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Understanding SCPHN students' experience of practice educator-led peer support groups

01 November 2016

Paula Elliott Health Visitor Practice Educator, Mid Yorkshire NHS Trust

Graham Ormrod Director of Health Partnerships, University of Huddersfield

Abstract

Specialist community public health nursing (SCPHN) students are expected to develop significant skills and competencies in practice, whilst also achieving academic success.

This workload can be very stressful for students, particularly as their placements with practice educators can isolate them from other students, reducing the valuable support that peers can provide. Practice educator-led peer support groups were established in an attempt to ameliorate student stress and improve wellbeing by providing peer support, whilst simultaneously delivering opportunities for learning and promoting preparedness for qualification. A service evaluation was subsequently conducted using focus group methodology to explore students’ experience of the peer support groups. This was to ascertain their effectiveness in supporting learning within practice placements and improving student wellbeing. Data analysis identified three key themes: peer support and emotional nourishment; and filling the theory-practice gap; with a further theme focusing on group organisation and planning. Findings indicated that the support groups were a valued and important element of SCPHN training for the student cohort involved in this service evaluation, engendering an improved sense of wellbeing and an enhanced educational experience.

Key words SCPHN, peer, support, stress, education

INTRODUCTION

During any student experience, the academic workload, coupled with limited time to master key clinical skills, can be a significant stressor (Evans and Kelly, 2004). Specialist community public health nursing (SCPHN) students are required to manage the competing demands of the academic course, professional development and work-life balance whilst working with a practice educator, but without frequent access to their peers for additional support. Therefore, opportunities to discuss and clarify uncertainties and gain support and understanding from other trainees whilst in practice are limited. These circumstances can be isolating and stressful for students.

High levels of work-related stress can lead to sickness, absence, burnout and high attrition rates for such students (Galbraith and Brown, 2011), a further consequence being reduced performance and adversely affected client care (Brown and Edelmann, 2000). Methods to alleviate such stress can be multi-faceted, including informal social support (Laschinger et al, 2001), social events, learning and teaching interventions (Gibbons, 2010), reflective groups (Peterson et al, 2008). and peer support (Günüsen and Üstün, 2010). Most of these approaches involve recognition of the unique support provided by peers and the resultant development of practice knowledge and skills, increased confidence and improved learning (Fountain, 2011).

Since 2011, an extended support and education mechanism has been implemented within Mid Yorkshire NHS Trust to meet both the educational needs and wellbeing of SCPHN students. This includes aspects of peer support, reflective practice, clinical supervision and joint educational experiences. These monthly, time-protected meetings allow the students to meet with their peers in a non-threatening environment, away from their practice setting, where they can learn and reflect on practice together and gain valuable support. The groups are facilitated by practice educators, which therefore concurrently allow the provision of clinical supervision, presentation of learning opportunities and occasion for the multidisciplinary team to provide education for students.

A service evaluation was conducted to explore what impact the groups had had on the professional development and wellbeing of the SCPHN students involved.

BACKGROUND

Peer support groups are a means of providing mutual support by drawing together colleagues or individuals with common experiences and can be used as a means of information and education provision (Gill et al, 2006). Such groups have been found to be effective in alleviating burnout (Peterson et al, 2008), reducing emotional exhaustion (Günüsen and Üstün, 2010), diminishing stress and improving individual skills in coping with it (Laschinger et al, 2001), improving student achievement and learning (Mangone et al, 2005) and reducing distress when work stress is high (Healy and McKay, 2000), all of which underpin the ability to learn and develop.

Students can be affected by stress in a number of ways, such as feeling clinically incompetent, irrespective of their previous experience and role, finding difficulty in achieving a balance between the demands of work, life and study, and pressure to produce academic work whilst learning a new and demanding role (Gibbons, 2010; Brown and Edelmann, 2000). Students can feel overwhelmed, which can result in a reduced ability to concentrate, decreased motivation and cognitive dissonance (Beck, 1995). In addition, students found to have these indicators have been shown to demonstrate lower levels of patient empathy and a reduced ability to learn clinical skills (Kim, 2003).

 

AIM OF THE SERVICE EVALUATION

The aim of the service evaluation was to explore the student experience of the practice educator-led peer support group and to inform decisions regarding the optimisation of future groups. Specifi cally, it was to explore the impact of the group on the wellbeing of the participants and the impact on their learning and development and to discover what worked well and what “better” might look like.

METHOD

A summative service evaluation employing a focus group methodology was utilised. A goal-free evaluative approach, where the perceptions or feelings of participants are elicited was used (Moule and Goodman, 2009). University ethical approval was sought and granted. Students were purposively recruited and invited to attend the focus group, which took place a month after the last support group session. The researcher was careful to explain the purpose of the evaluation and requested that the students were open and honest in their accounts of their experiences, as they would be influencing future direction for student support. All nine SCPHN students expressed an interest in attending, but only five were able due to work and other commitments. Written consent was obtained from those who attended.

Semi-structured questioning allowed the students to have candid discussions about their experiences with two facilitators, a health visitor, practice educator and another health visitor who was not involved in the delivery of the support groups. The two facilitators conducted the focus group, which was audio-recorded, and coded the resultant transcript and data. This reduced bias, avoided misinterpretation of the data and improved inter-rater reliability (Merriam and Tisdell, 2015). The data collected were transcribed verbatim using in-vivo codes and checked for accuracy and systematically reviewed and analysed using Braun and Clarke’s (2006) six-phase thematic analysis approach.

FINDINGS AND DISCUSSION

The data generated three distinct themes:

Theme one

Peer support and emotional nourishment

This theme describes the emotional effects that attendance at the support group had upon the students and confirms the encouraging impact of peer support on the wellbeing of the participants. A sub-theme of “becoming resilient practitioners” reinforced the positive effects of peer support on reducing stress and anxiety.

Students described the groups as providing a channel through which they could seek “emotional nourishment”: “In a sense we were all living and breathing the same experiences... Kind of sharing the trials and tribulations, which was supportive when we came together.” “It’s been a bit of an outlet as well – we’ve had a few tears.”

Other students described how improving knowledge about their new role influenced their wellbeing and how developing friendships with their peers had a positive effect upon them. They described an environment where they felt safe to share experiences and where they did not feel judged or criticised and one that provided emotional catharsis: “(I) always left kind of feeling refreshed and able to go and carry on really.”

The beneficial effects for students increased with each group as they felt more able to speak openly with greater familiarity with one another; emphasising the importance of an ongoing commitment to the process: “I suppose it’s how a group forms, because I didn’t feel safe to share that vulnerability until I knew the group.”

Peer groups, therefore, need to be allowed to “fully for” (Tuckman, 1965) before they can be genuinely beneficial as only when learners feel “safe” are they likely to contribute (Rimanoczy, 2007). Such feelings of wellbeing appear to have been prompted predominantly from interaction with peers (Jones, 2003) with more “educational support” resulting from the contribution of the practice educators.

Peer support normalised their feelings of stress and anxiety and promoted a sense of camaraderie and “fitting in” with a peer group: “It’s quite sociable as well... A bit of time out for us, just to get together.” “Without us, there wouldn’t be the group. The group is us.”

The peer support group provided an “outlet” for emotions, helping to manage the challenge of the new role as SCPHN. Students used the words “nourished”, “topped-up”, “refreshed” and “valued” to describe how the group made them feel, and how the experience had made them “feel better”, and more able to “get through the week”. Peer support, the sharing of knowledge and expertise and providing encouragement and support to one another has been found to increase productivity and performance (Joiner, 2007), reduce the risk of social isolation (Bennett et al, 2001), improve levels of perceived control, reduce anxiety levels and provide a sense of belonging (Mangone et al, 2005): “And I think it was shared, although we were all having different experiences, collectively we’ve had the same experiences.”

The peer support groups allowed the students to develop eff ective alliances with one another and ask questions without feeling judged, promoting new learning and confidence to try new behaviours (Rimanoczy, 2007): “And not being shy to share experiences if you’ve had a bad experience. You know, not being worried that if you say something people are not going to look at you funny. Ah… you should have done it that way.”

Overall, the peer support group provided a medium through which they were able to gain support from their peers and a sense of being valued by the practice educators: “Yeah, so in terms of their busy roles, they value, they have taken time to facilitate these groups so they value us therefore you know it’s… reciprocal, you feel valued.”

The groups provided a means to access and create social attachments, which had a positive impact upon the students’ wellbeing during their training, providing a buff er against the effects of stress: “I think just speaking to people who are going through the same thing isn’t it? We all supported each other really all the way through.”

Theme two

Filling the theory-practice gap

“Filling the theory-practice gap” relates to the educational and developmental impact of the support groups.

The groups appeared to reduce the gap between what was experienced in clinical practice and what was taught in the classroom, with classroom education focusing on theory rather than specifi c application to practice. Students are not always able to adapt theory to “real-life” situations and become confused when attempting to apply theory to practice (Monaghan, 2015): “It bridged that gap… Some of the academic stuff we got at uni, we weren’t necessarily getting it in practice. But we got it [practice-related theory] here. So it fi lled that theory-practice gap.” “We were taught things that we weren’t ever going to get taught at uni… All the kind of practical [things].”

The students suggest that their experience of the support groups help bridge the existing gap between university and practice. The support group provided a “classroom” within the clinical setting to ensure that student learning was contemporaneous, sequenced (Corlett, 2000) and contextualised (Hislop et al, 1996); with academic learning coinciding with application to practice.

The support group allowed time for the students to engage in refl ective practice (Jarvis et al, 2003), allowing them to develop deeper critical thinking through joint reflection, engaging in sharing perspectives, joint consideration of an issue and learning about the experiences of the other students (Mangone et al, 2005), integrating theory with practice for academic learning. “It kind of was a bit of a safe place where I knew I could just come and feel I’d got a bit of reflective time.” The students felt that the support from the group and the ability to reflect with their colleagues increased their confidence to practise differently.

In addition to inspiring new learning, group discussions gave the students the permission to take new learning away and practise it, to compare their practice with that of their contemporaries and accept that diff erent practitioners use diff erent approaches to reach the same goal:

“(I) actually talked to other health visitors who said: ‘We do it this way,’ so it was like comparing the practices really.”

Despite the general consensus that students felt more comfortable to refl ect together in the latter months, when group cohesion and a greater sense of “safety” had been achieved, there remained a suggestion that more time for refl ective practice should be made. However, group refl ective practice holds an element of exposing vulnerability which could inhibit some practitioners; this suggests that group refl ective practice, when practitioners don’t feel safe to share their experiences could be ineff ective, causing students to feel threatened and anxious (Pierson, 1998; Getcliff e, 1996).

Students were motivated to attend the support groups by their perception of what was offered and who was offering it; with the teachers’ knowledge related to the practice setting being a key component. The students were provided with research-driven education delivered by qualified educators and expert practitioners: “I think… you know, those that were facilitating it came with credibility and what they talked about was research-based… you know… the type of lectures you have at university are all kind of referenced and that echoed through to practice as well.”

Theme three

Group organisation and planning

This theme explores the impact of how the groups were organised upon the student experience. A sub-theme of “what would ‘better’ look like?” provides suggestions to enhance the student experience. The group always had an agenda to advise the student what was going to be taught at the following meeting. The provision of typed minutes and an agenda also allowed students to plan some of their practice learning to coincide with the subjects to be discussed: “So I didn’t structure any visits until after that… because I knew I was getting the information here…”

Students were requested to evaluate each group session to help promote the quality of future groups. Feedback indicated that they felt that they were contributing to the support group programme for subsequent students. They reported feeling central to the process and stated that they were aware that they were the key drivers for the group direction:

“Yeah… there was an evaluation after each group and anything that we put on that we thought… next time can we have this, we more or less got it on the agenda for the next meeting”, “Yeah… to send them to us (agenda and minutes) must mean that they want us to influence them.”

Students commented on not knowing what to expect when they first started to attend: “I also think… at the beginning… I saw ‘student support’, I didn’t realise it would be like that… meeting needs, which has ended up being really useful. But, at fi rst, I thought it was just like going for a cup of tea and a chat… like… ‘students’ support’. I didn’t think it was gonna be like that.”

The students observed that the process of developing a sense of belonging and developing trusting relationships with peers could have been accelerated and suggested a “meet and greet” session prior to the fi rst peer support group, to “get to know each other” and to allow an explanation about the purpose of the group sessions and for ground rules to be explored. A group format with consistent membership may also have encouraged this earlier group cohesion. Students also wanted to learn about their predecessors’ coping strategies whilst on the SCPHN course with a suggestion that newly qualifi ed health visitors share their experiences at future support groups.

While practice educator and visiting speakers’ time was a cost implication for the provision of the support groups, this was off set by the fact that all students were provided with an equitable training and education itinerary. No other costs were incurred.

KEY POINTS

● SCPHN training can be very stressful and community placements can be isolating for students

● Practice educator-led SCPHN student support groups were established to help ameliorate student stress and improve wellbeing by providing peer support while simultaneously delivering key training

● This service evaluation explored SCPHN students’ experience of the support groups

● Findings indicate that the support groups were a valued and necessary element of SCPHN training for the student cohort involved, improving wellbeing and providing an enhanced educational experience.

 

CONCLUSION AND RECOMMENDATIONS SCPHN

Support groups were a valued and necessary element of SCPHN training for the student cohort involved. They proved effective in providing peer support to improve wellbeing and an effective forum for education and the opportunity to reflect and develop knowledge and skills in a safe and trusted environment and, in doing so, increased professional confidence. Notwithstanding the fact that the students could fi nd social support elsewhere, they chose to attend the groups because they off ered something that social support alone appeared unable to.

Whilst the current format and organisation of the groups met some of the educational and wellbeing needs of the students, changes to the structure and processes involved in implementing the groups could enhance their capabilities. We recommend:

● Group size to be small (although greater than three) and remain closed to allow students to develop alliances with one another

● Encourage students to develop their own informal peer group, to run alongside the formal group, to reinforce the development of peer alliances and relationships

● Mutually agreed ground rules to be considered as key to group formation, learning, relationship development and refl ective practice ● Consider “meet and greet” prior to fi rst session, allowing students to prepare

● Utilise feedback from previous groups to inform future content and where possible facilitate meeting with previous SCPHN students

● Consider use of current and developing technologies, such as Whatsapp and Yammer, to further encourage peer support.

It is encouraging that one of the students felt that their feedback was influencing the groups being sustained in the future; a reassuring observation and endorsement of the impact of the group: “And I hope that by coming to the group and giving good feedback makes them continue.” The SCPHN support groups have been running since 2011 and continue to be delivered within Mid Yorkshire NHS Trust. 

 

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