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Evaluation of the Specialist Community Public Health Nursing Peripatetic Assessment Model

Dr Toity Deave, Dr Claire Novak, Judy Brook, and Dr Debra Salmon discuss their evaluation of the new model from the perspective of SCPHN students, mentors, practice teachers and managers.

Evaluation of the specialist community public health nursing peripatetic assessment model

Dr Toity Deave PhD, MSc Epid., MMedSci, PgDipHV, SRN Associate Professor for Family & Child Health, Centre for Child & Adolescent Health, Health & Applied Sciences, University of the West of England Bristol.

Dr Claire Novak PhD, MSc, PgDipHV, SRN Research Fellow, Centre for Child & Adolescent Health, Health & Applied Sciences, University of the West of England Bristol.

Judy Brook MSc, BSc, RHV, RN (Child), RGN, RNT, PGCHE Lecturer, Health Visiting, School of Health Sciences, City University, London. 

Dr Debra Salmon PhD, MSc, BA, HV, RNT, Cert Ed, RGN, RSCN Deputy Dean, School of Health Sciences, City University, London.


Key points

  • The government’s training plan for an extra 4200 new health visitors in England resulted in a vast rise in student numbers.
  • Responding to new NMC standards, Somerset introduced a peripatetic model of student practice supervision. Students were given mentors; both were supervised by practice teachers. 
  • Students reported favourably on their experiences of the assessment model, and enjoyed the chance to observe closely and be supervised by two experienced practitioners. 
  • More experienced practice teachers reported that students received more consistent experience and education than in the previous one-to-one model. 
  • Managers described the peripatetic model as influential in upskilling the wider health visiting workforce.
  • This assessment model, despite some criticisms, has been successful and well accepted and has provided a large number of high-quality, suitably trained health visitors. 

Abstract

The Health Visitor Implementation Plan 2011-15: a call to action, called for an additional 4200 health visitors to be trained by 2015. To accommodate larger numbers of students, specialist community public health nursing (SCPHN) programmes across the UK have undergone significant transformation in terms of practice supervision. Somerset Partnership NHS Trust introduced a peripatetic assessment model involving practice teachers and practice mentors. This differed from traditional one-to-one approaches of supervision to one-to-three. Practice teachers mostly supervised students through close collaboration with mentors who worked directly with students on a daily basis. Using a mixed methods approach, the evaluation aimed to assess the effectiveness of the new model from the perspective of SCPHN students, mentors, practice teachers (PTs) and managers. Data was collected through an anonymous online survey and individual interviews or focus groups. Overall, participants were positive about the peripatetic model’s impact on student learning and practice experience, in addition to the general up-skilling of the wider health visiting workforce and possible implications of continuation into the future. Any concerns raised focused on adequate preparation and support for mentors and the need for clear communication and role differentiation between practice teachers and mentors.

Key terms: evaluation, Health Visitor Implementation Plan, supervision, practice teachers, SCPHN students.


Introduction

The Health Visitor Implementation Plan 2011-15: a call to action (HVIP) set out a high-profile policy drive to revitalise and refocus the health visiting service across England (DH, 2011). The HVIP identified the need for greater capacity in the health visitor workforce and set out an ambitious target of training an additional 4200 new health visitors between 2011 and 2015 (DH, 2011). This resulted in an unprecedented increase in student numbers, which impacted on the design and delivery of educational programmes for SCPHNs across England. A significant component (50%) of SCPHN education includes learning in practice; the student spends half their time within the practice environment, supported by practice teachers who facilitate knowledge and skills development and assess the student’s competence. Practice teachers are accountable to the NMC for confirming the student’s fitness for registration (NMC, 2008). Historically, this model assumed a one-to-one relationship between student and practice teacher, which became unsustainable given the significant increase in student numbers and pace of policy implementation. In addition to the possible compromise to educational standards delivered and negative impacts on service quality and safety (Harries, 2011; Naughton, 2013; Mundy 2011), concerns were raised about impacts on the wider health visiting workforce, practice teachers and clinical placements (Mundy 2011). In response to these changes, the NMC issued guidelines (NMC, 2011) that allowed flexibility within the Standards to Support Learning and Assessment in Practice (NMC, 2008) to accommodate the implementation of the HVIP, which revised standards of one-to-one practice supervision to allow more flexible arrangements. In response to these changes, Somerset Partnership NHS Trust implemented the peripatetic model of student practice supervision: qualified practice teachers could supervise up to three SCPHN students simultaneously. Students were assigned to health visitor mentors in clinical practice who held an additional NMC recognised mentor qualification. Practice teachers supported several mentors and their students, working with the student to develop action plans to support their personal learning needs and working closely with the mentors to ensure that the student was offered opportunities to learn and develop appropriately. The practice teacher was accountable for the final assessment of student competence required to practise as a health visitor (NMC, 2004). In addition, the Trust had introduced practice teacher-led learning sets where students came together as a group with practice teachers to discuss and develop their learning.

While the peripatetic model was not new, as a similar ‘long-arm’ approach was previously used in a social work setting (Karban, 1999), the HVIP prompted commentary on health visitor educational models. This paper describes one of the first evaluations of this policy change associated with the delivery of a new model of health visitor student supervision. The evaluation assessed the effectiveness of the new model from the perspective of SCPHN students, mentors, practice teachers and managers. The three objectives of the evaluation were:

  1. To establish, from a range of stakeholder perspectives, the quality and value of the proposed model;
  2. To explore the experiences of SCPHN students of mentor and practice teacher support and any impact on their learning;
  3. To make recommendations for the development of health visitor education at local and national levels.

Methods

A mixed-methods approach, using qualitative and quantitative data collection, was used to elicit the opinions of participants.  CPHN students (n=32), mentors (n=38), practice teachers (n=14) and managers (n=3) from the Somerset Partnership NHS Trust were invited to participate. Liaison between the stakeholder groups was conducted by the Project Lead, a member of Somerset Partnership health visiting workforce, which ensured that the research team only had the contact details of stakeholders who wished to participate in the evaluation.

Data was collected using a two-stage process: completion of an anonymous online survey and participation in a one-to-one interview or focus group. A survey and semi-structured interview was developed for each group of participants and approved by the Project Advisory Group.

Survey data was analysed using descriptive statistics. Interviews and focus groups were audio-recorded and transcribed verbatim, and field notes were taken during the interviews. Data was anonymised and analysed using Braun and Clarke’s (2006) six-stage technique for thematic analysis, the analysis of the data was predominantly deductive and conducted at the semantic level.

Ethical approval was obtained from the UWE Research Ethics Committee and the Research and Development team from Taunton & Somerset Partnership NHS Trusts.


Results

In total 30 (94%) students (22 near completion, eight early in their training), 16 (42%) mentors and nine (66%) practice teachers completed the online survey (table 1). Twelve students, five mentors, three practice teachers and three managers were interviewed or took part in focus groups.  

Table 1: Participant data collection 

Table 1 - Participant data collection

 

Student survey data (n=30)

Students reported that the experience of becoming a SCPHN student had been rewarding (n=25 (83%) and enjoyable (n=27 (90%)(table 2). Learning in practice had helped them achieve their learning outcomes (n=27 (91%); n=7 (87.5%)); provided them with a varied and broad cross-section of health visiting practice (n=2 (90%) and, in turn, they felt their presence had helped maintain practice standards (n=28 (93%).

The majority of students felt well-supported in their placements by practice teachers (n=27 (90%) and mentors (n=27 (90%). Supervision had generally fulfilled their expectations (n=28 (93%) with the majority finding the advice they received consistent (n=25 (83%). Most students reported that it was easy to access support from the university (n=23 (77%).

Table 2: Students’responses to online survey (n=30)

Table 2: Students’ responses to online survey (n=30)

 

Students’ focus group and interview data (n=12)

Students reported feeling well prepared for independent practice and supported by their mentor and practice teacher. Although some students described feeling over-protected from the challenges of working as a health visitor, and shielded from workforce crises, others felt they had received a good grounding in the reality of the role.

Students nearing the end of their programme were less confident about their practice teacher’s ability to assess their competency, given the limited contact between them; they expressed doubts about the effectiveness of the communication between mentors and practice teachers. Variations in the amount of evidence their practice teachers expected them to provide to demonstrate their competency to meet the programme requirements was also reported.

‘...I think I would have rather have seen my CPT more…I just felt that sometimes my CPT she would sign me off and say “Yeah, that’s lovely, that’s really good,” and I was thinking, “You have not even asked my mentor about my practice… you are just getting this from me! How do you actually know I am any good in practice?”’ R4.

Overall, both student cohorts reported favourably on their experience of the assessment model. They valued the broad and varied experience of health visiting practices that had prepared them well for practising independently. They had enjoyed the opportunity to observe closely, and be supervised by, two experienced practitioners, be part of the wider health visiting team and experience the day-to-day reality of health visiting within a progressive training programme.

 

Mentor survey data (n=16)

Sixteen mentors responded (42%), of whom 14 (88%) reported finding their role was rewarding and was enjoyable, kept them updated (n=14, 88%)(table 3). Without exception (100%), they stated that helped maintain practice standards and a good way of preparing students for practice. Most felt prepared for the mentorship role (n=11 (69%), well supported by practice teachers (n=14 (88%) and managers (n=10 (63%) but were less positive about access to the university for support (n=6 (38%). They felt it was more time-consuming than expected (n=12 (75%) and the nature of the role was very challenging (n=8 (50%).

Table 3: Mentor survey data

Table 3: Mentor survey data

 

Mentors’ interview and focus group data (n=5)

Mentors considered mentoring a good method of preparing students for qualified practice, especially with large numbers to supervise. Compared to the previous one-to-one model, students were reported to be exposed to a greater number of practitioners, differing styles of working and varied experiences. They agreed that supervising SCPHN students in practice kept mentors up-to-date and resulted in improved levels of knowledge amongst qualified staff. The overall impact had been to rejuvenate, not only individual practitioners, but also the wider workforce:

‘Having somebody there with you saying “Why are you doing this?” and “What did you do that for?” is a real positive.’ (0182).

Good relationships between practice teachers and mentors were viewed as important to ensure students gained optimal experience during the placement. Face-to-face or email/telephone contacts between mentors and practice teachers varied and included preparatory discussions about the role and ongoing progression meetings with students. Beyond this, mentors expressed the need for training and supervision for their role, especially prior to taking a student. They suggested a formal process of preparation for mentors and locally run mandatory training for all the different pre-registration and post registration student groups. Whilst mentors were largely positive about the new assessment model, broader concerns were raised about issues of workload and lack of role recognition.

‘Acknowledgement of mentors is an important part of the process to have a strategy or guideline…that means everybody follows a similar guideline.’ (40025)

The absence of an explicit ‘exit strategy’ after completion of the HVIP in 2015 was a concern. Central to this view was that the gains that had been made might be lost in a return to the one-to-one model of student supervision, exclusively led by practice teachers.

‘I would recommend it…should be sort of proactive expectation. Formalised into a role…with time allocation..’ (40028) ‘…the Trust could learn…time is needed to work creatively.” (40027) ‘A similar strategy/guideline in terms of the process of students.’ (40025)

 

Practice teacher survey data (n=9)

Nine out of 14 practice teachers responded (64%) and reported that balancing caseloads and roles was challenging (n=7, 78%) but felt sufficiently supported by managers to guide and support mentors and students (n=7, 78%)(table 4). There was less consensus about the adequacy of time available to support the assessment process (n=4 (44%) disagree, n=3 (37%) agree). Opinion was divided on the degree to which the HVIP process had allowed mentors to be sufficiently prepared for their role (n=2, (22%) agree, n=2, (22%) unsure, n=5 (56%) disagree).

Table 4: Practice teacher survey data

Table 4: Practice teacher survey data

Practice teachers’ interview data

Practice teachers felt that the breadth of experience that students were exposed to and the wide range of practitioners enabled them to see different forms of practice, develop clinical reasoning skills and identify a personal style of working. More experienced practice teachers reported students now received a more consistent level of experience and education than in the previous one-to-one model, supported by regular attendance at action learning sets by both practice teachers and students. However, for some practice teachers there were drawbacks to the peripatetic model: some reported feeling uncomfortable relying on the mentor’s assessment of student ability, particularly given their own limited student contact time.

‘My preferred way of teaching is one-to-one…I have found it very difficult to...feel completely confident about…their abilities and when it comes to signing off.” (0024)

For those supervising three students, the model was thought to be time-consuming, as it was difficult to balance the needs of clients, mentors and students with insufficient protected time. As a result the wider health visiting team had picked up extra work.

Practice teachers felt mentors could have been better supported earlier in their mentorship role to equip them for their role with students, particularly in relation to assessment. This was thought to have been possible with a longer lead in time to the HVIP. In addition there were concerns that mentors’ commitment (and time given) to student training had not been explicitly acknowledged by managers, a problem compounded by pay differentials between the mentors and practice teacher:

‘Historically they have never had to do it…only pre-reg students…they are not gaining extra pay for it…just to say to them, “You are doing really well in this difficult climate” doesn’t always get said…’ (008)

The new model was felt to have impacted on practice teachers’ own practice: the perceived benefit of working closely with a more experienced student who could pick up some of the workload later in their programme was now lost. In the new model, students had not been placed with the practice teacher, so students working more independently drew from caseloads in other bases. Not only had the caseload benefits diminished for the practice teacher but in some ways additional work was created.

‘On a one-to-one basis we used to benefit from consolidated practice, now we don’t...so when I see a student doing a primary birth visit…it’s not one of my primary birth visits it’s another caseload and I have got five of my own so basically I have got six primary birth visits.’ (0026)

 

Managers’ interview data (n=3)

The managers described the peripatetic model as influential in up-skilling the wider health visiting workforce. Learning was no longer the preserve of those interested in education or substantive practice teachers who needed to have up-to-date knowledge and practice. Overall, they thought students received a more rounded experience compared with those trained under the previous one-to-one model; students were exposed to a wider range of health visitors, their practice, style and approach.

The HVIP was felt to be a policy that prioritised a rapid increase in workforce capacity rather than the quality of health visitor service delivery. A project lead for the HVIP had been appointed to maintain and enhance health visitor service quality; she worked closely with the university and the academic-in-practice (AiP) to support innovative service development and focus on preceptorship. Close links with the university, facilitated by the AiP, were greatly valued by the Trust.

Managers saw merit in continuing the peripatetic model and not returning to the previous model. The positive effects of the model meant that its continuation was a priority; practice teachers taking more responsibility for the quality of placements and the development of the established workforce. There was commitment to using the newly acquired skills developed through the HVIP creatively to continue to develop service development:

‘Many [mentors], though, appear to have risen to the challenge and provided excellent experiences. Need to…making it more robust as a role.’ (Man 1)


Discussion 

New and innovative programmes often present unanticipated issues: the short lead-in time to the HVIP challenged both the Trust and the university. In Somerset, a workable peripatetic model of a new method of teaching was successfully implemented. Practice teachers mainly worked in a different base to the students but had responsibility for their assessment, with the students’ day-to-day support provided by mentors. The practice teachers recognised the broad and varied health visiting practices that students had experienced and felt that it had prepared them well for practising independently. Students had enjoyed the opportunity to observe closely, and be supervised by, two experienced practitioners, be part of the wider health visiting team and experience the reality of every-day health visiting within a progressive training programme.

The peripatetic model of one practice teacher to three students was adopted in Somerset and was new and innovative for the Trust. It was widely-used elsewhere and, in some organisations, had been well-embedded with clear workload remission. In Somerset, the remission of work for practice teachers was less clear and student placements required the wider team to cover a greater proportion of the day-to-day work. Managers and practice teachers were also concerned about the future of the recently trained practice teachers since their role had been developed on the basis that it would cease post 2015 with a loss of valuable workforce upskilling. The frustration and de-skilling of staff resuming their previous posts has been highlighted elsewhere (McInnes 2013) and not been addressed at a strategic level nationally.

The influx of newly qualified health visitors within health visiting teams suggests that maintaining a mentorship or a CPD-training role for less experienced health visitors may prove to be cost-effective and utilise the skills of existing staff developed through HVIP implementation. For example, in the East of England, the Practice Teacher’s role includes leading preceptorship, leading and providing CPD, research and capacity building, restorative and clinical supervision (HENHS, 2014). Participants in Somerset suggested development of a clear career pathway to allow progression and acquisition of skills over time and promote further up-skilling of the workforce.

All stakeholder groups in this evaluation promoted formal recognition of the mentors for the key teaching and supporting role they perform for students. The extra work for mentors entailed in this essential role echoes the experiences of mentors nationally (Mitcheson, 2012: Naughton, 2013) and supports findings from earlier evaluations of established mentoring roles in other disciplines such as nursing and midwifery (Fischer & Webb, 2008).

The mentors suggested a reduction in caseload to improve their workload/teaching balance, clear guidelines for their role as well as supervision for themselves. All of these would ensure greater consistency in their support of students. Availability and access to training, both prior to and during mentorship, is needed (Morton, 2013). It appears that mentors who had received training and had good communication with their practice teacher felt more confident, understood more clearly the academic requirements of students and were able to tailor effectively their support to address the practice needs of their students. Like practice teachers, many of the mentors had embraced the opportunity to acquire new skills to support the SCPHN students and felt a career pathway was needed (McInnes 2013).


Recommendations

Development of specific guidelines and training to support the practice teacher/mentor partnership (if retained) in the assessment of students: clarify roles, responsibilities and levels of assessment

More explicit progression pathways for newly qualified SCPHNs are needed, both within the profession and individual health care providers. For example, routes from qualification to mentorship and practice teaching, management or specialist roles such as supervision of the Family Nurse Partnership.

Use existing mentors and SCPHN trained practice teachers to support newly qualified HVs individually and to support HV teams with high numbers of relatively inexperienced HVs.


Conclusions

The peripatetic assessment model, as implemented and experienced by the Somerset Partnership NHS Trust, despite some criticisms, has generally been successful, well accepted and provided a large number of high quality, appropriately trained health visitors. This evaluation demonstrates that the assessment model also up-skilled the wider health visiting workforce. The issues raised by the participants pertained, mainly, to the very large numbers of students undergoing training before 2015 rather than the model of assessment itself. The short lead-in time of the Health Visitor Implementation Plan challenged both the Trust and the university. The findings and recommendations provide guidance to health organisations nationally, adds to the evidence-base for the support of students in practice and can help to inform strategy and methods of working across England.


Acknowledgements

Our thanks to the practice teachers, mentors and placement students of Somerset, managers of Somerset Partnership NHS Trust; the Academic HV and University SCPHN Team for their support and co-operation in this evaluation.


References

Department of Health (2011) Health Visitor Implementation Plan 2011–15. a call to action. Available from: dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124208.pdf

Devlin, A. and Mitcheson, J. (2014) Evaluation of Models of Practice Teaching in Health Visiting. Presentation at UKSC Community for a Specialist Community Public Health Nurse Education, London, 25 March 2014.

Fischer, M. and Webb, C. (2008) What do midwifery mentors need? Priorities and impact of experience and qualification. Learning in Health and Social Care 8(1) 33-46.

Harries, C. (2011) Concerns over practice ratios. Community Practitioner 84(9)

Health Education NHS (HENHS) (2014) Excellence in Practice Health Visiting Case Studies https://heeoe.hee.nhs.uk/sites/default/files/excellence_in_practice_final_0.pdf accessed 02.12.15

Karban, K. (1999) Long-arm practice teaching for the diploma in social work: the views of students and practice teachers. Social Work Education: The International Journal, 18(1) 59-76.

McInnes, E. (2013) Understanding the role of peripatetic community practice teachers. Journal of Health Visiting 1(12).

Mitcheson, J. 2012. A preliminary survey of the practice teacher with due regard model to prepare Specialist Community Public Health Nursing (HV) students for practice in the East of England. University of Suffolk.

Morton, S. (2013) What support do health visitor mentors need? Community Practitioner 86(8) 32-35.

Mundy, D (2011) Widespread fears over misinterpretation of NMC advice on SCPHN practice teaching. Community Practitioner (84) 8. London: CPHVA.

Naughton, L. (2013) Getting ratios right. Community Practitioner 86(11) 22-25.

Nursing Midwifery Council (2004) Standards of Proficiency for Specialist Community Public Health Nurses. London: NMC.

Nursing Midwifery Council (2008) Standards to Support Learning and Assessment in Practice. London: NMC.

Nursing Midwifery Council (2011) Circular 26/07. London: NMC.


  1. Why is this topic important?

    New models of health visitor student supervision in practice were introduced during the Health Visitor Implementation Plan. It is important to explore the impact of different models on the experience of key stakeholders

    Research in regard to student, mentor, practice teacher and manager experience who engaged with a peripatetic assessment model contributes to the national commentary on health visitor educational models and may feed in to revision of NMC standards.
     

  2. What does this study attempt to show?

    The study attempts to establish from the perspectives of students, mentors, practice teachers and managers, the perceived value and quality of the peripatetic student supervision model adopted in Somerset.

    This allows recommendations to be made for the development of health visitor education at local and national level.
     

  3. What are the key findings?

    Students were generally positive about the experience of working closely with both a mentor and a practice teacher. Their exposure to a greater number of practitioners and different styles of working was thought to be beneficial.

    The overall impact was to rejuvenate mentors who found they were motivated to keep up to date, and managers felt that the initiative resulted in general up-skilling of the workforce.
     

  4. How is patient care impacted?

    The broad and varied health visiting practices that the students experienced prepared them well for practising independently with clients.

    The rejuvenation of the wider workforce also contributed to maintaining a high standard of health service delivery to help meet the needs of the Somerset community.

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