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Using the real world to develop nurses' skills

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Walking the neighbourhood can help student nurses better understand the local community and public health issues that may feature in their work


Student nurses develop skills in observation, communication and reflection, as well as public health knowledge while walking in neighbourhoods near the hospitals where they will practise. This article explains an award-winning innovative teaching approach to enable students to use the real world as a learning environment. On their walk, students apply learning about social determinants of health to develop their understanding of communities and how they change.

Citation: Davies J (2015) Using the real world to develop nurses’ skills. Nursing Times; 112: 6/7, 23-24.

Author: Jacqueline Davies is lecturer in applied social sciences, City University London.


Reflection on a public health walk is a way of developing student nurses’ skills and knowledge in observing, reflecting and being in the neighbourhoods of future patients. In the first weeks of training, nurse undergraduates at City University London attend a taught module called Relating Social Sciences to Healthy Communities. The curriculum steering group included user and carer representatives. The course was developed by lecturers who explored various models of learning by walking, prioritising chances for students to meet local people in non-clinical contexts.    

For their assignment, students write about a walk they have done. They must walk at a leisurely pace in public spaces for two hours near the hospitals where they will practise. Walking in groups of two to five students, they are instructed to observe the real world using all five senses, and reflect on the community’s healthiness. The aim is not to cover territory, but to:

  • Notice, and think about, ideas and feelings experienced while noticing;
  • Develop a deeper reflective account about how these thoughts and feelings help them understand observations by the end of the module.


Social determinants of health are discussed in the classroom before and after the walk. An understanding is developed of how health is determined by the conditions of people’s daily lives, from when they are born to when they die, as summarised by the Royal College of Nursing (2012).

The module allows learning, then first-hand observation of the transition from “old” public health initiatives like sanitation and combatting infectious diseases, to “new” concerns of health inequalities and chronic illness (Rayner and Lang, 2012).

Students learn about the community nurse tradition of “walking the patch” (Bryar and Orr, 2012), practise the nursing skill of observation (Newland, 2011) and learn how sociology applies to this skill (Plummer, 2010). They also consider how psychology is applied to health and the environment, and the importance of proximity to relationships, as noted by Hayes (2010). Before walking, they find out about the area using selected online resources, such as the Office for National Statistics’ online neighbourhood statistics tool.  


The aim of the module is to think about the challenges of changing social determinants. Public Health England (2015) presents key health indicators including low birth weight, excess weight in adults, smoking prevalence, and falls in those aged over 65, but there is not a fixed list. What influences health varies by area and time. PHE figures show that those living in deprived areas of East London this century are more likely to have lung cancer than those in the less-deprived West London. However, breast and prostate cancer incidence are greater in less-deprived areas than deprived areas (possibly because people live longer). The reflective walk by students values their skills in observing and understanding the real world around them.

Instructions to students

On their walk, students observe the places that are typical of a guided public health walk, focusing on social and economic conditions of people’s lives over 100 years ago. The signposts of historic spaces that were once public baths, drinking fountains (Fig 1, attached) and Victorian lavatories may be seen underfoot as well as high up on buildings.

It is important to learn about historic public health innovations, but students are encouraged to consider:

  • Which innovations are still in use;
  • How their use has changed;
  • What influences health now.

To observe the causes of 21st-century premature morbidity and mortality, something more than a treasure hunt or guided walk is required. Understanding the health inequalities identified in theory classes requires a compassionate approach to observation. Students are encouraged to talk to the people they meet on their walk. These are not interviews, but conversations – sometimes started as a request for local information by students and sometimes initiated by local people asking students who they are and what they are doing.

Themes developed by students

In their assignments, students write narratives based on compelling themes about the healthiness of communities. An example of a theme that developed from student discussion was about work-life balance based on observations of older buildings designed so inhabitants could live above their small businesses and current transport initiatives for commuters who travel to inner-city areas for work. The difference in these lifestyles is reflected on, with observations of domestic life, such as a homeless woman, the celebrated street art of East London, smoking areas outside buildings and the new norm of making phone calls in the street.

Reflection on themes such as work–life balance in which there is a concept that behaviours belong in certain places and times is relevant to nurses’ practice; their work often crosses these boundaries. The social norm in modern life is that beds are private and intimate places but a bed where someone else sleeps is the nurse’s workplace. Thinking about public spaces and what is considered appropriate in a space shared by strangers is useful for students preparing to nurse members of the public.

The need to walk focuses the learning experience back on student skills in team working, observation and thinking, and away from a wealth of online resources such as local authority reports that are just a click away. Those undertaking locality projects in the last millennium had to go to libraries and make notes on reports held for public use. Today, a request to write an essay on transport could be compiled by taking information from strategic plans available online without any need to visit the area. Essays that do not require a visit to the area often lack any sense of what the place is like.

One barrier to students walking in neighbourhoods is a fear of the real world. Green (2012) describes the experience of a student who asked her supervisor to escort her to the bus stop. CUL nursing students explore their perceptions of their communities of practice. Rather than just repeating online information that says an inner-city area is “vibrant”, they visit the area to experience what that means. They report the pleasure of walking in a busy street with a culturally diverse population of locals and tourists, despite evidence of vandalism and measures to prevent it (Fig 2, attached).


The Nursing and Midwifery Council commended the module and the innovative approach to the walk when the course was submitted for validation in 2011. At the end of year one, 80% of adult nursing students in the September 2012 cohort were asked “what was the best part of year one in the university?”. Their answers included: meeting people from different cultures, ability to look around London, great placements, simulated practice and the public health walk.

After an annual internal awards ceremony celebrating innovations, the walk module was nominated for the Health Education North Central and East London Quality Awards. It won the prize for innovation in healthcare education and training; the prize money is being used to further develop and disseminate the innovation.

Key points

  • Understanding local communities can improve nurses’ practice
  • It is beneficial for nurses to know how psychology links to health and the environment
  • Students can use online resources to find out about their local community before walking
  • The module aims to make students think about the challenges of changing how health is determined
  • Students are encouraged to think about what influences health now 
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