Download Developing a Quality Clinical Learning Environment for Nurses

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Transcript
Developing a Quality Clinical Learning Environment for
Nurses - A Good Practice Guide
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Why read this guide?
The health and care system faces a period of radical change, which is set out in the NHS Five Year
Forward View (FYFV) and framed as a series of new models of care and care strategies. However in order
to develop a workforce that is responsive to changes in care, now and in the future, we need to ensure
there is a sufficient supply of highly skilled staff.
'We can design innovative new care models, but they simply won't become a reality unless we
have a workforce with the right numbers, skills, values and behaviours to deliver it'
There is a national shortage in supply of qualified nurses and this is likely to be made more challenging
with the cap on agency spend and the proposed reduction to overseas recruitment. It is therefore vital that
we reduce avoidable attrition from pre-registration nursing programmes and that the students who
graduate from these programmes are recruited and retained in the workforce.
The government announced in the 2015 Spending Review that from 1st August 2017, all new nursing,
midwifery and allied health professional students will receive their funding and financial support through
student loans rather than through the current NHS bursary scheme. This may give the opportunity to
increase the numbers in training, however service and education providers will need to work together
differently to attract and retain the right students and to ensure they provide a high quality clinical learning
environment.
This paper outlines work that has taken place across Health Education England in the East and service
providers in the East of England to address the issues presenting within the nursing workforce.
2
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Background
The following sections provide a summary of a review that took place across the East of England, the
findings from that review and then provides a description of the actions taken to address the issues
identified. The summary highlights the common themes and actions that have the potential to be
replicated.
Review
This work was initiated followed the fundamental review of nursing and other quality assurance reviews
within the East of England, which highlighted some key challenges in promoting the quality of learning
within the clinical learning environment. The review, which involved significant engagement with all
stakeholders including providers, students and Higher Education Institutions (HEIs), indicated that the
culture within the clinical learning environment was a particular challenge. In particular it indicated that
there was significant variability in the quality of mentorship available to learners and pressure upon
placement capacity, which in turn affected the quality of engagement learners were offered in clinical
situations and with patients. In light of the expenditure on and the need for robust education and
recruitment into the nursing workforce, the implication of these issues with avoidable attrition from nursing
programmes, impact on patient experience and employability, indicated a need for a detailed review about
how the quality of the clinical learning environment could be improved.
3
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Actions Taken
The key actions undertaken were to:
 Review work already undertaken in relation to clinical learning, e.g. Health Education England (HEE)
publication re practice teaching
 A detailed analysis of the policy and research literature around clinical learning
 Piloting and evaluation of 3 new approaches to supporting learners in the clinical learning
environment:
Collaborative Learning in Practice (CLiP)
Practice Education Based Learning Suffolk (PEBLS)
Enhanced Practice Support Framework (EPSF)
The national and international research literature identifies the mentor as a key influence in the quality of
clinical learning in terms of what learning opportunities are offered to students, how able they are to have
hands-on experience and how well they develop clinical knowledge and skills, i.e. are assessed as ‘safe to
practice’ in terms of providing ‘good’ care for patients. Equally important is the role that mentors and other
clinical educators have in transmitting the culture of the clinical workplace to students which indicates
some concern if there is variability linked with the quality of mentorship.
4
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
The evidence would indicate than one important aspect of promoting quality within the clinical learning
environment is a disaggregation of a dominant one-on-one model of mentorship and engaging the wider
workforce in clinical education while remaining compliant with Professional, Statutory and Regulators Body
(PSRB) requirements. In light of this the pilot and evaluation of 3 new approaches to mentorship was seen
as a central factor in addressing two important indicators of quality clinical learning, variability in
mentorship and a positive workplace culture.
The following section describes the key principles identified in all three models. The models are described
in more detail later on in the paper.
5
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Clinical Learning Environment Principles
Following the introduction and evaluation of these three approaches it became apparent that there are a
number of key similarities or principles that could be more widely adopted. The models each promoted
local loyalty and ownership, but were essentially based on the same principles and delivered the same
improvements. These are therefore a core set of universal principles that could be used across providers
to enhance the clinical learning environment. Whilst all of the examples have been applied to nursing
learners the principles have the potential to be replicated across the wider multidisciplinary workforce,
although this is as yet untested.
Key Principles
There are six principles identified through the programme of work.






A model based on coaching
A model not based only on 1:1 mentor relationship
Learners delivering hands on care
Leadership for education and executive sign up
A sustainable infrastructure
Linking education and workforce supply to trust business
6
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Clinical Learning Environment Principles
A Model based on coaching
All of the models tested embedded a coaching approach to the clinical areas before introducing the model. Specific team
based learning was provided to all clinical areas adopting the new model. Students were also provided with input on
coaching in order that they were aware of what to expect and their role in this approach. A day coach approach was
adopted which enabled the learners to work with and build relationships with the wider team. This also enabled support to
mentors who could seek a rounded view of the learners’ progress. The students were no longer reliant on a relationship
with one mentor some of whom may be of variable quality. The learners take increasing responsibility for coordinating
care. This ensured that all staff had responsibility for the learning environment, that learners were an integral part of the
clinical team. Placement areas also reported wider benefits of adopting a coaching model across clinical teams.
A model not based only on 1:1 mentoring
The initial research prior to implementing the models identified the risks of a 1:1 mentor relationship and the impact on the
students learning and progress. Pressure on mentors was also reported. The evaluation describes the benefit of coaching
model for learners and for mentors. The use of day coaches and clinical educators spreads the responsibility, supports
learners to work with a range of leadership and learning styles whilst maintaining the current 40% time requirement of the
NMC. Reported also that is improves the mentor reviews especially with learners who are struggling.
Learners delivering hands on care
Learners strongly reported the improvement in the model of identifying planning and delivering care under the supervision
of the RN, it developed empowerment leadership and delegation skills in the learner, reported improvement in the delivery
of holistic care to patients and the learners were encouraged to reflect on practice and care during the shifts had an
impact on theory application into practice.
There was a strongly reported improvement at the transition from learner to RN particularly focused on leadership
autonomy and delegation.
7
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Leadership for education and executive sign up
The implementation succeeded where there was leadership across the organisation and evidence of a strong learning
culture. This required executive leadership and championing of the models. Executives ensured they worked with leaders
implementing the model and regularly met with learners to ensure the importance of the model and their role was
recognised. Using student feedback was also seen as invaluable within these organisations and ensuring that issues
raised by learners were addressed.
A sustainable infrastructure
The models required alignment of the educational and learning infrastructure within the organisations to ensure the
coaching model was adopted and clinical educator infrastructure delivered the relevant support to placement areas. This
demand was greatest as areas were adopting the model but reduced as the model became embedded. Executive support
and alignment to trust business ensured this was effective within organisations.
Linking education and workforce supply to Trust business
The alignment of the approach to the learning environment to Trusts strategic direction objectives and workforce
strategies was essential, and a fundamental part of ensuring an effective supply pipeline. Linking to Board structure and
governance arrangements ensure regular reporting to Board’s of Directors and ownership of this crucial Board business
by all of the Board of Directors.
8
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
The Models
The following section gives an overview of the three approaches Collaborative Learning in Practice (CLiP),
Practice Education Based Learning Suffolk (PEBLS) and Enhanced Practice Support Framework (EPSF)
and included feedback comments from staff involved.
Collaborative Learning in Practice (CLIP)
A new model of practice learning for pre-registration nurse education was pilot-tested in Norfolk. The
Collaborative Learning in Practice model (CLiP) was taken from a similar model of practice learning
used in the Netherlands.
The model is distinct from the traditional mentorship model both organisationally and philosophically.
Organisationally, rather than working individually with a mentor, students work collaboratively alongside
other students under the guidance of a coach. Coaching underpins the philosophy of learning so that
students are supported to take on greater responsibility for their own learning within a culture that values
student identification of solutions to patient focused care.
The aims of the project were to consider the challenges of implementation, to consider the perception of
gains and losses of students and stakeholders experiencing the new model of practice learning and to
consider the sustainability of the new model in the context of service delivery.
9
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
10
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Key Roles
One of the first steps of the project was to identify key roles and describe the remit of each role within the context of the
project.
The Clinical Educator
This new role is seen as pivotal to the success of the project and in exercising this role clinical educators would directly
influence the quality of the learning environment. The clinical educator needed to be an experienced mentor with strong
facilitating skills who would oversee the project in a particular practice area and could provide on-site support and
guidance to coaches, mentors and students. The importance of this role was enhanced by Health Education East of
England (HEEoE) which provided shared funding with each of the Trusts. The role of the clinical educator is to:





oversee two or four wards or practice areas.
provide training and support to the day coaches and named mentors.
work with HEIs in supporting practice areas to ensure learning opportunities are compatible with learning outcomes.
support the practice areas in allocating students to patients
support student formative and summative practice assessments through up-skilling mentors and acting as a source
of expert advice.
Named Mentor and Sign-Off Mentor
The role of the Sign-Off Mentor (SoM) mirrors that set out in the Nursing and Midwifery Council (NMC) Standards to
Support Learning and Assessment in Practice (SLAiP) (2006, 2008) whereby the student must have one hour a week
protected time with their SoM and the SoM is responsible for determining the students competency and fitness to enter
the NMC register. This role will be an adjunct to the CLiP project although the SoM may also act as a day coach or mentor
on occasions. In addition, where the Clinical Educator is also a qualified SoM, and where no other SOM is available, there
may be a necessity for them to carry out this function. The benefit of CLIP to the SoM is that Daily Feedback sheets and
input from Day Coaches, Mentors and Clinical Educators can help support their decision making. Students will work with
their named mentors for a minimum of 40%, however they will also be working with coaches and the mentors will need to
be up-to-date with their student’s learning and progress. The named mentor will need to ensure that they create
11
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
opportunities to meet with and work with their allocated student to ensure learning opportunities are maximised, learning
outcomes met and assessments are robust. The presence of the Clinical Educator and Day Coach made this very much a
collegiate approach to student learning. The role of the named mentor is to:
 have a role consistent with NMC standards ensuring each student has access to a mentor forty per cent of the time.
 have a maximum of three allocated students.
 be responsible for liaising with coaches and other people that their student might have worked with in order to
develop an informed assessment of the student’s practice.
 be able to request to spend time working with a student on a one-to-one basis
 be expected to review the students learning on a regular basis to ensure they are meeting their learning outcomes.
 Liaise with coaches and familiarise themselves with feedback through the daily learning logs to support the
assessment process
Day Coach
The Day Coach role is new and can be undertaken by any registered nurse within the practice area who is overtly
interested in supporting student learning and willing to take on the role and further preparation. In order to execute this
role satisfactorily, day coaches do not have any other responsibilities during that particular shift. The day coach is:
 a registered nurse but not necessarily a qualified mentor.
 a regular ward based member of staff (long-term bank staff may be suitable but short term or agency staff are not).
When acting as a day coach they:
o have a maximum of three students per day.
o have a maximum of nine patients to care for at any one time, ideally only having responsibility for the patients
directly cared for by ‘their’ students.
o have no other patient / service responsibilities.
12
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Students.
The model is underpinned by a philosophy of student-led and peer learning. Students need to be prepared for what to
expect of their role in this new learning environment. Students will:
 normally have not more than three patients allocated to them but this would be in relation to their developmental
stage, their competency and the complexity of the patient’s needs.
 be afforded some flexibility in order for them to achieve learning outcomes of specific clinical opportunities,
management and leadership.
 Second and third year students will be involved in supporting and facilitating learning for other more junior students
Link Lecturers.
Link Lecturers are identified as key players in supporting partnership working. There is an expectation that they will be
involved from the outset in the project plan development. Link lecturers work with the clinical educators in supporting
coaches and mentors and play a key role in cascading the coach training to practice level. Link lecturers will:





organise on-site training in coaching skills
support practice by attending the student case study presentations
support coaches and mentors in executing their roles by role modelling coaching skills
work with Clinical Educators to identify new placement areas/opportunities
Support clinical teams to deliver satisfactory educational audit outcomes
13
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Preparing Practice
All members of the practice area need to be aware not only of the significant increase in the number of students to be
placed but also of the change in philosophy of learning. This is crucially important if the aim is also to influence,
incorporate and embed coaching as a culture of the learning environment. Preparation involves ensuring all levels of the
organisation are aware of the proposed changes as well as all staff, including Health Care Support Workers and the multidisciplinary teams working in the practice area. This practice preparation is part of the project plan.
Training
Training was the final key factor to be considered. The university took responsibility for this aspect with a view to
developing a ‘training the trainers’ programme. Initially a series of short study sessions were delivered in the School to link
lecturers, pilot project mentors and clinical educators. This was followed by two master classes delivered by a visiting
clinical educator and coach from V U Medical Centre Amsterdam Holland. Subsequently, the training is cascaded to the
practice areas delivered by the clinical educators and link lecturers. The two main theories underpinning the training
programme are Hersey and Blanchard’s (1977) situational leadership and Miller’s pyramid of assessing clinical
competence (1990). The current programme involves:
 a series of screen casts available on the internet that explains the project, explaining the theory of coaching, role
plays depicting coaching in action.
 a number of coaching sessions are delivered in the practice area to all staff of the nursing team before students
arrive
 a further series of sessions half way through the student’s placement are delivered to the coaches and mentors that
enable the application of the theoretical models to practice.
 Students are prepared before going into practice around the expectations of student- led learning
 A resource booklet explaining the project has been developed for students and coaches.
14
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Implementation
CLiP implementation was eased when the model of implementation was perceived to be flexible and easy to adhere to.
Positive ward culture was the most significant feature for successful CLiP implementation; a culture receptive to change
and educationally focused was important to the success of CLiP implementation, as was training and support of the whole
clinical team , and strong and positive leadership.
Enabling features were identified in relation to the success, or otherwise, of CLiP. Student numbers, their experiences,
preparation, allocation and support were factors perceived as fundamental to CLiP working effectively. The clinical
educator role was seen as essential to the success of CLiP, whilst the coach was also key.
The staff: patient ratio, the level of support offered, and preparation, were factors influencing coaches’ ability to perform
their role successfully. Staffing levels within placement areas were considered to be the most important factor in ensuring
the role of the coach was effective.
Organisationally, having distinct learning bays, access to information technology, resources room and the allocation of
regular learning time were perceived to be important.
Conclusion
The model has been perceived to be highly successful in both increasing placement capacity and improving the quality of
learning for nursing students – particularly in preparing them for the realities of qualified practice. It has also resulted in
perceived improvements to the assessment process and up-skilling of mentors, thus addressing failing to fail issues. It
may also demonstrate improved patient care quality outcomes, although this will need further evaluation.
However, the rigidity of project parameters has been too restrictive at times and may have acted as a barrier rather than
an enabler. Going forwards, increased flexibility will be introduced whilst ensuring consistent CLiP principles are agreed
and delivered.
15
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Whilst the model needs to be resourced in relation to supernumerary Clinical Educator posts these were perceived to be
essential to the success of the model and therefore a very worthwhile investment. Removing or reducing clinical
caseloads for day coaches to enable a supernumerary coaching function should be offset by the increased student care
giving role.
Summary of Evaluation
A. The most influential aspect of the project has been the introduction of an independent Clinical Educator post which
carries no clinical or line management responsibilities. The role requires the clinical educator to support and monitor
day coaches, mentors and sign-off mentors, with consequent involvement in supporting students through the mentors.
This has resulted in a number of key benefits including:
 Perceived improvements in “failing to fail” issues – students who are struggling are identified much earlier
through this model and a supportive team approach is facilitated by the Clinical Educator. This means there is
more likely to be a positive turnaround for the student, due to additional support available, and where students
are failed mentors are supported through the process.
 Clinical Educators are able to help mentors understand “due process” in relation to assessment processes
ensuring more robust assessment in practice takes place.
 Mentors unable to articulate their concerns about students are able to explore these with the Clinical Educator
for clarification.
 Clinical Educators themselves are perceived to have shown professional development and growth associated with a
number of key leadership attributes that are above and beyond those which are normally observed in these level posts.
 Clinical Educators are more visible, more available and more accessible than the Link Lecturer and thus are
likely to be the first port of call for students and staff needing advice and support.
 Clinical Educators have a key role in setting up new CLiP areas and providing on-going training for coaches
and mentors. This is a challenge in community nursing teams where a train the trainer approach is not
appropriate in patient homes and innovative ways of overcoming this need to be determined.
16
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
B. Early data review suggests quality of patient care has been improved in a number of areas ,this includes reports of:
 Reduced length of stay by up to 3 days (CLiP learning bays versus non-CLiP bays. Random allocation of
patients).
 Reduced incidence of pressure ulcers and falls (measured through patient safety thermometer).
 Improved results in friends and family tests.
C. The CLiP model has resulted in increased capacity. For example adult areas at James Paget hospital increased
from 4 to 12 students. High numbers of students in a mix of years are necessary to facilitate peer to peer learning
and coaching; this can however, lead to depleted student numbers in other areas. In community hospitals, capacity
in CLiP areas has increased from 4-6 students to 16-20 per year. In community nursing teams capacity has
increased from 60 to 200 per year (although it must be noted that this is due to increased commissions not just
implementation of CLiP). The way students are managed through CLiP has made these increases successful
without consequent loss of placement quality often seen under these circumstances.
D. Due to the difficulties in undertaking a robust evaluation of a multi-site project such as CLiP, fairly rigid parameters
of the project were agreed at the outset. These have proved overly restrictive in some cases and service leads have
perceived these to be a barrier at times.
E. High student : coach ratios in very acute areas can also lead to concerns around staff burn out which could
potentially benefit from the ability to rest or rotate CLiP areas. Increased flexibility of the model with local decisions
regarding parameters such as student: patient and coach: student ratios would be beneficial.
17
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
F. There is no doubt from a service perspective that the model is beneficial to students with service ( including students
and mentors) reporting increased confidence and competence from students at all levels. It is also reported that the
model has an impact on the whole team with a perceived increase in critical thinking for all staff.
G. Service changes also provide a challenge for this model. In community areas healthcare assistants (HCAs) are now
undertaking essential nursing care with registered nurses mainly involved in the most complex cases. Thus first and
second year students, in order to enhance essential skills training, need to spend time with the HCAs whilst still
having 40% time with an RN mentor. In future the role of HCAs as day coaches might need to be considered.
H. The model in Amsterdam had never been tested in mental health areas, thus in the mental health Trust the model
was adapted within the parameters of the project as it was implemented. Adaptation was necessary since, unlike
other pilot areas, wards did not have dedicated learning bays and service users were mobile and not restricted to
particular ward areas. This was largely achieved by providing a structure to the CLiP day which enabled staff and
students to better visualise the model.
I. One of the biggest sources of controversy for the project was the daily learning logs. These were introduced to allow
identification of learning objectives and meaningful feedback for students which in turn helps inform mentors for
formative and summative assessments. However, it has been clear that there is a dichotomy between academic
and service perspectives of these key documents. Service reports difficulties in completing them with such
frequency in a meaningful way and the current format does not suit all areas. Student feedback is variable about
their successful implementation.
18
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Comments From Participants
“It’s a better way to prepare students and to involve students and therefore when they qualify they will be more ready to
practice.” (Stakeholder 4)
“The growth within the students is huge. They`ve grown in professionalism and actually in their skills and confidence ...
and actually have learnt a lot from their coach and a lot from the whole experience.” (Stakeholder 2)
“My confidence has dramatically improved, that’s the best way I can describe it really, I think from the CLiP that it’s made
transitioning to a qualified nurse much easier” (CLIP student)
“I think there was a lot of responsibility on us on the CLiP project...I feel like it’s made me a lot more autonomous. It was
the first time that I’d had the opportunity to develop delegating, prioritising, all those sorts of skills that are involved in
managing your own caseload, just never really had the opportunity to do it before. I did gain a lot of leadership and
management skills ...it helped me a lot, to gain more confidence in my skills and how I’m doing.” (CLIP student)
“Positively I would say the move towards thinking about coaching, towards standing back, towards using a different kind
of language with the students, I think that’s, that is a big advantage of CLiP.” (Stakeholder 7)
“So relationships, I think its better that a mentor or student isn’t feeling necessarily that one person is making the
judgement, you know, on their own. They’ll actually take a range of evidence from a range of people.” (Stakeholder 12)
“I did really enjoy the chance to work with other students, I really enjoyed passing on my knowledge - it helped my
confidence because I realised that I did know things, because I could teach them.” (CLIP student)
“It works better with larger groups of students, if there’s only one of them on duty the model can slip back to mentoring.
More students makes it easier than less, definitely.” (Stakeholder 10)
“..preparation of the student is important, because I don’t think it’s just student attitude, I think especially those students
who came to us having experienced the other model, which is a very safe, it’s very supportive, it’s a model in which
you’re held very closely by a mentor and I think to some extent molly-coddled maybe. There are some who either through
lack of preparation about what CLiP was about or an attitude about what it is to be a student nurse, have come along not
prepared to do the hands on face-to-face getting stuck in type of learning that we’re describing on CLiP. Few and far
between but enough for me, you know, and I think it was probably about preparation.” (Stakeholder 6)
19
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
“I think the Clinical Educator is particularly key to this because I mean essentially what we’re trying to do with CLiP is
change the entire culture of the way that placement experience takes place for the mentor and the student. You’re
looking at a completely different model of coach mentoring, you’re looking at a completely different model of student
experience, student learning, and with any culture change you will get resistance and again, all the clinical educators
have experienced that at some time or another where they’ve got mentors or day coaches who are resistant to this
model....the Clinical Educator will reinforce the model.” (Stakeholder 1)
“What the clinical educators need to do is focus on up-skilling the mentors. Not necessarily the students and I think that
has, not in all cases, but in some areas, got a little bit lost.” (Stakeholder 7)
“Actually it’s quite a challenging role because they’re being expected to go into practice areas and challenge ward
managers at band 7, you know, they need to have the credibility and they need to be able to have those challenging
conversations that take place. So I think it’s crucial that we’re given the support and the training to take on that role. At
the moment all they’ve had is the same basic coach training that everybody else has had. They’ve had nothing beyond
and above that.”(Stakeholder 1)
“The doctors were told that they need to come to the students first and then the students will tell the actually qualified
nurses afterwards, so the doctors and OTs and physios, everyone knew that you need to come to the students first,
which is nice really. You definitely need whole team buy-in.” (Stakeholder 10)
“Ward philosophy is key, I think. Good leadership, valuing education generally. I guess a steady team, a tight team that
trust each other. The implementation needs to be supported from the highest level on the ward. Because the ward
manager wants it to work and that is what you need, you need that support. “(Stakeholder 5)
“Students then who go on to non-CLIP wards feedback that they feel restricted, stifled, their skills aren’t valued”
(Stakeholder 5)
“My concern is going, moving onto a next placement, which doesn’t sort of run in the same way and, kind of, feeling that I
have to prove myself all over again and, sort of, show my abilities, show my capabilities, and having there be that
possibility that I might not be able to take on a similar role and almost feel like I’m taking a back step and, you know,
potentially losing those skills that I've gained from being part of CLiP. I think, you know, definitely, definitely increasing
confidence and learned so, so much. My biggest concern is just kind of losing all those skills and not having that
opportunity to work in the same way continuing throughout the next placement.” (CLIP student)
20
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Practice Education Based Learning (Suffolk) (PEBLS)
Increasingly this work needs to take place across STP footprints.
Practice Education Based Learning (Suffolk) was introduced following a review of practice education in
Australasia and early learning from the CLiP model. The model is based on a learning bay comprising
6 to 8 patients cared for by 3 students one of whom assumes the role of coordinator. A coach supports
the students. A clinical educator is in place to support the ward team. Overall capacity of the clinical
area increases taking 9 to 12 students in total. This model is also based on the use of coaching to
empower students, increase their leadership, problem solving and critical thinking skills and enable a
smooth transition to the RN role. The model was commenced in both acute and community settings.
21
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
22
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Principles of PEBLS Project
 The philosophy of learning will be underpinned by a coaching style of mentorship
 The learning will strongly support a student led and peer learning philosophy
 Parameters will differ for acute and community pathways
 There are four main roles identified in the model:




Clinical educator
Link lecturer
Mentor/Sign- off mentor
Coach
Project Position as at December 2016
The model is currently being implemented in one acute ward at West Suffolk Hospital and two acute wards at Ipswich
Hospital. Students are approximately halfway through their placement and so far student feedback is very positive
particularly in relation to student satisfaction with the model. Some mentors have raised concerns about not having
sufficient time with their allocated students, but they all meet the 40% NMC guidelines and this is an anticipated part of the
cultural change required when adopting this model. New areas seeking to adopt the model in the autumn are Community
(DN team and community hospital) plus additional areas at Ipswich and West Suffolk.
The evaluation of the model is already underway and will continue alongside roll out of the model.
23
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Community Pathway
The Clinical Educator
 Clinical Educators will oversee a coverage to be determined by audit – NB differences will occur dependant on practice area
e.g. community wards/team/locality teams etc. Account will also be taken of ratios, travel, geography and allocated time the
individual would spend with students
 The role is supernumerary and the individual would not be a member of the pilot wards/ teams.
 Their role is to provide training and support to the coaches and mentors of the pilot.
 Clinical Educators will work with HEIs in supporting practice areas to correlate learning opportunities with learning outcomes.
 Clinical Educators will support the practice areas in allocating students (e.g. allocating to buddy, allocating to named coach,
ensuring time with mentor are all built in)
 Clinical Educators will undertake a targeted approach for assessments attending 1st assessment supporting mentors and
attending assessments where issues have been identified with the student. They will also provide support to mentor lacking in
confidence or requiring additional support.
Mentor/Sign Off Mentor
 This role will be consistent with the NMC standards
 The mentor will be responsible for liaising with others to develop an informed assessment of the student practice.
 The mentor will be expected to review the students learning on a regular basis to ensure they are meeting their
learning outcomes.
 The mentor should spend one day per week with their student providing direct supervision plus 1 hour per week
dedicated 1:1 time.
24
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Coach
 This must be a registered nurse, assistant practitioner or other healthcare professional.
 3rd year students will act as a coach for no more than one day per week to facilitate development of coaching
skills
 They must be a regular member of staff but must be suitably prepared i.e. long-term bank staff are suitable but
short term or agency staff are not.
 Coach to have a maximum of 3 students to support for that day with ideal standard that they will only have
responsibility for the patients ‘their’ students have.
 The Coach has no other patient responsibilities.
 Third year placement students may act as a coach for no more than 1 day per week to facilitate development of
coaching skills
 Assistant Practitioner’s or equivalent, other health care professionals and students will provide feedback to the
mentors on the demonstration of NHS Values and behaviours, areas the student has exceled at and areas where
further support and improvement is required
 Coaches have no other patient responsibilities as a general rule although we accept that exceptions will need to
be made in cases of staffing crisis (e.g. sickness).
 Numbers of students allocated to student or assistant practitioner coaches will be decided locally by the
registered nurse/coach on duty based on capability and confidence of the individual student/assistant practitioner
coach.
Daily Supervision Model
Where the coach is an assistant practitioner or a 3rd year student, a registered nurse on each shift will have overarching
responsibility for students (to include allocation, point of contact in absence of coach etc).
25
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Student Allocation
 Allocation of student numbers will be determined locally based on audit and local conversation however the number
will be even.
 Students can be allocated, according to the need to achieve their learning outcomes, to non-nursing
areas/integrated teams providing they can support this model through other health care professionals or assistant
practitioners (and equivalents) supporting students providing they have had appropriate training.
Students
 Students will have a small caseload to include 2 long-term complex cases and a maximum of 4 others. Patients will
be allocated to them in relation to their developmental stage, their competency and complexity of the patient
condition.
 At the relevant stage of training and underpinned by NMC standards, students will lead the caseload.
 In the final year students are afforded some flexibility in order for them to incorporate management outcomes in their
learning, for example when acting as a team co-ordinator.
 Mapping core competencies of the care certificate to the 1st year Student nurse competencies will ensure at the end
of their 1st year, students undertaking unsupervised visits have acquired the necessary level of competence to
undertake those allocated tasks subject to further confirmation by the registered nurse.
Acute Pathway
The Clinical Educator
 Clinical educators will oversee two areas in the implementation phase
 The role is supernumerary and the individual would not be a member of the pilot wards/ teams
 Their role is to provide training and support to the coaches and named mentors of the pilot.
 Their role will also support initiatives for practice based learning such as mentor and preceptor training.
 Clinical educators will work with HEIs in supporting practice areas to correlate learning opportunities with learning
outcomes.
 Clinical educators will support the practice areas in allocating students (e.g. allocating to buddy, allocating to named
26
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
day coach, ensuring time with mentor are all built in)
 Clinical educators/clinical liaison nurse will undertake a targeted approach for assessments - attending 1st
assessment to support new mentors, attending assessments where issues have been identified with the student,
and providing additional support to mentors as needed.
Mentor/Sign off Mentor
 This role will be consistent with the NMC standards
 Each named mentor will have a maximum of three students allocated.
 The named mentor will be responsible to liaise with others to develop an informed assessment of the student
practice.
Coach
 This must be a registered nurse, assistant practitioner or equivalent health care professional 3 rd year students will
act as a coach for no more than one day per week to facilitate development of coaching skills
 They must be a regular member of staff i.e. long-term bank staff are suitable (providing they have been
appropriately prepared for the role) but short term or agency staff are not.
 Coaches will have a maximum of 3 students per day.
 Coaches to have a maximum of 8 patients to care for that day with ideal standard that they will only have
responsibility for the patients ‘their’ students have. Coaches have no other patient responsibilities as a general rule
although we accept that exceptions will need to be made in cases of staffing crisis (e.g. sickness). Assistant
practitioners, health care professionals and students acting as coaches will provide feedback to the mentors on the
demonstration of NHS Values and behaviours, areas the student has exceled at and areas where further support
and improvement is required.
 Numbers of students allocated to student or assistant practitioner coaches will be decided locally by the registered
nurse/coach on duty based on capability and confidence of the individual student/assistant practitioner coach.
27
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Student Allocation
Allocation of student numbers will be determined locally based on audit and local support capacity.
Students
 Students will have a small caseload of up to 3 patients per shift. Patients will be allocated to them in relation to their
developmental stage, their competency and the complexity of the patient condition.
 Management students can have a maximum of 8 patients per shift and this could incorporate acting as a day coach.
 In the final year students are afforded some flexibility in order for them to incorporate management outcomes in their
learning, for example when acting as a team co-ordinator.
Comments From Participants
“Having to hand over patients gives you confidence that you know them”
“I have learned so much and increased in confidence I prefer PEBLS to ward days as I’m busier”
“Relationships between students can be challenging”
“I enjoy having increased responsibility rather than being a sheep following people around”
Engaging with the wider MDT was scary but insightful”
“I really value the learning hour, helps me apply new knowledge to my patient”
“I have learned more in this placement and now really understand the role of the nurse.”
28
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Enhanced Practice Support Framework (EPSF)
The challenges of supporting learners in practice settings, in general, and those of mentorship, in
particular, are well documented (Robinson et al 2012, Willis, 2012, Health Education England, 2015).
The juxtaposition of balancing client care priorities, with the needs of learners in demanding,
resource limited environments, presents an enduring and on-going challenge to quality practice
based learning in the UK. Initial research, exploring the experiences of mentorship, undertaken by
Anglia Ruskin University and the University of Essex, has resulted in the development of an
alternative framework to support students and their mentors. The Enhanced Practice Support
Framework (EPSF) has been formulated to create a cultural change in practice learning and utilises
existing resources in a more effective way. This framework can be placed within the existing
infrastructure for practice learning with minimal disruption. The EPSF is underpinned by the view that
the facilitation of learners is every registered nurse’s responsibility and not the sole remit of a
registered mentor – a principle supported by the Nursing and Midwifery Council’s (NMC) Code
(2015). It also recognises the need for a role model to support mentors with their decision-making
around assessment and development of mentorship skills, as well as to develop and maintain a
quality learning environment. This section will outline the findings of a pilot study undertaken by
Anglia Ruskin University, exploring the implementation of the Enhanced Practice Support Framework
in six clinical areas; located within three acute NHS trusts in the East of England.
29
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Background
The Enhanced Practice Support Framework comprises 3 key roles:
 Lead Mentor, Mentors, and Coaches
The diagram identifies the roles within the EPSF and represents a notional staff ratio rather than a hierarchical approach
in the support of student learning. Descriptors of each of these roles are as follows:
30
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Lead Mentor [one in each practice area]
The Lead Mentor will be an experienced and credible sign-off mentor who has demonstrated excellence in their
mentorship role and will be responsible for helping to establish the best possible learning environment for all students in
their area. Within this role they will therefore be responsible for promoting and monitoring the quality of education in the
practice setting, ensuring students have been allocated to a ‘live mentor’ or to a coach, on a daily basis (when the
student’s mentor is not available to do this). The Lead Mentor will also act as a support for mentors, sign-off mentors and
coaches and a point of communication for Education Managers. It is anticipated that the Lead Mentor will be in an ideal
position to recognise registered staff who demonstrate the potential to become quality mentors, so that only those who
want to mentor and can mentor become mentors. These individuals should be encouraged to pursue higher level
mentorship as an aspect of their Continuing Professional Development.
Mentor
A student will also be allocated to a mentor who will retain responsibility for facilitating and directing their learning. The
mentor will also remain responsible and accountable for undertaking all on-going (formative) and final (summative)
assessments of their student. Mentors may also undertake the role of coach if they have not been allocated a student to
mentor at that point in time.
The mentor will liaise with coaches within the practice setting to seek and obtain feedback to support their assessment
decisions. The student coaching log will provide further evidence of student learning related to course practice outcomes.
Whilst a mentor will be required to comply with the Standards to Support Learning and Assessment in Practice (NMC,
2008) and provide supervision of learning for 40% of the student’s allocation, some of this will take the form of allocating a
suitable coach to develop their student’s experience and learning. To inform their assessment decisions, mentors will also
be required to spend time working directly with their student.
Coach
In the EPSF, all registered health care practitioners will be expected to undertake a coaching role and will participate in a
coaching workshop to help prepare them for this role. The coach is responsible for teaching, supporting and giving
feedback to the student, with the aim to improve the student’s performance around skills and competencies. Registered
practitioners do not need a mentorship qualification to coach students.
31
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
On a daily basis, each pre-registration student will be assigned to work with one coach and negotiate a goal that is linked
to one of their course practice outcomes. The coaching relationship may be relatively short term and may only span one
shift every 1-3 weeks (depending on the number of registered staff available in the practice area). The coach will be
required to sign the student’s coaching log to confirm accuracy of the student’s entry. The coach will not be responsible for
the assessment of a student or completing /signing any aspect of the practice assessment document.
Evaluation
The purpose of the Enhanced Practice Support Framework was to support mentors in their role by creating an
environment in which practice learning became the responsibility of all registered nurses. The findings of the pilot of this
framework demonstrate the positive impact that this has had. Mentors report the EPSF to have improved their experience
of mentorship by making their role more manageable, less stressful, less time-consuming and useful in informing their
assessment decisions.
Non-mentors reported their experience of coaching to have prompted an increased desire to become mentors
themselves. Whilst the literature debates the suitability and aptitude to mentor (Willis, 2011, Robinson et al, 2012), these
findings suggest that exposure to facilitating learners, in an environment where collegiate support of students is the norm,
may result in the development of key skills to mentor and the mentorship role being viewed more positively.
Acting in the coaching role was regarded by non-mentors as influential in the development of their professional
knowledge, clinical practice and the skills to facilitate learners. Maintaining and developing a contemporary knowledge
base can only enhance the quality of patient care delivery. This presents a powerful rationale for all practice areas and
indeed all practitioners, to be actively involved in supporting their future colleagues and health care workforce.
With the exception of a small group of final year students, who expressed a preference for greater autonomy, all students
reported this new method of practice support to have provided them with increased support from registered nurses, a
more focused learning experience and the opportunity to work with and learn from a wide range of registered practitioners.
Students further considered their coaching log as a useful tool for evidencing their learning and progress towards their
prescribed practice outcomes that must be achieved in their placement. The setting of a daily goal related to their practice
32
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
outcomes proved an effective learning strategy for students and many considered this to be a valuable approach for future
practice learning.
The identification of a suitable and motivated Lead Mentor, with the skills to embed quality mentorship and support in their
practice area, coupled with appropriate preparation of the participants, was key to the success of the EPSF. With their
reputation for delivering quality mentorship, the credibility and accessibility of the Lead Mentor were important factors in
the support of mentors and coaches within the framework. Lead Mentors undertook this role as part of their routine work,
only requiring additional time to set the framework in motion and to support staff in their relevant facilitation roles. As such,
one of the key benefits of the EPSF is the minimal cost implication in terms of set up and sustainability.
In preparing the future workforce for their role in facilitating learners, the project team have considered how the skill of
coaching and an educational ethos may be developed amongst final year students. To explore this further, a peer
coaching pilot involving senior and junior students is currently in progress in two Acute Health Care Trusts in Essex.
The EPSF is a simple, effective and transferable recalibration of the existing support mechanisms in practice settings,
which has clearly improved the experiences of practice learning for students, mentors and coaches. The success of this
framework is reflected in the fact that pilot areas have embraced this new approach and have opted to continue with this
of their own volition.
With the recruitment and retention of nurses across the UK becoming more challenging, and in a climate of financial
scarcity, it is essential that existing resources for supporting learners are utilised to best effect. At a time of on-going
changes in healthcare service provision, the EPSF offers a readily available and viable solution, which can be
implemented without disrupting the existing fabric of practice learning or NMC (2008) requirements for mentorship. With
its potential to support overstretched mentors, motivate and develop non-mentors and to promote quality practice learning
experiences, the Enhanced Practice Support Framework is an alternative model of practice learning that merits serious
consideration.
33
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
Comments from Participants
‘I think they were really important in establishing an understanding... the level of preparation has given
us a lot of guidance, so in the role of Lead Mentors we knew exactly what was expected of us.’ LM2
‘they (workshops) were really helpful and useful and I knew exactly what I needed to do in my role, It
gave me an opportunity to let staff know what was going on as well before they came on the coaching
course’. LM4
‘I think the fact that everybody was individually invited to come along for their own involvement in this,
they had an introduction from yourselves, I think that gave them more buy in, so when it came to being
on the ward, between us it wasn’t hard to keep that momentum of motivation going. Because they’d
come to something specific, because they’d been given that first introduction to it, it was something that
then they felt that they were involved’ LM2
‘From (organisation) we got 100% buy-in.... when it came to sending the staff on the coaching study
days, for them to be brought up to speed with everything, they were totally behind us, so there wasn’t
any conflict with releasing staff or any concerns at all.’LM2
‘I found that actually they like the fact that they get to know the whole team... they had the opportunity to
work with different people, and learn skills in various different ways, because some people impart things
very differently, so their scope of learning has increased I think’.LM2
‘I think the students have liked the fact that they’re engaged in the team as opposed to just having one
mentor that they work with.’ LM2
The Lead Mentor was always available if we had any questions or queries. (2.1)
It was good to know that they were always there for advice. (1.8)
34
Developing a Quality Clinical Learning Environment for Nurses - Good Practice Guide
I went to my Lead Mentor as I was struggling with a student and did not know how I should put this in
their book. They helped me write things down in a way that would help the student and show that I had
tried.’ (3.1)
Coaches were able to give me their opinions. It enables me to make informed assessments. (1.8)
(I have a) Wider view of students and their attitudes all the time. (2.3)
It helped guide a balanced view of the students’ progress. It can help to confirm or refute my
assessment. (3.3)
Enabled me to be aware of their progress when not working with me. (3.3)
Enabled me to reflect on
how they were performing when working alongside other mentors of staff. (1.3)
35
Similar