL.pdf (accessed 22 September 2017).

Willis Commission. (2012) Quality with compassion: the future of nursing education report of the Willis Commission. See: macmillan.org.uk/documents/newsletter/willis-commission-report-macmail-dec2012.pdf (accessed 22 September 2017).

Wilson K. (2015) Making the most of the student-mentor clinical partnership. Nursing Times 30(5): 73.

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