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EDUCATORS

Setting standards for high-quality placements

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Standards were developed to help give organisations offering clinical placements confidence that their placements provide high-quality realistic learning opportunities

Abstract

As part of a project undertaken by a local education and training board, a wide range of stakeholders across South London were asked what makes a high-quality practice placement for student nurses, and how that quality could be effectively measured. This article outlines the drafting and testing of a set of quality standards in a mix of provider settings. Although further refinement is required, the standards enabled placement sites to question themselves about their own education and training processes, strengthened their partnership with the training and education board and facilitated the assurance that student nurses receive safe, effective and compassionate preparation when they are on placement.

Citation: Aitkenhead S et al (2015) Setting standards for high-quality placements. Nursing Times; 111: 36/37, 22-25.

Authors: Susan Aitkenhead was previously project lead on behalf of Health Education South London and is now interim head of nursing, NHS England (London region); Sean Farran is associate director of education and quality, Health Education South London; Ian Bateman is head, Pan-London Quality and Regulation Unit.

Introduction

Clinical experience is seen as the core of education and training for non-medical health professionals and nurses in particular, both nationally and internationally (Smedley and Morey, 2010; Stevens et al 2009; Levett-Jones et al, 2006). This experience is primarily gained on practice placements with healthcare providers.

Responsibility for assuring that education for nurses and other non-medical professionals in England is of high quality sits with various organisations, including national regulatory bodies, universities and local education and training boards (LETBs). However, it can be difficult to confirm whether working environments are providing students with a high-quality placement that is fit for purpose, enabling them to meet their learning objectives.

Several high-profile failures of care have been well documented and the final report of the public inquiry into Mid Staffordshire Foundation Trust recommended that organisations should be prevented from taking students on practice placement in areas that do not comply with fundamental patient safety and quality standards (Francis, 2013). The government’s response to the report (Department of Health, 2013) additionally highlights that “education and training are critical to securing the culture change necessary for the best patient care now and in the future”.

As commissioner of both academic and practice-based components of education, the LETB, Health Education South London (HESL), began a project in November 2013 to develop:

  • A set of standards to assure the quality of non-medical practice placements;
  • A process to monitor and assure the placements’ achievement.

We aimed to focus on the areas in which students can be placed to gain practical experience across all sectors and specialties. In placement settings, learners are most often pre-registration students participating in an educational programme provided by a university. However, the focus of our project also included qualified professionals undertaking structured learning in a practice placement environment, and was therefore applicable to placements for:

  • Pre-registration students;
  • Post-registration students;
  • Returnees to practice;
  • Healthcare workers undertaking a period of adaptation to allow for registration with a professional regulatory body.

Drafting the standards

The literature highlights the importance of students having a high-quality experience when undertaking practice placements (Coyne and Needham, 2012; Jokelainen et al, 2011; Murray and Williamson, 2009; Hoel et al, 2007; Andrews et al, 2006). We therefore reviewed a range of documents relating to guidance and standards for practice-based learning to identify whether any organisation had successfully implemented structured assessment and measurement of learning environments and associated learning. A mixed approach was reported, with no one method standing out as exemplary.

We also held meetings with a wide range of multi-professional and academic stakeholders, including many students, asking:

  • What makes a high-quality practice placement?
  • How could that quality be measured?

We also requested information about existing standards from the colleges representing the various non-medical health professions. We explored the abundance of data to identify themes; the information was divided into the following groups:

  • Current assurance practices that work well (Box 1);
  • Challenges and gaps (Box 2);
  • Exemplar practices;
  • Suggestions from stakeholders.

We also held a teleconference with NHS Education for Scotland, which offered advice from its work in this area (NHS Education for Scotland, 2010; 2008).

After drafting a first set of standards, we held a stakeholder event in February 2014 with many representatives attending from across London. Delegates were asked to examine the drafts in detail and:

  • Further define the standards where necessary;
  • Consider how they could be measured;
  • Propose what evidence organisations would require to demonstrate how they met the standards.

After the stakeholder event we agreed the standards should be refined to produce a version for testing in pilot sites. We then finalised six quality standards and accompanying indicators, so organisations offering placements could submit evidence to demonstrate they had achieved each indicator and did indeed offer high-quality practice placements.

Box 1. Successful quality assurance practices

  • The identification of a great deal of “strong and committed mentorships”
  • Local award schemes to identify good mentors and clinical teaching environments
  • Students being more confident in raising concerns about patient care
  • Local approaches to student feedback similar to the Friends and Family Test methodology
  • Key account meetings strengthening higher education institution/provider relationships
  • Helpful National Student Survey data
  • Local learning contracts to enable the translation of theory to practice
  • Student support skills for nursing assistants
  • The Chartered Society of Physiotherapy’s ePortfolio interactive online resource (Bit.ly/CSPePortfolio)

Box 2. Challenges and gaps

  • Education is not always recognised as a core component of every staff member’s role
  • Increased interprofessional working and assessment is needed
  • There is sometimes a reliance on “relationships” rather than clear systems and processes
  • Approaches to mentorship and supervision differ between organisations
  • Banding and structures vary within provider educational roles
  • There was a request for consideration of whether ratios could be worked out for educational supervision and day-to-day clinical environments, particularly during fluctuations in patient acuity, bed numbers, and so on
  • A balanced relationship between staff and students is needed
  • Language – sometimes students may be assumed to be present to “work” not “learn”
  • A clearer process and structure is needed around information sharing between organisations
  • Exemplar practices should be highlighted to help align best practice across “the patch”

Piloting the draft standards

We agreed that a combination of sites was required to pilot the standards and provide a good mix of settings that would help us develop appropriate, adaptable ways of assessing the draft standards in organisations of varied sizes and structures. Pilot sites were to be developmental to gain as much interactive feedback as possible.

The Royal Marsden Foundation Trust agreed to participate in the project, as did Greenwich and Bexley Community Hospice (GBCH). The Marsden is a renowned cancer centre with two acute hospitals, and also incorporates Sutton and Merton Community Services as a large non-cancer division. This is the foremost provider of specialist palliative care to a population of more than 500,000 people. Patients with active, progressive and advanced disease may be eligible for hospice care, including those with non-malignant disease.

During the project, the principal author and project lead was also employed on a part-time basis at the Royal Marsden Foundation Trust to backfill the chief nurse post. Although the Royal Marsden Foundation Trust was one of the pilot sites, via the governance of the project board it was agreed that the methodology removed any potential bias/conflict of interest.

Two acute hospitals were also approached and, although initially interested, they later felt unable to participate. To fill the gap, Guy’s and St Thomas’ Foundation Trust kindly offered to provide detailed feedback on the draft standards and undertook a “tabletop” exercise considering what might be suitable evidence to demonstrate that standards could be met.

Site participation

The sites undertaking the test quality assessment process submitted their evidence in June 2014. This was assessed by the LETB Pan-London Quality and Regulation Unit to determine how well each site met the standards. Overall, the information and evidence provided were found to be of extremely high quality, although some indicators appeared easier to demonstrate than others.

To further explore the evidence submitted by pilot organisations, we carried out test quality visits with teams led by a senior HESL clinician and comprising external visitors representing expert non-medical clinicians, student representatives, a lay representative, an executive representative and senior educationalists. We described the visit as a “critical friend”, with the aim of avoiding replication of, or increasing, any regulatory burden, as well as obtaining feedback from the sites about the draft standards and visit approach.

Findings

Positive
The pilot sites reported that the draft standards themselves were focused and clear, and enabled them to question their own education and training processes. They said the standards were helpful in identifying local areas that required improvement and the assessment process had raised awareness of the extensive work that goes into both non-medical education and practice placements throughout their organisations; they particularly welcomed the fact that Standard 2 meant non-medical education was highlighted at executive and board level.

All pilot sites felt involving staff from various roles in both their own and external organisations throughout the visit gave them the recognition for the work they do with students and allowed them to meet colleagues with similar roles. Sites agreed they had much to learn from other roles and organisations, and many opportunities for making the student experience truly multiprofessional. Another positive aspect of the process highlighted was improved working with the LETB - the visiting team was able to advise the pilot sites of relevant initiatives, funding possibilities and processes they may not have known about otherwise.

Sites reported having a good understanding of the draft standards at the end of the process and felt they were in a much better position to collect the evidence on an ongoing basis; this would make collection easier in the long term if it was required.

Negative
Several negative aspects were also highlighted, particularly the work involved in gathering the evidence and coordinating the visit. This was agreed to be substantial, involving significant time and contributions from many staff. All sites had asked for, and were given, time extensions for submission, which was felt to be crucial.

Sites had struggled to decide how much evidence to submit and said they could easily have sent twice as much information; questions also arose as to whether evidence should be submitted via a ward/unit, department or directorate. Test visitors also suggested a maximum of two to three pieces of key evidence should be submitted for each indicator.

There was significant discussion about whether it was useful to have a list of suggested examples of evidence. It was agreed there should be a “pre-meet” with a representative of the LETB to consider each standard and discuss what evidence might be meaningful for each organisation; this would ensure a less-prescriptive approach. A similar meeting took place with the project lead at GBCH before data submission; this had been recognised as helpful.

Although it was reaffirmed several times that the visit was to act as a “critical friend”, the organisations reported that it still felt like an inspection.

After feedback from the developmental pilot work had been gathered, a few further refinements were made to the draft standards. These mainly related to language, conciseness and the aligned process of measurement; Box 3 shows the amended version of the standards.

Box 3. The amended standards

STANDARD 1. The organisational culture in supporting education

The organisation aligns its values, strategy and resources to demonstrate how it values its role as an education setting in helping students meet the relevant curriculum requirements, while encouraging and supporting individual, team and professional responsibility in delivering high-quality learning environments and training opportunities

Indicators

  1. A learning culture has been created, and invested in, across the provider, enabling all staff to consider education as an integral component of their role
  2. Interprofessional learning opportunities aligned to the patient journey are promoted
  3. There is a commitment and time investment to support continuous professional development and lifelong learning of all staff
  4. Students are supported to provide contemporaneous and candid feedback on the placement experience via a safe and supportive system, including a process for ensuring feedback is given to the learner on actions taken as a result
  5. There are transparent and collaborative quality improvement processes in place to align best education practice across the organisation

STANDARD 2. Executive ownership of practice education

The organisation provides effective senior leadership and direction, demonstrating a clear commitment and accountability to the delivery of high-quality education

Indicators

  1. An accessible and up-to-date education strategy, including a budget, is reported and monitored regularly at board level. The strategy explains the major responsibilities, goals and quality assurance responsibilities in relation to interprofessional health education
  2. The organisation has a named executive director with accountability for interprofessional education, with parity to a dean of faculty
  3. All business planning and service development processes include consideration and reporting of the impact of service change on education
  4. The board receives updates on the quality oversight of all areas of education, with risks identified

STANDARD 3. Staff in place to effectively support education

The organisation values staff who mentor, supervise and educate, ensuring there is appropriate workforce and capacity planning, recruitment, and training and development opportunities to enable those staff to successfully undertake the responsibilities required in this role

Indicators

  1. Staffing levels allow the practice placement environment to be properly resourced with an appropriate ratio of professionally prepared staff to learners, working collaboratively with the relevant link staff from education institutions
  2. All educational supervisors are professionally prepared, competent, up to date and fully committed to their role in supporting, teaching and inspiring learners
  3. Opportunities are provided for ongoing professional development for educational supervisors and other staff responsible for education and support
  4. Local leaders in individual practice settings value the opportunity to host a learning environment
  5. All staff within the placement environment, whether professionally qualified or not, are committed to helping support, teach and inspire learners when they are learning alongside them in the delivery of patient care

STANDARD 4. Physical support for education

The organisation has resources and facilities to facilitate an encouraging learning environment for students

Indicators

  1. IT is used to support the delivery of health education by enabling students to access up-to-date placement information and advice. A range of learning opportunities is available including library facilities and evidence supporting practice
  2. Adequate time and resources are available to facilitate effective local inductions for students
  3. Students are able to access and use electronic patient applications such as electronic patient records to support safe and effective patient care across sectors
  4. Students have timely and relevant access to clinical areas and appropriate equipment

STANDARD 5. Standards of service

The organisation has robust governance structures and processes in place to ensure a safe and effective physical and professional environment for students

Indicators

  1. Professional staff have current active registration with the relevant regulatory body and work to their professional codes of conduct and standards, particularly in relation to professional accountability, transparency, candour and a duty of care to patients
  2. The service that hosts practice placements has been approved as relevant by regulators, professional bodies and commissioners, and any changes requested by those bodies are addressed swiftly
  3. All staff understand local service responsibilities, such as maintaining a safe working environment
  4. The board receives the results of all internal and external monitoring, surveys and inspections, and ensures action is taken to resolve any issues identified
  5. Planning for service activity and change includes systematic consideration of any impact on the delivery of education

STANDARD 6. Partnership working

The organisation has effective structures and processes in place to promote and implement strong partnership arrangements, such as service planning, the sharing of information and quality improvement activities

Indicators

  1. There is evidence of key partnership working across organisations, professions and departments in support of high-quality health education
  2. There is a formal joined-up approach between practice and education to the preparation and allocation of practice placements
  3. Staff and working practices in placements help students to understand the context of care delivery in a wide variety of roles, sectors and specialties
  4. An identified senior staff member within the provider organisation is responsible for formal liaison with the relevant education institution, including agreement of cross-organisational policies and processes
  5. Robust systems are in place for raising and addressing any concerns about the placement, with clearly identified processes and systems of communication between the education institution, the provider and students

Next steps

Several recommendations have been made following the analysis and conclusion of this project. The principal one is that the testing of different approaches should continue in other organisations, particularly to reduce the administrative burden for organisations and the analytical burden for LETBs. The positive components of the process that were fed back as part of the developmental pilot site work should be maintained.

It has been agreed the London LETBs will work in partnership to align this process due to the frequency with which education commissions cross boundaries across the capital. This is to further test the recommendations and ensure the key learning from this project is strengthened.

There will also be an examination of whether other ongoing monitoring processes could be streamlined alongside this assessment. After a meeting with the Nursing and Midwifery Council, we agreed to explore some joint working to enhance the sharing of intelligence and, again, reduce any risk of regulatory duplication.

Conclusion

More work is needed to refine this process of measuring whether organisations value their role as an education setting and how they demonstrate this commitment and accountability. However, this project has enabled sites to question themselves about their non-medical education and training processes, strengthened their partnership with the LETB and facilitated the assurance that students receive safe, effective, compassionate preparation.

A major review of nurse education and training in England has recently been undertaken to explore whether nurse and care assistant education and training will be fit for purpose to deliver high-quality care over the next 10-15 years. The Shape of Caring review (Bit.ly/HEEShapeofCaring) called for examples around eight themes, one of which is “assuring high-quality practice learning environments, which support the development of the future workforce”.

Our project was submitted to The Shape of Caring review and will hopefully contribute to making sure the multi-professional practice placement environment - so critical to all students - is fit for purpose across all healthcare sectors and specialties. Only when this is achieved can we be confident that today’s students are being fully prepared to be safe, effective and compassionate clinicians of the future.

Key points

  • The more closely nurse education and training resemble working experiences, the better prepared students will be
  • Clinical experience is seen as the core of nurse education
  • It can be difficult to confirm whether working environments always provide student placements that are fit for purpose
  • Developing standards to show that organisations offer high-quality placements enables a credible measurement approach
  • Recognition of the importance of practice placements at executive board level is crucial
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