With more care being provided outside acute hospitals, placements in the private, voluntary and independent sector can widen newly qualified nurses’ career choices
The need for private, voluntary and independent placements in nursing programmes has become more important in recent years due to changes in where health services are delivered. These placements can be used effectively within nursing programmes to show students the realities of healthcare, and to challenge myths and attitudes. Dedicated time and resources need to be provided to discover and maintain these placements, and to ensure appropriate, high-quality learning opportunities. This article presents the findings of a national Higher Education Academy workshop, held at the University of Derby in November 2012. It explores three key issues discussed at the workshop: current practice and opportunities for learning; myths, attitudes and solutions; and maintaining the quality of placements. The use of PVI placements is seen as valuable and a set of recommendations are provided to assist in their use.
Citation: Sherratt L et al (2013) Using more healthcare areas for placements. Nursing Times; 109: 25, 18-21.
Authors: Lou Sherratt is senior lecturer and PVI lead; Bill Whitehead is assistant head of subject; Alwyn Young is senior lecturer; Guy Collins is senior lecturer; Heather Brundrett is senior lecturer; all at department of nursing, radiography and healthcare practice, University of Derby.
- This article has been double-blind peer reviewed
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Practice placements are an essential to all pre-registration nursing courses. Throughout Europe, all such courses are to have at least 2,300 hours of practice-based content (Nursing and Midwifery Council, 2010).
Traditionally, student nurses have spent the majority of these placements on NHS hospital wards but, in recent years, governments have changed policy in the direction of moving as much care away from acute hospitals as possible (Department of Health, 2006), leading to a reduction in the number of NHS hospital beds. Consequently, the hospital placement capacity has dropped, as more emphasis has been placed on preparing students for newly qualified nursing positions in posts outside traditional NHS hospitals and community settings.
There is a need for nurse education programmes to use private, voluntary and independent sector (PVI) placements in a more integrated way than they generally do at present. This is in line with the recent National Nursing Research Unit report that indicates the existing system of mentorship is under strain (Robinson et al, 2012). An increase in PVI placements would also address the need for more mentors to provide the practice education required for the number of students commissioned and needed by employers for workforce planning.
Access to placements within the PVI sector may increase the likelihood of newly registered nurses applying for jobs in the sector, which is a growing area of employment for first destination nurse graduates.
The main qualifying definition of a PVI provider is that it is outside traditional NHS and community placement settings. These providers exist in all healthcare settings across the whole patient journey, in primary, secondary and tertiary care.
Examples include NHS treatment centres, hospices, nursing homes, out-of-hours service providers, prison services, GP surgeries and private hospitals.
In November 2012, the University of Derby hosted a national Higher Education Academy workshop on PVI placements entitled “Developing placement learning opportunities within the private, voluntary and independent sector” (HEA, 2012). Colleagues from universities, NHS and PVI sectors around the country participated in the event. This article is based on this workshop and our experience as educators in developing PVI placements.
Current practice and opportunities for learning
The need to develop non-NHS placements is seen as essential as these will expose students to diverse practice learning environments, which will help them to develop the knowledge, skills and competence they will need (NMC, 2010). This is preparation for professional registration and reflects the future configuration of services.
Since the development and validation of its nursing degree in 2012, the University of Derby has been applying a locally designed version of the hub and spoke approach to practice learning (Fig 1 and Fig 2). Many other approved education institutions (AEIs) providing nursing education have also taken this approach.
Roxburgh et al (2011) defined hub and spoke placements as “contrasting but complementary learning experiences”. A “hub” is defined as the main base for practice learning. Students return to the same hub placement at different points during their training, giving them guaranteed access to the same mentor and mentor team. “Spoke” placements are secondary learning opportunities that provide additional learning experiences not offered in the hub placement. Spoke placements can be in health or social care settings, but all such placements follow the patient journey and give the student experience of models of local care delivery and integrated care pathways (Roxburgh et al, 2011).
Despite the extensive adoption of the hub and spoke approach, anecdotally it appears that the interpretation of its principles vary across AEIs. This variation may be due to several reasons, including:
- The requirements of the distinct fields of nursing;
- A reflection of local service provision and hence opportunities;
- Transformation of both NHS and non-NHS services, leading to logistical challenges in placing students.
Therefore, anyone reviewing examples and recommendations for the adoption of hub and spoke models to PVI settings need to be mindful that flexibility should be built in, so that practice learning reflects current and future service configurations.
During the workshop, to facilitate discussion of potential opportunities, we encouraged participants to talk about the issues surrounding PVI. During one of these discussions, participants were asked to explore their current and future practice learning opportunities, including PVI experience within a hub and spoke framework. This was suggested, rather than the use of PVI as a separate entity, or as a filler for overstretched placement capacity demands.
The diversity of representatives from practice placements improved the understanding of those who worked in health services who had no experience of the hub and spoke framework, and facilitated the sharing of good practice for those developing the framework. The manager from a local private hospital that supports people with learning disabilities and comorbid conditions, including mental health problems, personality disorders, forensic issues and physical health problems, was interested in his hospital being a practice placement area. During the workshop, this manager, with the support of a placement area already following the framework, was able to see the huge potential of what his hospital had to offer to a student’s learning experience. In particular, this reflected its philosophy of providing a holistic approach to individuals’ recovery.
The sharing of good practice highlighted a number of benefits of the hub and spoke framework relating to PVI placements. These included an increase in the number of learning opportunities and hub placements as a result of spokes being able to take on this role. Students developed an in-depth understanding of patients’ journeys and hub placements were able to identify and support students who had difficulties early on in their training. Opportunities for the development of interprofessional learning were easier to instigate. Through a service improvement exercise, third-year students made a significant contribution to practice and the patient experience based because they had spent time on the placement and developed an in-depth understanding of the service provided.
To sum up, the adoption of PVI placements can usefully be expanded and deepened. PVI placements can be used as both hubs and spokes to increase the range of experience for students, improve their access to the complete patient journey and give them a fuller exposure to holistic care.
Myths, attitudes and solutions
This part of the workshop discussed the myths and attitudes that pre-registration student nurses had before accessing placements in the PVI sector. The groups were presented with statements relating to common misconceptions, which include:
- Placements in the PVI sector offer a restricted learning experience;
- PVI experiences are not suitable for final management placements;
- Newly qualified nurses do not take up posts within this area as preceptorship is not available.
Is there any substance to these myths? Do students have preconceived ideas about PVI placements that provide clinical learning experiences?
Anecdotally, traditional placements in the NHS are perhaps viewed by students as the areas to be valued and PVI placements considered second rate. In the literature on nurse education, there is ample discussion on challenging the myths and beliefs of students who are placed in care of the older person nursing home settings, identifying attitudes that include seeing this area as an unattractive career option with limited learning opportunities. Robinson et al (2009) argue that this attitude is affecting recruitment; they believe that exposing pre-registration student nurses to this area will weaken this prejudice and result in more students being willing to consider a career in older people’s nursing.
There is also evidence in the literature that working with practice nurses at GP surgeries is an overlooked placement within the PVI sector, with more value being given to placements with community nursing teams. Yet a study conducted by Halcomb et al (2012) highlighted that many practice nurses believe they could offer valuable learning experiences, with a diverse range of clinical skills being practised, many of which are limited to traditional acute hospital placements. This study also suggests that recruitment to this area is also improved through offering clinical placements to pre-registration student nurses.
Delegates had a number of suggestions to identify how myths could be tackled in practical ways, including altering student expectations, improving partnership working and ensuring adequate pre-placement preparation.
The value of PVI placements needs to be supported by a rigorous audit tool. With regards to curriculum design, it would be worthwhile to class all placements as “clinical learning experiences” rather than categorising them as either PVI or NHS.
In conclusion to this section, PVI placements can be a valuable experience where nursing skills and knowledge can be gained. Their use will also expand the potential career choices for newly qualified nurses, as these workplaces will be familiar to students exposed to them on placement.
Maintaining the quality of placements
The key areas discussed during this part of the workshop centred on clinical placement audit procedures, the role of the Care Quality Commission, mentor training and updating support mechanisms. A theme that emerged was the focus on the importance of clinical placement audits as a tool to monitor and maintain quality.
The current, locally agreed audit system requires clinical placement areas to be audited every 22 months. The audit tool contains information relating to health and safety, learning opportunities, student support, mentors and patient care (University of Nottingham et al, 2011). This locally agreed system is bespoke for Nottinghamshire, Derbyshire and Lincolnshire, other localities will have different policies. Porter et al (2011) suggest that education providers are responsible for ensuring appropriate clinical placements, which is the aim of the current audit process.
To further ensure that the audit process addresses quality, delegates identified the role of the CQC as crucial, saying that audits should be linked to CQC inspections. The suggestion was that auditors should be required to access inspection reports before conducting a placement audit. Furness (2009) supports this practice, stating that inspections are vital to quality, as they provide an assurance of minimum standards that act as a safety net as well as giving care providers support and guidance.
Delegates identified access to mentor education programmes and updates as key to the support of staff in clinical areas. Different localities in the UK have attempted a variety of solutions. In this region, staff within the PVI sector can access funding from the local education and training board to pay for their attendance and assessment on the university module designed to meet the NMC standards to become a mentor (NMC, 2008), provided that they accept pre-registration student nurses on a clinical placement within their practice area. This agreement has led to an increase in the number of PVI placements available as more staff complete the mentoring module.
Mentor updates are provided annually in each PVI placement area by link lecturers from the University of Derby, which further strengthens partnership working and promotes quality. Requirements for mentors’ triennial reviews are managed in partnership with the PVI placements and link lecturers.
It is worth noting that funding is not restricted to mentoring modules; it can also assist nurses in the PVI sector with further professional development needs.
Support mechanisms focus on the role of the link lecturer who provides support via email, telephone and placements visits. Students and mentors are visited at least once during a placement by a link lecturer, which gives mentors and students an opportunity to discuss any issues relating to the placement.
The discussion among delegates focused on the implementation of a dedicated practice (education) facilitator role to provide this support, with delegates identifying that this would be best practice, as similar roles exist at NHS placement providers (Whitehead, 2010). This is supported by Halcomb et al (2012), who believe that, while it may be unreasonable to adopt the same model as large NHS trusts, the resources needed to support PVI placements should be acknowledged.
Use of existing audit processes and reference to CQC standards ensure the quality of PVI placements. In addition, the PVIs themselves gain additional support and education opportunities by their association with the AEIs. This access to CPD is likely to improve staff morale and patient care as well as student experience.
Recommendations for practice
The outcome of this workshop was to agree a simple checklist and a support cycle to help ensure education providers and health services work together to provide best practice with regards to student education. A five-step guide for developing and maintaining PVI placements was developed. This includes:
- Dedicated time allocated to this role;
- Implementation of support networks;
- Robust quality assurance mechanisms;
- Sharing of best practice through evaluation;
- Adequate pre-placement preparation.
Fig 3 illustrates the process involved in securing, developing and maintaining placements within the PVI sector.
The University of Derby has implemented these recommendations. A member of academic staff - the PVI lead - has been allocated time and responsibilities to ensure the selection and maintenance of PVI placements. PVI placements are included in practice team support networks alongside NHS clinical placements of a similar type.
Educational audits are carried out to the same stringent standards for all placements. CQC reports are examined before placement selection and placements are monitored by the PVI lead to ensure continuing quality of clinical experience; when new types of placements are used, the PVI lead monitors and evaluates them closely. Pre-placement preparation is provided by staff from the PVIs themselves and by former students of these placements, which encourages students to view these placements in the positive light in which they deserve to be seen.
All placements are evaluated by anonymous student review, which is shared with placement and academic staff. If any quality issues arise, action plans are devised and the outcome monitored by the PVI lead.
PVI placements should not be seen as simply a way of expanding student placements out of hard-pressed NHS environments. It is clear from the findings of the national HEA workshop that they are a valuable learning resource in their own right and should be used even if there were sufficient traditional placements. It is recommended that PVI placements are used to the fullest possible extent nationwide to the benefit of employers, students and patients.
- All pre-registration nursing courses in Europe must include at least 2,300 hours’ practice-based learning
- As care is moving away from hospitals, more placements in the private, voluntary and independent sector are needed
- PVI placements can be used as both hubs and spokes to provide a range of experience
- The use of PVI placements increases potential career choices
- A negative attitude to some areas, such as older people’s nursing, is affecting recruitment in these areas
Department of Health (2006) Our Health, Our Care, Our Say: a New Direction For Community Services. London: HMSO
Furness S (2009) A hindrance or a help? The contribution of inspection to the quality of care homes for older people. British Journal of Social Work; 39, 488-505.
Halcomb EJ et al (2012) Practice nurses’ experiences of mentoring undergraduate nursing students in Australian general practice. Nurse Education Today; 32, 524-528.
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Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education. London: NMC.
Nursing and Midwifery Council (2008) Standards to Support Learning and Assessment in Practice Settings. London: NMC.
Porter J et al (2011) Development of an undergraduate nursing clinical evaluation form. Nurse Education Today; 31, 58-62.
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Roxburgh M et al (2011) The Development, Implementation and Evaluation of New Approaches to Practice Placements in Pre-Registration Nursing Programmes: The Final Report. University of Stirling.
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