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Student CPs: lessons in resilience

11 January 2021

How student health visitors and school nurses found that learning during a pandemic proved to be positive and empowering.

Resilience, the ability to adapt and progress in challenging situations, is an essential nursing quality. During the Covid-19 first lockdown, Wiltshire’s student health visitors and school nurses – specialist community public health nurses (SCPHNs) – developed resilience and confidence in a facilitated learning environment. This article reflects on the factors that influenced their development and how the challenges they faced became opportunities.

There have been huge shifts in the way we live and work as a result of the pandemic. In public health nursing, virtual and telephone consultations replaced some face-to-face drop-in sessions and home visits. Essential face-to-face contacts with PPE were offered. Teams were connected through virtual platforms. Mobile working became home working. Student SCPHNs had their training interrupted, with limited exposure to full service delivery.

In Wiltshire, despite emergency transformation measures, there was no redeployment. HVs and school nurses adjusted to the new way of working and contracted service. As soon as lockdown began, student SCPHNs saw their university programmes immediately suspended or extended, which left unanswered questions about future practice. Many of the post-registration student cohort in south-west England were in redeployment posts, but Wiltshire students remained as students in Wiltshire Children’s Community Services, Virgin Care.

Finding new roles

The new NMC standards (2018) for learning were embedding within Virgin Care’s public health nursing teams. All practice teachers and mentors had transitioned into their new roles of either practice assessor or supervisor, and were working in a team model. This new approach created a supportive culture.

During the Covid-19 outbreak, students continued with their practice assessor and practice supervisor. Students benefited from this new approach by having a team to facilitate their learning. This was particularly helpful where some colleagues were shielding and working from home. Recognising the value of the practice assessor and supervisor team in terms of imparting knowledge and experience was an important factor in maximising the learning environment. Students were not locked into a one-to-one relationship with a practice teacher; instead they had a team to facilitate a breadth of learning and support.

A SWOT analysis (strengths, weaknesses, opportunities and threats) of the learning environment highlighted the need to map the requirements of an SCPHN practice placement on to the opportunities available in the limited service delivery. It was concluded that, while the service was changing, the health needs of the population and families were still present. Anxiety and poor mental health were becoming increasingly prevalent among young people and families. Rising to the challenge of the changing health landscape was a shared endeavour by the public health nursing workforce and maximised the learning culture. The development of skills for new ways of working was embraced and prioritised. The impact of the pandemic on coping abilities and resilience was also a feature. Our students, as well as our colleagues, had families and were affected by factors outside their control too, such as school closures, isolating family members, furloughed partners and their own health.

Placements and service delivery

Assessing the requirements of a practice placement, the qualities of SCPHN and the advanced skills necessary for public health practice was vital as the service changed. The underpinning evidence for SCPHN practice was re-examined, and the literature was searched. This enabled us to gain confidence in our approach and to ensure that the student learning was evidence-based and relevant.

At the core of SCPHN practice is the Healthy Child Programme (Department of Health, 2009) and HVs and school nurses need a myriad of skills and attributes to deliver the 0-19 agenda that has been based on home visits and face-to-face contacts in school (Department of Health, 2009). There were concerns that the limited service delivery thwarted the usual learning from home visiting and face-to-face contacts in the community, schools and clinics. In Health for all children (2019), Adams and Cowley state that home visiting is essential for assessing risk factors in young children and engaging with parents where sensitive issues and concerns have been raised. The literature also suggests that for universal families the outcomes are the same whether in a clinic or home setting (Hall, 2019). Studies with limited evidence on virtual contacts in primary care and outpatients have concluded that the flexibility for service users contributes to positive outcomes and relationship building, as long as the patient or client is not in acute need (Wherton et al, 2020).

Relationship building requires advanced communication skills in giving and gathering information, interaction with clients, observation of behaviours and engagement. This is not specifically focused on a home visiting service, although in some circumstances, home visiting may be preferable and necessary.

Sensitive communication is of particular importance where the SCPHN attunes to the parent’s situation or young person with a readiness to shift focus to match pressing needs (Cowley, 2008). It was possible to build these relationships using virtual methods, and for some young people it was preferable.

A programme of virtual learning and virtual shadowing was created to build skills, attitudes and communication with guidance from academic colleagues. The students continued to be supernumerary, supervised and assessed by their practice supervisors and practice assessors. They continued to work in accordance with the lone working policy guidance to ensure safety, including checking in and out at the end of each practice day.

Building resilience through technology

The motivation to use the new world of technology available for communication set in motion a supportive learning environment for the students. Combining creativity and influence – as Maslow’s hierarchy of needs theory (1971), cited in Quinn and Hughes (2007) suggests – facilitated this. The aim was to enable students to feel part of the team, and to achieve a sense of self-esteem, worth and self-actualisation, even in the virtual world of Microsoft team meetings and Skype calls (Maslow, 1987). The weekly virtual sessions were successful and well received by the students. It made the learning feel valuable and gave the students a structure. Difficulties in not being able to read nonverbal cues or pick up on the emotional atmosphere of a room was a limitation. Face-to-face contact with students was, therefore, prioritised where possible, either in the hubs where social distancing allowed, or out on visits to schools where PPE could be used.

Managing the changing environment

Recognising that everyone copes differently when faced with transformation was a key discussion point. Kindness, honesty and acceptance of others’ emotions was a necessary first step. Adjusting to the new ways of working required new ways of communicating with each other, and checking in with how everyone was doing emotionally became an important part of the daily routine. That sense of learning together was a priority, to ensure the development of advanced communication skills. Thomson (2009) says that ‘good mentorship encourages a two-way flow of learning’, and Quinn and Hughes (2007) suggest that the more someone learns and achieves, the more they are motivated to progress further. This was at the heart of the learning sets, as the practice assessor team really tried to keep student motivation going and to keep up the momentum of learning in practice.

Student feedback

The students reported mixed feelings, from fear to hope, as they were faced with changes to their training programme and an adjusted service delivery, (see 'Students report back' below).

Student SCPHNs are adult learners who develop their leadership skills, reflective practice and self-management through self-directed learning. The practice assessors responded to the students’ feedback, which influenced the transfer of knowledge. The need for reassurance and value was high on their list of needs, and as those needs were addressed with regular virtual contacts, so the students began to direct their own learning. Reflection and making sense of the shared experience became a source of resilience. The change of working patterns created an opportunity to develop autonomy, new skills and adaptability. All the students concluded that the experience of being a learner in the middle of the pandemic was positive and empowering. They recognised some barriers to learning due to the reduced service delivery, but regular access to practice knowledge and the evidence behind public health nursing skills resulted in increased confidence and competency.


Students report back:

‘I felt that I was failing, mainly due to uncertainty of my role and my future: what was my purpose in this organisation now? When would I qualify? Would I qualify at all? At our regular virtual meetings we discussed practice-related issues and assignments from experienced practitioners and each other. I felt contained and was able to make the links between theory and practice.’

‘I am aware that I have missed so many safeguarding and shadowing opportunities, but I have had to learn how to be adaptable, to work in different ways and to acquire new skills. As I look back over this period of the lockdown, I feel very positive about how things have been.’

‘A typical day consisted of a virtual learning set and Microsoft Team allocation meetings, Skype safeguarding meetings, face-to-face Universal Partnership Plus visits and managing the ChatHealth text service. Debriefing with our practice supervisors and assessors at the end of the day brought together our learning and helped us to develop confidence. Obstacles became learning opportunities.’

‘As an experienced nurse I regard myself as resilient and adaptable to change. However, I can honestly say that undertaking a public health postgraduate diploma during a global public health pandemic has not only been a challenge, but also a once-in-a-lifetime experience. I have gained a new-found resilience for which I am grateful.’


Conclusion

The learning for the practice assessor team at Virgin Care, Wiltshire, has been transformative during this pandemic. Evaluating the importance of structured and deep learning for students through weekly learning sets has shown the place knowledge has in practice. Observation of practice, shadowing and the supervision of practice is essential for nursing. Nevertheless, the blended approach of virtual and face to face learning and practice has shown its value and opportunity. Structured reflective learning has accelerated learning and skill acquisition (Benner, 2001).

New ways of working and new approaches to learning in practice has facilitated confidence and resilience, for the practice assessor team as well as the student cohort. Technology has created an enabling culture.

The outcome of this analysis is that future student placements will be adjusted to combine both the transfer of knowledge and experiential learning through face-to-face and virtual learning experiences.

Marian Judd is a health visitor and Kirsty Dalton is a specialist school nurse, at Wiltshire Children’s Community Services, Virgin Care Ltd. 


References:

Adams C, Cowley S. (2019) Primary prevention and health promotion in childhood. In: Edmond A. Health for all children (fifth edition). Royal College of Paediatrics and Child Health: Oxford University Press.

Appleton JV, Cowley S. (2008) Health visiting assessment: unpacking critical attributes in health visitor needs assessment practice: a case study. International Journal of Nursing Studies 45(2): 232-45.

Benner PE. (2001) From novice to expert. Prentice Hall: Upper Saddle River, NJ.

Department of Health (2009) Healthy Child Programme: pregnancy and the first five years of life. See: gov.uk/government/publications/healthy-child-programme-pregnancy-and-the-first-5-years-of-life [Accessed 07 September 2020]. 

Edmond A. (2019) Health for all children (fifth edition). Royal College of Paediatrics and Child Health: Oxford University Press.

Maslow AH. (1987) Motivation and personality (third edition) Harper and Row: New York.

Maslow AH. (1971). The farther reaches of human nature. Arkana/Penguin Books.

NMC. (2018). The code: professional standards of practice and behaviour for nurses, midwives and nursing associates. See: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf (accessed 19 November 2020).

Quinn FM, Hughes SJ. (2007) Teaching in the clinical setting. In: Quinn’s Principles and Practice of Nurse Education (fifth edition). Nelson Thornes: Cheltenham.

Nursing and Midwifery Council (2018) Standards framework for nursing and midwifery education. See: https://www.nmc.org.uk/globalassets/sitedocuments/standards-of-proficiency/standards-framework-for-nursing-and-midwifery-education/education-framework.pdf (accessed 19 November 2020).

Thomson S. (2009) How to support learners. In: Hinchliff S (ed). The practitioner as teacher (fourth edition) Churchill Livingstone Elsevier: Edinburgh.

Wherton J, Shaw S, Papoutsi C, Seuren L, Greenhalgh T. (2020) Guidance on the introduction and use of video consultations during COVID-19: important lessons from qualitative research. BMJ Leader 4(3): 120-3. 

Image credit | Getty

 

 

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