Resources

Supporting pre-registration nurses within health visitng and school nursing

28 December 2016

Adelle Shaw-Flach and Georgina Hoy discuss the method and benefits behind the support of pre-registration nurses.

Adelle Shaw-Flach, Research Project Consultant, Anglia Ruskin University

Georgina Hoy, Senior Lecturer, Anglia Ruskin University

Key points:

  • The benefits for pre-registration nursing students having placements with health visiting and school nursing teams
  • Revisits regulatory requirements for learning and assessing preregistration nursing students
  • Assessing practice and supporting learning for student nurses
  • Developing the quality of the learning environment for student nurses
  • The professional and personal benefits in hosting student nurses.

Abstract

During the Health Visitor Implementation Plan (DH, 2011), health visiting teams were flooded with high numbers of health visitor students and, as a result, preregistration student nurse placements for both health visitor and school nurse placements were reduced or temporarily suspended until its conclusion in 2015.

Since then, pre-registration placements within health visiting and school nursing have been reactivated, and pre-registration students are once again able to join the clinical learning environment of specialist community public health nursing (SCPHN). The reintroduction of student nurses to some clinical areas and first time introduction in others has generated questions from health visitors and school nurses about pre-registration nurses and their learning needs. This article aims to answer some of the queries we have encountered about developing the quality of the practice learning environment, so that student nurses’ development is supported in accordance with the NMC Standards for pre-registration nursing education (NMC, 2010). This article may provide the opportunity for professional development, refl ection and learning that can contribute towards revalidation.

Key words: Mentor, learning, pre-registration student nurses, SCPHN, SLAiP


Introduction

Following a gap during the completion of the Health Visitor Implementation Plan (DH, 2011) in 2015, most health visiting and school nursing services will now be experiencing the reintroduction of pre-registration nursing students to the clinical environment.

Pre-registration students differ in their regulatory and learning requirements from those of specialist community public health nursing (SCPHN) students. Within our role of supporting mentors and students in practice, we have sought to resolve and answer queries that have arisen as practitioners seek to (re) acquaint themselves with the requirements for supporting pre-registration students on placements in SCPHN practice settings. This article seeks to share issues raised about the reintroduction of pre-registration student nurses by mentors, managers and students, during mentor forums and updates, student forums and from placement evaluations.

Queries have primarily focused on how to interpret the standards to support learning and assessment in practice (SLAiP) (NMC, 2008) and how to meet students’ learning needs with regards to assessing practice and supporting learning within SCPHN settings. For the purposes of this article, we will be referring to nursing students who are undertaking a pre-registration nursing programme at a higher education institution (HEI).


What are SLAiP and what does this mean for practice and learning?

SLAiP (NMC, 2008) are the professional body standards governing the support, mentoring and assessment of students within their practice placements. SLAiP (NMC, 2008) determines that mentors and practice teachers have to remain on the live mentor register, and stipulate that at least 40% of a student’s time in practice is under the direct or indirect supervision of a mentor/practice teacher (NMC, 2008 section 3.2.3). Named mentors retain ultimate accountability for the assessment of students, even if the student spends time with other practitioners during their placement, within a coaching capacity. So communication between staff supervising students is crucial.

What are the benefits of hosting Student Nurse placements in HV and SN teams?

  • The primary reason for hosting student nurses is to support the next generation of nurses by enabling them to meet their NMC requirements of 2300 hours in practice during their programme (NMC, 2010; NMC, 2008 section 3.4). The NMC stipulates that pre-registration programmes should be divided between acute and community settings. A community placement enables nursing students to learn about the world outside acute care.
  • Health visiting and school nursing services are aligned with the government’s vision for integrated care, which aims to improve ‘outcomes and experiences for individuals and communities’ through public health (DH, 2013: 13). Embedding the ethos and skills required to practise early in students’ professional journeys is key to move towards integrating care within public health practice (DH, 2013), and to upholding the NHS Constitution values (DH, 2015).
  • SCPHNs and the wider team work to infl uence the health and wellbeing of both individuals and communities. The vision for health services of the future pivots around public health and primary care, and nurses increasingly need to have an understanding of population-based preventative and early intervention approaches to public health (NHS England, 2014; DH, 2013). The recent Shape of caring review (Willis, 2015: 44) emphasises how ‘public health needs to be embedded within pre-registration education from the outset’ and is integral to the future of health care. Nursing students need the opportunity to observe and learn from those at the forefront of public health delivery (NHS England, 2014).
  • The NMC code (2015) states that we, as nurses, have a collective responsibility to share skills, knowledge and experience with nursing students. So education and responsibility for the learning of the next generation of nurses is not just for mentors and those with education in their role – it is everyone’s business. We are all involved in shaping and infl uencing their learning. These future nurses may or may not take an SCPHN career path, but they will qualify with an understanding of these services and how they fi t into the overall jigsaw of health service provision.
  • Students placed within health visiting and school nursing services benefi t from the opportunity to see how the staff uphold the NHS Constitution principles and values (DH, 2015), and to role model this within their own practice.
  • Good quality placements within school nursing and health visiting services are a fi nite resource. As such, each and every placement, and the commitment of the staff who provide students with quality learning opportunities, is highly valued by both students and HEIs.

Box 1: Case study

Q: Ali Mohammed is a school nurse and a qualified mentor, who hasn’t mentored a student for four years and hasn’t attended any mentor updates within this time period. He has been asked to mentor a student for a second year placement, and, whilst very keen, isn’t sure whether he can or not.

A: Ali will need to contact the education and learning team within his trust for support to re-enter the live mentor register. The mentorship qualification that he undertook originally will need to be reviewed to ensure currency. He will need to be updated/attend an update, and ensure that he is familiar with the current curriculum and assessment requirements of the HEI(s) that his healthcare organisation works with. He will also need support from his line manager around starting the process of working towards a triennial review. Mentors need to support and work with two students within a three- year period in order to fulfill requirements for triennial review. One way of updating could be to co-mentor a student and so, in addition to fulfilling the other requirements, build confidence and skills while practising.


Placements and assessments

There are a variety of types of placements that student nurses require, which may be organised diff erently from one area to the next. Formative and summative assessments are characteristic of ‘core’ or ‘hub’ placements and so require a live mentor, which is an NMC requirement (NMC, 2008, section 3.2.2). Others are ‘insight’, ‘short’ or ‘spoke’ placements, during which students may not be formally assessed. However, professional behaviours, skills and competencies form part of a continual assessment process throughout students’ practice placements.

What is a live mentor?

It is mandatory that a mentor will have successfully completed a recognised mentorship qualifi cation that will prepare them to practice in accordance with the SLAiP (NMC, 2008). In order to be recognised as ‘live’ on the mentor register, SLAiP requires mentors to participate in yearly updates, plus successfully complete the criteria for the triennial review (NMC, 2008). The responsibility for both holding and ongoing maintenance of the live register lies locally with placement providers (NMC, 2008).

Responsibility and provision of the annual updates is delivered in partnership between placement providers and the HEI (NMC, 2008). Locally, mentors may have the opportunity to choose diff erent formats for updating – in some areas, for example, the option of using online updates may be available. Some mentors may achieve additional criteria to become sign-off mentors (SOMs). This qualifi es the mentor to sign off a student to join (or rejoin as in the case of return-topractice students) the NMC register at the end of their programme (NMC, 2010). All practice teachers and midwives are SOMs. The NMC (2010) specifi es that, in order to fulfi ll the role, SOMs should be allocated the equivalent of one hour per student per week.

Triennial review

All live mentors, including SOMs, are required to complete a triennial review to stay on the live mentor register. Triennial review is a threeyearly process of refl ection mapped against the eight NMC domains in SLAiP (NMC, 2008). Meeting the below requirements for triennial review contributes to the evidence required for revalidation:

  • Current registration with the NMC
  • Staying up to date with students’ curricula
  • Mentored a minimum of two students over a three-year period
  • Supervise students directly or indirectly for a minimum of 40% of their placement
  • Meet the standards of the eight domains in the SLAiP (NMC, 2008) standards
  • Engage in continuing professional development
  • Since SLAiP (NMC, 2008) was published, a new requirement is to comply with revalidation (NMC, 2016a).

What if I haven't mentored a student for some time?

If you wish to mentor students and have a mentoring qualifi cation, but have not had yearly updates or triennial reviews that relate to pre-registration nursing programmes, then it is likely that you are not currently live on the register. In order to reactivate your mentorship, become live and assess students, you will need to make contact with your trust’s education and learning team. Every year, large numbers of nurses lapse from the live register because they have not fulfi lled SLAiP requirements (NMC, 2008). If someone who has lapsed from the register mentors a student, it has serious implications for the student whose placement may be nullifi ed – see box 1 on page 45.


Box 2: Who can assess students’ learning?

First-year students Progression pointAny ‘mentor who is a nurse registered in any of the four fields of practice’ (NMC, 2010; sections R8.2.2b and G8.2.2b: 85)
Second-year students Progression pointAny ‘mentor who is a nurse registered in any of the four fields of practice’ (NMC, 2010; sections R8.2.2c and G8.2.2b: 85)
Third-year students Final placement onlyRegistered nurse (and a live SOM) registered on the same part of the register as that which the student is intending to enter. The registered nurse must also be currently practising in the same field of practice as that which the student is intending to enter (SLAiP (NMC, 2008) section 2.1.3; NMC, 2010 section R8.2.2d). NB: Students may also be supported by a SOM in training who is themselves being supported by a live SOM.

 


What does the 40% supervision requirement mean?

SLAiP (NMC, 2008, section 3.2.3: 39) states it is mandatory that ‘whilst giving direct care in the practice setting at least 40% of a student’s time must be spent being supervised (directly or indirectly) by a mentor/practice teacher’. So mentors must spend enough time with students to make an informed assessment of the student’s achievement and progression in relation to their practice outcomes.

Other practitioners who are not mentors can work with students, as long as the mentor coordinates this in advance and formally communicates with and follows up afterwards for feedback from their colleagues. The mentor retains overall accountability for the student and for the protection of service users and the public. This also means that mentors who are part time do not need to be working with students all the time, but they do need to set goals with the student when they are working with other staff . This model also means that qualifi ed staff who are not currently mentors have the opportunity to become involved with supporting students’ learning in practice, and they may then decide to train as a mentor.


Box 3: Case study 

Q: Abigail Brown is a child field student in her third year final placement and has requested a placement with a health visiting team. She has been allocated to a HV who is a child trained nurse and a live SOM. Can this mentor assess Abigail and sign her off as a registered child nurse at the end of her placement?

A: Close inspection of SLAiP (NMC, 2008, section 2.1.3) indicates that the SOM, in addition to due regard, must currently work within the same field of practice as the field that the student is intending to enter. Our interpretation of this is that because, in this scenario, the mentor is working as a HV and not clinically as a children’s nurse, the student’s clinical learning opportunities may be compromised, which has implications for the due regard of the final assessment for this student.


How does the wider team fit into this?

Students benefit from spending time with and learning from members of the wider team – for example, someone with an in-depth knowledge of child development, play, or child and adolescent behaviour. An example of this could be the nursery nurse, whose specialist knowledge and skills are a fundamental part of health visitor (HV) and school nurse (SN) teams. Despite the nursery nurse not being an NMC registrant, they can still support students’ learning, providing the mentor oversees this. This applies to other professionals too.


Box 4: Addressing cluster skills 

  1. Care, compassion and communication – consultation styles used for sensitive issues
  2. Organisational aspects of care – Healthy Child Programme (DH, 2009)
  3. Infection prevention and control – childhood illnesses and diseases
  4. Nutrition and fl uid management – healthy nutrition
  5. Medicines management – non-medical prescribing

What is ‘due regard’?

There are different regulations attached to who can assess students in diff erent years and their fi elds of practice – see box 2. In some situations interpreting ‘due regard’ and ensuring learning needs are met can be challenging – see box 3.

What do students need to achieve during their placement?

According to the NMC (2010), there are four areas of competency that pre-registration student nurses need to achieve before they are able to apply to be registered as nurses with the NMC. These are:

  1. Professional values
  2. Communication and interpersonal skills
  3. Nursing practice and decision-making
  4. Leadership, management and team-working.

During core placements, students are required to work towards and achieve specific competencies within their practice assessment documents that will be assessed by a live mentor, or SOM. The NMC (2010) also stipulates that student nurses must address five essential cluster skills during their assessed placements. These are:

  1. Care, compassion and communication
  2. Organisational aspects of care
  3. Infection prevention and control
  4. Nutrition and fl uid management
  5. Medicines management.

During non-core placements, students are also required to demonstrate that they are achieving requisite competencies.

In some areas, pre-registration nursing practice is also graded, as opposed to being given a pass or fail. This is not an NMC requirement. HEIs have the option of how they interpret this so mentors may encounter a variety of assessment documentation if working with students from different HEIs. Midwifery education diff ers from nursing in that the NMC (2009) has stipulated that practice should be fine graded.

Given these potentially signifi cant diff erences in how HEIs assess practice, it is important that mentors have a robust understanding of the requirements for assessing practice within the locality in which they are working and mentoring students. In addition to the requirement for students’ to pass their practice placements, there are two progression points within the degree, which students are required to pass in order to move from one part of their training to the next (NMC, 2010).

Interpretation of the NMC’s cluster skills requires some creativity for those in a community setting, as they can initially appear to have an acute care focus. When looking at the fi ve cluster skills, many community practitioners perceive barriers to fulfi lling these within SN or HV practice. However, there are a breadth of opportunities for supporting pre-registration nursing students to achieve cluster skills. Perrin and Scott (2016) give a range of examples in their informative article. We have used some to illustrate how they can be linked to meet the essential cluster skills – see box 4.


What about action plans?

Some mentors tell us that they are apprehensive about writing action plans with students, and deciding when they are needed. Both students and mentors should routinely work together to devise action plans at both the beginning and formative stages of placements. The content of these will diff er depending upon the placement area and the student’s needs, field and year of study.

The process of working together for the students’ learning goals is fundamental to the assessment of students’ progress through their placement. It is required for all students regardless of ability, since even students who are surpassing expectations need to be extended.

Additional action plans may be required for students who need extra support, such as those who are experiencing difficulties. This process should be the fi rst step to be taken if the mentor has concerns about the student’s practice, and would also need to be undertaken in partnership with the HEI. Mentors need to ensure that action plans are specific and can be understood by all who need to read them so avoid abbreviations that may be misinterpreted. For an example, see box 5.


Box 5: Developing action plans

Learning need: Student X needs to gain experience in professional communication using the telephone in practice

Learning actions:

  1. Student X to telephone five clients to arrange developmental reviews
  2. Student X to contact another healthcare professional to refer a client to them
  3. Student X to telephone a school to make arrangements to visit
  4. Date for review of action plan. These specific goals make it easier to see if the outcomes have been met.

How are student numbers determined for a placement?

Each placement is required to have a current education audit (NMC, 2016b). The education audit process diff ers between HEIs but is, in essence, a quality assurance process stipulated by the NMC. Audits capture information about the learning opportunities available to students, staffi ng levels and numbers of live mentors. Audited capacity, which is the number of students who can be taken on placement at any given time, is driven by SLAiP guidance (NMC, 2008) and is agreed between the education lead for the healthcare organisation and the HEI. Audits review the learning resources available to students, previous student evaluations, particular learning opportunities within that area of practice, and the outcomes of external reviews such as Care Quality Commission inspections. Audits are required to be revised every two years as a minimum requirement, although they may need to be revised more frequently to retain currency.

What's in it for you?

  • You have the opportunity to be a signifi cant role model in a student’s journey
  • Facilitating student learning can keep you up to date
  • Students can be given projects about current or new areas of practice or research, and then might update the team by developing a display board or a short presentation
  • Potential for recruitment in the future when the students qualify
  • The preparation and coordination of students’ placements demonstrates leadership skills
  • Supporting students can be used as evidence that can be submitted as part of revalidation
  • It could lead to further professional development/new roles/promotion
  • Working with students can be rewarding on a personal level
  • There is the potential to shape a new workforce generation
  • You are part of a wider network of mentors and educators, including representatives from the HEI as well as from the trust
  • You are sharing your skills and knowledge with students and hence leaving a legacy for future generations
  • Standards of care may be raised as you become more critical and refl ective of your own practice when working with a student.

Conclusion

This article has focused on answering queries raised by the reintroduction of pre-registration student nurses into SCPHN settings following the completion of the Health Visitor Implementation Plan (DH, 2011). Student nurses benefit greatly from learning about the skills and expertise of HVs and SNs, and the exposure to observing public health practice. Some examples have been given showing how practice can be linked to the essential cluster skills.

We have discussed the SLAiP (NMC, 2008) standards that relate to the learning and assessment of students in SCPHN settings, using practice examples and a question and answer format.

This article can be used as a guide to help busy practitioners review the key points relating to learning and assessment of student nurses. The wider personal and professional benefi ts of supporting students’ learning in practice have been highlighted, particularly in relation to revalidation.


References

Department of Health. (2009) Healthy child programme. HMSO: London.

Department of Health. (2011) Health visitor implementation plan 2011-2015: a call to action. HMSO: London.

Department of Health. (2013) Integrated care: our shared commitment. See: gov.uk/government/publications/integrated-care (accessed 6 November 2016).

Department of Health. (2015) The NHS constitution for England. See: gov.uk/government/publications/the-nhs-constitutionfor-england (accessed 6 November 2016).

NHS England. (2014) Five year forward view. See: england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed 6 November 2016).

NHS Improvement. (2016) Evidence from NHS Improvement on clinical staff shortages: a workforce analysis. See: gov.uk/government/uploads/system/uploads/attachment_data/file/500288/Clinical_workforce_report.pdf (accessed 6 November 2016).

NMC. (2016a) Revalidation. See: revalidation.nmc.org.uk (accessed 6 November 2016).

NMC. (2016b) Quality assurance framework: for nursing and midwifery education and local supervising authorities. See: nmc.org.uk/globalassets/sitedocuments/edandqa/nmc-qualityassurance-framework.pdf (accessed 6 November 2016).

NMC. (2015) The code. See: nmc.org.uk/standards/code/readthe-code-online (accessed 6 November 2016).

NMC. (2010) Standards for pre-registration nursing education. See: nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-pre-registration-nursing-education.pdf (accessed 6 November 2016).

NMC. (2009) Standards for pre-registration midwifery education. See: nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-preregistration-midwifery-education.pdf (accessed 6 November 2016).

NMC. (2008) Standards to support learning and assessment in practice. See: nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-to-support-learning-assessment.pdf (accessed 6 November 2016).

Perrin L, Scott S. (2016) Health visitors have much to off er pre-registration child branch student nurses. Community Practitioner 89(5): 44-7.

Willis L. (2015) Raising the bar. Shape of caring: a review of the future education and training of registered nurses and care assistants. See: hee.nhs.uk/sites/default/files/documents/2348-Shape-of-caring-review-FINAL_0.pdf (accessed 6 November 2016).

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