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What constitutes a community placement?

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While the Nursing and Midwifery Council says student nurses must have a minimum level of community experience, what constitutes community nursing is poorly defined

Abstract

When developing pre-registration adult nursing programmes, education providers in both educational institutions and clinical areas must decide what is a community nursing placement and how much time students should spend there. This article considers definitions of what constitutes “community” in terms of clinical placements for student nurses. It suggests what might realistically be termed community nursing and home nursing and explains how these can enrich student nurses’ experiences. The practice requirements for other pre-registration nursing fields, such as child, mental health and learning disabilities, have not been considered here, although some of the discussion would be relevant to these areas.

Citation: Temple J (2013) What constitutes a community placement? Nursing Times; 109: 37, 16-17.

Author: Jenny Temple is academic director for placements and partnerships at the Faculty of Health and Human Science, Plymouth University.

Introduction

The Nursing and Midwifery Council (2010) states that adult student nurses should ideally be exposed to community nursing in each year of their programme. Its definition of community placements as “the time students spend learning about, and experiencing care provided outside the hospital setting” is vague, but it does state that student nurses must experience home nursing as part of their programme (NMC, 2005).

What is community nursing?

The Oxford University Press dictionary (2013) defines community as follows:

“The condition of sharing or having certain attitudes and interests in common: the people of a district or country considered collectively, especially in the context of social values and responsibilities; society: a group of people living in the same place or having a particular characteristic in common.”

In many rural areas in the UK, the district general hospital and smaller local health centres are key parts of the community; staff and patients live locally and may have similar social values or care for friends and relatives.

In terms of nursing, the definition of community care is often linked to that of primary care, as øvretveit (1993) stated:

“Primary/community care is about helping clients and their carers in or near their home, rather than in hospitals away from the community in which they live.”

However, Ali et al (2011) provided a definition of primary care as “the term for health services that play a central role in the local community; GPs, pharmacists, dentists and midwives”. This is supported by the Department of Health’s (2010) definition that:

“Primary care describes community-based health services that are usually the first, and often the only point of contact that patients make with the health service. It covers services provided by family doctors (GPs), community and practice nurses, community therapists (such as physiotherapists and occupational therapists), community pharmacists, optometrists, dentists and midwives.”

This definition does not help to identify community in terms of student nurse placements, as these professions are different from nursing.

However, The NMC (2011) states that community care offers:

“Many valuable learning opportunities in the community that provide the broad experiences needed to meet the competencies. They include settings such as walk-in centres, polyclinics, outpatient departments, call centres, residential care homes, nursing homes and settings related to criminal justice. Each of these can bring a different dimension to learning, providing an insight into the ways in which knowledge and skills are needed to meet complex needs in challenging environments.”

This definition differs from the traditional view of a community nursing experience being a placement with a community nurse, such as a district nurse or health visitor, and allows students to experience a broader experience of care delivery.

A Canadian website, Nursing Theories, identifies six settings for community health nursing:

  • Homes;
  • Ambulatory care settings;
  • Schools;
  • Occupational health settings;
  • Residential institutions;
  • The community at large.

This provides a wider range of potential practice experiences, but overlaps with placements where child health might be involved and includes some where field-specific mentorship might not be available.

The RCN’s (2010) statement on the development of the registered nursing workforce in the community takes a more traditional view of care settings, identifying them as the home, health centres, care homes or schools. It also says that pre-registration education does now prepare newly qualified nurses for roles as staff nurses in the community.

The Willis Commission (2012) into nurse education noted the difficulty education providers have often experienced in identifying and funding placements in the community. In its recommendations, it states:

“Employers and universities must together identify positive practice environments in a wide range of settings. Many more placements must be made available in community settings, including general practice.”

Discussion

It would appear that there is no clear definition of what makes a community nursing practice setting, except that it probably does not encompass a prolonged inpatient hospital stay. However, even this could be questioned in a rural setting where one major hospital meets many of the needs of its local community.

Home nursing requires students to attend to patients in their own homes, which is likely to mean a placement with a district nursing team. While this implies that patients are living in their own home, some may have moved permanently into residential care homes where registered nurses work on site (RCN, 2010).

Clinical nurse specialists in areas such as continence and tissue viability may also nurse patients in their own homes, but this may not be considered home nursing as many of these services are provided by acute trusts or private companies and are not linked with district nursing teams.

These differences make it more difficult to define home nursing and the accepted district nursing experience. However, the variety of work means a much wider range of experiences can be offered, as well as opportunities to work with specialist or consultant nurses working independently.

Medical care delivered by GPs fits many of the definitions of care given in the community so, by default, practice nurses working for GPs are an example of community nursing. However, student nurses are rarely assigned prolonged practice nurse placements due to funding issues and the independent nature of GP contracts. Since GPs and practice nurses are key figures in meeting most patients’ healthcare needs, building this experience into student nurses’ practice profile would be beneficial.

In addition to there being no clear definition of community placement, there seems little agreement on the ideal length of each placement. Evidence supports placements being longer than one week, as this enables students to do more than just observe practice. Levett-Jones et al (2008) conducted a brief literature review and a survey of a group of student nurses in Australia and concluded that placements should last for at least for four weeks. This gives students time to find their feet and feel they belong in the area, and helps them gain a greater understanding of the care being delivered.

With no guidelines defining community or home nursing, the following placements might reasonably be termed home nursing:

  • District nursing;
  • Nursing in a care home or supported living unit;
  • Nursing alongside specialist nurses in patients’ own homes.

Similarly, the following placement areas might reasonably be termed community nursing, as the majority of the experience occurs in the home, although the clinic or resource might be located in a district general hospital:

  • General practice nursing;
  • Health visiting or school nursing;
  • Outpatient services;
  • Pre-assessment services;
  • Hospices;
  • Day surgery settings;
  • Community hospitals;
  • Drop-in centres;
  • Minor injury units.

Patients receiving care at home or in other community settings are increasingly older and frailer, tend to be discharged earlier from secondary care and have more complex nursing needs.

Planning a range of experiences for adult student nurses that includes many of these home or community placements will expose them to the reality of nursing care and will also reduce pressure on the traditional community nursing placements. However, it remains to be seen if these options will be acceptable to education providers, the nursing body as a whole and students.

Key points

  • Although the NMC states students must have community experience, this is poorly defined in nursing literature
  • Pre-registration education is effective in preparing newly qualified nurses for roles as staff nurses in the community
  • Placements should be over four weeks in length to give students a realistic exposure
  • Community placements are essential to give student nurses a true picture of current nursing
  • A flexible approach to the term “community” will lead to a variety of placement types
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