Creating a community of learning and practice

03 August 2017

Fiona Cuthill, Judith Anderson and Alison Shiel share their experiences of increasing capacity, quality and learning skills in health visiting practice.

Creating a community of learning and practice

In recent years, the role of the health visitor in addressing health inequalities has gained greater attention from policy-makers. As health practitioners, they have moved to centre stage in implementing policy objectives to give every child the best start in life, a key factor in tackling health inequalities. As a consequence, both the English and Scottish Governments have worked to increase the numbers of health visitors (HVs) in the workforce; the goal in England was an increase of 4200 by April 2015 (Department of Health, 2011); and the Scottish Government committed to train 500 new health visitors over four years between 2014 and 2018. While the changes have been welcomed by the profession, the rapid implementation of the policy and the urgent need to train as many new HVs as possible, particularly in Scotland, has put pressure on practice teachers in community settings.

This case study reports on a community setting in NHS Lothian, Scotland, where two practice teachers (co-authors Judith and Alison) rose to these challenges by designing a ‘community of learning and practice’ (CoLP) approach to practice teaching.


The big picture

Over the past decade, there has been an increasing awareness of the impact of adverse childhood experiences in the early years on health outcomes in later life (Campbell et al, 2016). Also, policy recommendations to tackle increasing health inequalities have focused around the need to give every child the best start in life (Department for International Development, 2010). This has resulted in an increasing focus on the role of the HV, and in 2014 the Scottish Government committed to allocate funding to increase the number of HVs. It also increased the frequency of HV visits to families in the first five years of life from four to 11 with the Universal Health Visiting Pathway – eight contacts within the first year of life and three between 13 months and four to five years (Scottish Government, 2015).

While this has been welcomed by the profession, there has been increasing concern over the availability of qualified HVs to meet these demands, especially when demographic changes in an ageing workforce have resulted in a deficit of HVs.

The Scottish Government’s response has been to allocate funding for 500 new HV posts over four years. Higher educational institutions have in turn increased educational places to meet this demand; however, a problem arose – the number of NHS Lothian practice teachers available to supervise HV students while on community placement remained the same.

Although the number of practice teachers is planned to increase, the figure lags behind demand, and new practice teacher students need supervisors too. New and innovative solutions are required to ensure each practice teacher student and HV student has a qualified practice supervisor, and that the capacity for excellent quality supervision is increased over the service.

In September 2015, practice teachers Judith and Alison, along with their team, community manager and steering group, created a new model of practice supervision and learning in NHS Lothian. The aim was to achieve a more-for-less outcome by using existing practice supervision expertise.


Underlying values

While the importance for students to be provided with opportunities to learn through observation and ‘doing’ are well documented (Holland et al, 2012), the experience for students can be variable and inconsistent. While there are many different factors, the relationship between the supervisor and student is crucial (Roxburgh et al, 2012). Poor interpersonal relationships between supervisors and students create detrimental learning outcomes (Unwin et al, 2009). This can be exacerbated in a community setting, where students can spend the majority of their time with one member of staff.

In addition, supervisors can also act as gatekeepers to what the students experience (Holland et al, 2010) resulting in inconsistent learning experiences between students in different placements. This can result in a broad range of learning experiences for some HV students and more limited experiences for others. This impacts on the ability of the student to meet the demands of their new HV role, post-qualification.

From its inception, the primary purpose of the CoLP approach in NHS Lothian was to increase the capacity of the two practice teachers to supervise two HV students and two student practice teachers in the community, while also increasing the quality of the learning in the placements. The programme addressed three main concerns identified by the practice supervisors and steering group: lack of capacity in practice placements; problems with inconsistency in the practice experience for HV students; and isolation of students and practice teachers in community placements.

Traditional models of practice teacher supervision are based on a numerical ratio of practice teachers to student HVs. Various models exist: 1:1 models (one practice teacher to one HV student); mixed 1:1 (one practice teacher to two HV students who are also allocated a mentor each); ‘long-arm’ 1:6 (one practice teacher to six HV students, each with an additional allocated mentor).

While these traditional ratio-based models ensure adequate supervision by practice teachers in meeting the requirements of the NMC (2008), they create an environment in which student HVs can experience inconsistencies in their experience of being in the community. It also means individual practice teachers carry all of the responsibility for individual students; and as student numbers increase, there is an ensuing rise in responsibility, workload and pressure.

In addition to these models, HV students are supervised by practice teachers on an ‘arms-length’ basis. The sudden influx of large numbers of HV students in Scotland necessitated new approaches to incorporating increased numbers of student practice teachers into supervision structures.

The two practice teachers in NHS Lothian devised the new approach to student supervision to share learning in the practice environment. They did so by focusing on underlying values, rather than on ratios. While the new programme was a 1:1 traditional model – ensuring safety of supervision and meeting NMC standards for teaching and assessment in practice – the focus on underlying values provided a different kind of supervision.

The values underlying the new programme were twofold: first, to take an ‘authentic learning’ approach to supervision (Herrington et al, 2014) and second, to ensure that shared learning took place between all students and supervisors in an open, collective and reflexive way. In this approach, learning was valued as a reciprocal and shared responsibility between student HVs, student practice teachers and practice teachers. The rationale for this approach was to minimise difficulties caused in supervision through problematic interpersonal mentor-student relationships (Kilcullen, 2007), to work towards a more consistent learning experience for students, and to foster a collaborative and authentic learning approach (Herrington et al, 2014).

Nine elements of authentic learning

  1. Provide authentic contexts that reflect the way the knowledge will be used in real life
  2. Provide authentic tasks and activities
  3. Provide access to expert performances and modelling of processes
  4. Provide multiple roles and perspectives
  5. Support collaborative construction of knowledge
  6. Promote reflection to enable abstractions to be formed
  7. Promote articulation to enable tactic knowledge to be made explicit
  8. Provide coaching and scaffolding by the teacher at critical times
  9. Provide for authentic assessment of learning within the tasks. (Herrington et al, 2014)

The sharing structure

Shared learning was central to the programme; in addition to intense one-to-one supervision sessions with the practice teacher, two to four weekly group meetings were arranged for the HV students to prepare a topic for discussion, lead the discussion and reflect on practice. While these meetings were facilitated by one of the practice teachers, they were largely student-led and involved learning between students and practice teachers.

The programme was structured so that the CoLP grew as the cohort changed. At the beginning of the programme, the practice teachers each had one HV student plus one practice teacher student. Between September 2015 and January 2016, the student practice teachers observed group supervision and individual supervision, as well as joining in with the regular group learning.

In January 2016, a new cohort of two additional HV students started in the community, joined the CoLP and worked with the two student practice teachers. They were able to observe good practice and group learning. The practice teachers both worked full-time and were already carrying full patient caseloads, so the new programme had to meet the learning needs of the practice teacher students, without adding an unrealistic burden to the workload of the HV practice teachers.

While this model has some resonance with the ‘community of practice hubs’ set up in London (Donetto et al, 2017), this appears to be the first approach of this kind written about in Scotland. The theoretical approach of this model aligns with Lave and Wenger’s ‘communities of practice’ (1991) and are underpinned by theories of ‘authentic learning’ (Herrington et al, 2014). Authentic learning embraces nine different elements (for full list, see the box, below left).

Its contexts for practice should be provided to reflect the way that knowledge is used in real life. Other important aspects of authentic learning include providing access to a variety of ‘expert performances’, the modelling of processes, and providing multiple roles and perspectives. The NHS Lothian practice teachers provided this by devising a placement programme where the HV students shadowed both practice teachers in a range of different settings and they also worked with a variety of different professionals across a range of health and social care contexts.

This often broadened out the student HV experience to include spending time in childcare contexts that are beyond the traditional reach of health. Examples of these included the children’s hearings system, not-for-profit organisations, special interest groups and statutory providers, such as housing and social work.


A positive outcome

The case study programme ran from September 2015 to August 2016. On its  completion, the two practice teachers and two original student HVs were interviewed by an independent nurse consultant from the University of Edinburgh (researcher and co-author, Fiona Cuthill) to explore their experience of the CoLP for the student HVs. The feedback from the practice teachers and HV students was extremely positive.

While this case study describes the experiences of mentors and students in only one community placement, there were many reasons why the CoLP was seen as inspiring and positive. The practice teachers were insistent that success was predicated on them both being located in the same health centre, but the advantages were many: the HV students were delighted by the breadth and consistency of their experience; capacity was increased as the practice teachers were able to supervise a student practice teacher (and their HV student), as well as the HV student they were allocated; learning was enhanced by observing different expert performances and approaches modelled; the HV students recognised the consistency of the CoLP approach; and the practice teacher students learned the expectations of their role in relation to supervising HV students in a supporting learning/practice environment.

The HV students particularly valued the community aspect of learning; having two full-time practice teachers; other students’ support; the healthcare information system, TRAK; being able to discuss assignments together and how they related to the course; group discussions; and learning with teachers.

These experiences correspond to research by Devlin and Mitcheson (2013) evaluating different models of practice teacher/HV student supervision, who state that ‘a key factor associated with a positive student perception of practice learning were proximity, continuity and reciprocal positive regard’. The practice teachers also benefited from the CoLP model, comparing it with the previous, more traditional 1:1 model. They found that working together in a learning community made them more accountable for learning experiences they gave student HVs and that team-working gave them more confidence in their work as mentors. As one of the HV practice teachers said: ‘We all have different styles but accept we can learn from each other... It is about giving each other the confidence, and knowing [what] each other has committed to, and you are carrying it through.’

In a period of austerity and NHS budget constraints, HVs and practice teachers are at the forefront of innovations that enable us to think differently and to develop approaches to working that build capacity while also enhancing both learning and practice experiences. By working in partnership with another practice teacher, using new and innovative approaches to learning – underpinned by strong theoretical foundations – and by working with partner community organisations, these two practice teachers achieved the elusive outcomes that are the delight of managers, leaders and educators alike: using existing resources with greater efficiency and imagination to achieve more.

  • Fiona Cuthill is a lecturer in nursing studies at the University of Edinburgh; Judith Anderson and Alison Shiel are health visitors and practice teachers at NHS Lothian.


Campbell JA, Walker RJ, Egede LE. (2016) Associations between adverse childhood experiences, high-risk behaviors, and morbidity in adulthood. American Journal of Preventive Medicine 50(3): 344-52.

Department of Health. (2011) Health visitor implementation plan 2011 to 2015: a call to action. See: gov.uk/(accessed 17 July 2017).

Department for International Development. (2010) Fair society, healthy lives: the Marmot Review: strategic review of health inequalities in England post-2010. See: gov.uk/dfid-research-outputs/fair-society-healthy-lives-the-marmot-review-strategic-review-of-health-inequalities-in-england-post-2010 (accessed 4 July 2017).

Devlin A, Mitcheson J. (2013) An evaluation of three models of practice teaching in health visiting in NHS East of England. Journal of Health Visiting 1(10): 574-81.

Donetto S, Malone M, Sayer L, Robert G. (2017) New models to support the professional education of health visitors: a qualitative study of the role of space and place in creating ‘community of learning hubs’. Nurse Education Today 54: 69-76.

Herrington J, Reeves TC, Oliver R. (2014) Authentic learning environments: In: Spector M, Merrill MD, Elen J, Bishop MJ. (Eds.). Handbook of research on educational communications and technology. Springer: New York: 401-12.

Holland K, Roxburgh M, Johnson M, Topping K, Watson R, Lauder W, Porter M. (2010) Fitness for practice in nursing and midwifery education in Scotland, United Kingdom. Journal of Clinical Nursing 19(3-4): 461-9.

Kilcullen NM. (2007) Said another way: the impact of mentorship on clinical learning. Nurse Forum 42(2): 95-104.

Lave J, Wenger E. (1991) Situated learning: legitimate peripheral participation. Cambridge University Press: Cambridge.

NMC. (2008) Standards to support learning and assessment in practice. See: nmc.org.uk/standards/additional-standards/standards-to-support-learning-and-assessment-in-practice (accessed 4 July 2017).

Roxburgh M, Conlon M, Banks D. (2012) Evaluating hub and spoke models of practice learning in Scotland, UK: a multiple case study approach. Nurse Education Today 32(7): 782-9.

Scottish Government. (2015) Universal health visiting pathway in Scotland – pre birth to pre school. See: gov.scot/Publications/2015/10/9697 (accessed 4 July 2017).

Unwin S, Stanley R, Jones M, Gallagher A, Wainwright P, Perkins A. (2010) Understanding student nurse attrition: learning from the literature. Nurse Education Today 30(2): 202-7.

Image credit: iStock

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