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One step sideways

04 October 2019

What happens when a health visitor wants to become a school nurse? Practice teacher Caron Robinson supervises those who choose to change career paths.

I have supported 11 health visitors through the transfer of fields (TOF) programme to become school nurses (SNs) in various universities over three years. Recently, the number of SCPHNs completing the TOF programme appears to have increased considerably within health visiting and school nursing. An ever-growing number of universities now offer this programme, suggesting that this is in response to county councils’ new responsibility for commissioning of 0 to 19 health services for families, children and young people rather than the more traditional separate HV and SN offer. Lewis (2017) acknowledges that an increasing number of SCPHNs are changing their field of practice in order to reflect local changing needs.

The TOF programme was instituted 13 years ago, when the NMC circulated advice to registrants on undertaking further education and training to work in another field (NMC, 2006).

TOF is evaluated by an appropriately qualified practice teacher or educator and assessed through a registrant’s portfolio. This would demonstrate how the student could apply theory to practice in their chosen additional field and provide written evidence to reflect this. The portfolio uses the same four domains of public health practice comprising 10 key principles determined by the NMC (2004) within the context of SCPHN.

The programme could last up to a year, or as little as 10 weeks, providing the practitioner was able to complete a minimum of 50 full days in practice. The programme enables the practitioner to gain appropriate knowledge and skills by working within their new chosen field of practice, but does not lead to an additional recordable qualification.

All change, please

As the NMC does not record the TOF programme, it is impossible to assess the numbers of nurses completing this without requesting information from universities offering the course.

The criteria for completing the programme are very varied. Some universities offer assessment by portfolio only; some also require attendance at taught sessions, as well as submission of an assignment or an oral exam. Some universities offer no academic credits while others offer up to 30 credits at level 7 study. Some practitioners I have supported who gained no academic credits would have preferred them; conversely, those who gained credits felt it wasn’t necessary unless these could be used to put towards a recordable level 7 qualification or similar. This led to frustration among some practitioners, which they perceive as due to a lack of direction by the NMC.  

Taxonomy of learning

The first cohort of HVs to successfully complete the programme was assessed by portfolio only, which included a written piece of critical reflection and was signed off by the practice teachers purely on a pass or fail basis. The programme did not accrue any academic credits, but academic and clinical rigour was applied by implementing tripartite reviews in practice and moderating the completed portfolios in conjunction with the programme lead at the university. These staff had previously secured posts within a well-established SN service that was almost fully staffed with standard operating procedures, guidelines and practices fully embedded in practice.

The HVs were initially employed in SN roles as difficulties had been encountered in recruiting specialist practitioner SNs, and we understood that the currently separate SN and HV services were likely to evolve into a 
0 to 19 service in due course.

Working only with an SN caseload enabled the students to easily access good-quality placements and experiences to enable them to progress readily through the ‘taxonomy of learning’ (Steinaker and Bell, 1979). In addition, it was agreed locally that the students could progress at their own pace, and therefore take control of their own learning needs, in conjunction with the support of the practice teachers and the university.

"Evaluation should be about determining difficulties and finding solutions to bring about a positive change"

Potential job losses

A year later, a second cohort of seven HVs undertook the programme at another university that offered 15 credits at level 7 and was assessed by portfolio, a written piece of critical reflection and an oral exam. This time, the SN service had transferred by TUPE process to another local NHS trust and a 0 to 19 model was started, a new concept for the HVs and SNs in post. The vision of the new 0 to 19 offer was that all specialist practitioners would eventually be able to work competently and confidently across the complete age range, offering a seamless service to families, children and young people.

However, the new service had only just been implemented after a difficult management of change process, which meant that staff had been placed into new posts and new work bases, and the service specification and offer was not yet embedded in practice. The new specification had been developed in order to deliver a service within a considerably smaller financial envelope than previously, leading Unite to warn of potential job losses they believed would leave children and families vulnerable (Ford, 2018).

These changes meant that virtually all staff within the 0 to 19 service were at the early stages of team development – ‘forming’ and ‘storming’ (Tuckman, 1965) – with accompanying high stress levels. This created an environment unconducive to learning that led to feelings of frustration and job dissatisfaction. Tuckman’s model has been adapted in order to demonstrate how the practitioners were feeling throughout the duration of their course (see Team development model below).

 

 

Lessons in the community

Before both cohorts began their course, the practice teachers discussed creating meaningful learning opportunities. The decision was made to plan some theoretical taught content and incorporate some practice-focused activities such as action learning sets, critical reflection and discussion. The planning and delivery of the learning opportunities proved to be considerably different for the two cohorts as the programme requirements and the service specifications diverged considerably. This required a degree of flexibility but did not prove to be insurmountable.  

The four practitioners in the first cohort had staggered start times for their course (two at a time), which did not allow for ‘formal’ taught sessions; therefore, the majority of teaching and learning took place within the community settings, being delivered by the practice teachers and by specialist practitioner SNs acting as mentors.

The SN team leaders were able to support by offering some protected study time during work hours for completion of their portfolios. The practice teachers were able to work with the practitioners on a one-to-one basis in schools and colleges, attend a variety of public health activities, multi-agency meetings such as safeguarding meetings and occasional external training opportunities such as national conferences. The practitioners were also offered the chance to attend any relevant taught sessions at the university that were being offered to the SCPHN students.

Protected time

Ongoing learning logs and a note of students’ practice days were encouraged, using portfolios as a working document. We later decided to allow practitioners to progress at their own rate, with the proviso that they try to complete within six months. This greatly reduced pressures to complete and submit portfolios and was particularly beneficial for those staff working part-time or in term time only.

The seven students in the second cohort were given half a day per week as protected time to focus purely on teaching and learning. The practice teachers, in conjunction with a different university, made the decision to ‘front-load’ the course with content delivered by the academic staff. These sessions evaluated well, although the students felt they would have benefited more if the sessions were more evenly spaced out, allowing for more regular contact with academic staff. This will be reviewed for the next cohort.

The practice teachers also taught sessions during the first semester that covered aspects of SN practice such as five to 19 child development and its theories, sleep, enuresis, consent, child sexual exploitation, emotional health and wellbeing, the National Child Measurement Programme and SN-led medical needs training for schools and colleges (Lee, 2018).

During the second semester, the protected time was used for portfolio work, oral exam preparation and critical reflection and discussion. Scenarios, action learning sets and clinical issues or other concerns could also be reviewed. Difficulties were encountered initially, with this cohort being unable to access a range of good-quality learning experiences as the 0 to 19 staff were now working in three distinct roles: the Strengthening Families team (essentially safeguarding), the Universal team (delivering universal services), the Hub (two phone contact centres that acted as the two points of access for the 0 to 19 service) and a small schools training team delivering medical needs training to school staff. The newly commissioned 0 to 19 service came with substantially reduced funding; staff were then lost through redundancy, competitive interviewing processes and by staff deciding to look elsewhere for posts.

Avoiding disillusionment

At the time of writing, the service was still not fully staffed and difficulties were still being encountered with recruiting suitably qualified staff, particularly SNs. As the SN service model had changed considerably, staff were no longer delivering sex and relationships education to young people, or SN and sexual health ‘drop-in’ sessions. Emotional and mental health input was limited to assessment, minimal SN input and onward referral. Although the model allowed for ‘responsiveness time’, practitioners still encountered issues with accessing meaningful experience and exposure to SN practice as there were insufficient qualified SNs in practice to mentor the practitioners. This meant that progression along the taxonomy proved difficult to achieve and required a number of measures to be put into place to ensure that the practitioners did not become too disillusioned.

Some staff experienced unprecedented levels of stress and anxiety throughout the course, and this resulted in several applications for delay because of exceptional circumstances. Despite interventions and support processes being put into place, the course was extended by three months, moving oral exam and portfolio submission dates.

Evaluation

The practice teachers evaluated the first cohort using a model of clinical supervision. The evaluation was very positive and was fed back to the other practice teachers within the trust at the next bimonthly meeting. However, it was decided to develop a more robust evaluation tool following completion of the second cohort of practitioners because many of the practitioners had struggled with completing their clinical hours and found writing at level 7 to be difficult and the current working environment not favourable for learning.

Evaluation, including self- or personal evaluation, can be an uncomfortable experience, but it is an important component of reflective nursing practice (Burns and Bulman, 2000). Evaluation should be about determining difficulties and problems, and finding solutions and answers to bring about a positive change.

The practitioners’ evaluations from the second cohort contained a number of negative comments, but when practice teachers reflected on the feedback, they saw it was centred on two main areas: first, students felt ill-prepared for the programme, particularly with the amount of self-study required; second, they felt that the timing of the course was ill-judged following on so soon after a difficult management of change process. The practice teachers were thus conscious of trying to ensure that the next cohort of practitioners would have a more positive learning experience. This was achieved by disseminating the evaluation to key members of the trust as well as the university.

The feelings and attitudes of the practitioners prior to the programme proved interesting. Those highly motivated practitioners who possessed belief in the new model and actively chose to study were much more likely to adopt a positive attitude that persisted throughout the programme. Those practitioners given little or no choice about being opted onto the course were naturally more resistant, and their feelings of negativity persisted for a prolonged period of time and adversely impacted upon their learning.

The practitioners also voiced concerns regarding the feasibility of an adequate period of preceptorship and consolidation following successful completion, they were very conscious of being able to work safely within the limits of their own competence (NMC, 2018).

Conclusion

The SN practice teachers felt that the courses offered by both universities, although very different, were robust and comprehensive, and ultimately equipped the practitioners for their additional field of practice.

The difficulties and challenges faced by the second cohort were the direct result of implementing a demanding academic course during a period of immense change and adjustment, and it was recommended that a period of consolidation managed by either the practice teachers or the mentors working in clinical practice was crucial to ensure that the practitioners could continue to build upon their newly developed skills.    

Caron Robinson is a school nurse practice teacher based in the Midlands.


References

Burns S, Bulman C. (2000) Reflective practice in nursing: the growth of the professional practitioner. Blackwell: Oxford. 

Ford S. (2018) Health visitor and school nurse jobs at risk in Staffordshire. See: nursingtimes.net/news/workforce/health-visitor-and-school-nurse-jobs-potentially-at-risk-in-staffordshire/7024434.article (accessed 3 September 2019).

Lee D. (2018) School nurses lead training for school staff members across the city of Stoke on Trent. British Journal of School Nursing 13(7): 351-3. 

Lewis L. (2017) Harnessing a public health asset. Community Practitioner 90(8): 20-21. 

NMC. (2018) The code. See: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-c... (accessed 3 September 2019).

NMC. (2006) Circular 26/2006: specialist community public health nursing (SCPHN) requirements for education and training in a differing field of specialist community public health nursing practice. See: https://www.nmc.org.uk/globalassets/sitedocuments/circulars/2006circular... (accessed 3 September 2019).

NMC. (2004) Standards of proficiency for specialist community public health nurses. See: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standard... (accessed 3 September 2019).

Steinaker N, Bell R. (1979) The experiential taxonomy: a new approach to teaching and learning. Academic Press: New York. 

Tuckman B. (1965) Development sequence in small groups. See: https://pdfs.semanticscholar.org/cd78/c763010e6eb856250b939e4eec438e14ef... (accessed 16 August 2019).

 

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