A pilot study ascertained the feasibility and benefits of attaching student nurses to local primary care patient participation groups, as well as the barriers to doing so
Student nurses have few opportunities to engage with patients in non-clinical activities, and patient participation groups often need additional resources and skills. A pilot study explored the feasibility of linking students with these groups to see whether either party could benefit from the association. This article describes the activities students undertook, along with the barriers and benefits encountered.
Citation: Young K et al (2016) Linking students to patient participation groups. Nursing Times; 112: 29/30/31, 14-17.
Authors: Kim Young is lecturer in adult nursing; Ray Jones is professor of health informatics; both at the school of nursing and midwifery at Plymouth University; Heather Eardley is national projects director, the Patients Association.
- This article has been double-blind peer reviewed
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The concept of using patients and service users as educators in nurse education has existed for at least 50 years (McCutcheon and Gormley, 2014; Atkinson and Williams, 2011; Towle et al, 2010; Stacy and Spencer, 1999), but has recently attracted more attention (Terry, 2013). However, patient involvement – which would give students opportunities to engage with patients or their representative groups in non-clinical activities – is not consistently embedded in current UK nursing pre-registration undergraduate programmes.
NHS England’s (2014) Five Year Forward View emphasised the need to empower patients to take responsibility for their own health, improve public health and contribute to how services are monitored. Patient participation groups (PPGs) provide opportunities to encourage feedback from the public, patients and staff to influence commissioning and improve services. Since April 2015, there have been contractual requirements for all general practices to have a PPG and to make efforts for this to be representative of the practice population (NHS England, 2015). PPGs currently vary greatly in size, effectiveness and influence (Smiddy et al, 2015), but practices must consult them at regular intervals to:
- Encourage patient participation;
- Jointly review feedback about services;
- Agree required improvements.
The Patients Association, commissioned by NHS England, ran eight workshops between October and December 2014 in Devon and Cornwall on setting up and running PPGs for practice managers, GPs, patients and patient representatives. Discussions between 180 participants suggested the need to widen membership and expand PPG skillsets. Plymouth University was approached to undertake a pilot study of student nurse voluntary attachments; this article describes that pilot.
The pilot had two aims:
- To explore the feasibility of student nurse volunteer links to PPGs;
- To explore the views of students, PPG members and other stakeholders on such attachments.
The Patients Association contacted 228 practice managers and PPG chairs in Devon and Cornwall (February-March 2015), inviting them to take part in the pilot. Thirty-five (15%) expressed some interest in accepting volunteer students for nine weeks between May and July 2015, and the possibility was explored further with 25 practices. Simultaneously, 571 students in the second and third years of Plymouth University’s adult field pre-registration programme were offered the opportunity to be linked as volunteers during their clinical placement period. Twenty-five students (4%) expressed an interest and were given a letter for their nurse mentors explaining the pilot.
We wanted students to have opportunities to work alongside patients on PPGs in non-clinical wider engagement activities, such as reaching out to younger patients using social media or helping with practice surveys. Those undertaken by students depended on their particular PPG’s agenda.
No minimum or maximum hours were set but students needed permission from their personal (academic) tutor and to negotiate with their clinical placement nurse mentor to undertake PPG activities, either instead of some practice hours or in their own time (days off or study days). The hours allocated to clinical placements by the university exceeded Nursing and Midwifery Council requirements by up to 150 hours, so for this short pilot (May-September 2015), we decided that, although students might ‘use’ some placement hours, this would not be detrimental.
Clinical placement periods varied from 8 to 16 weeks, during which students were assessed on specific practice competencies. In consultation with mentors, they could also use PPG activities to meet various competency criteria in the ongoing achievement record (OAR; Table 1).
Twenty-three students were attached to 17 PPGs for nine weeks. Some PPGs covered multiple general practices and had more than one student attached. Participating PPGs were given information explaining that students were undertaking clinical placements during the pilot period and would need to negotiate any PPG activities during this time. Despite exploring attachments in some detail, eight of the 25 PPGs considered for the pilot were not allocated students for practical, geographic reasons.
A one-day conference, including workshops on student volunteering opportunities, was advertised to all 228 GP practices in Devon and Cornwall; the 23 participating PPG students; 500 first-year students via an email through the student portal; and wider audiences via social media.
The conference comprised presentations and two workshops with delegates divided into five planned discussion groups. The first workshop discussed the pilot. Each discussion group (mean size 20 participants) included student and PPG representatives, and addressed the following questions:
- What are the benefits to the PPGs and practices of student attachments?
- What are the benefits for the students?
- What ideas are there for the future of this initiative?
Comments were recorded on flipcharts and merged to provide a master list. After the conference, all attendees were emailed a link to a short online questionnaire asking for their views on the attachments.
The time spent by students working with PPGs ranged from zero (those whose PPGs did not meet in the pilot period) to 10 hours. On average, half of the time came from placement hours and half from private study. Box 1 shows examples of non-clinical activities that students undertook; some examples are given below.
One student engaged in many of the activities in Box 1, as well as some clinical activities (assisting with wound dressings, taking patients’ blood pressure); the latter was not within the guidelines sent to students and PPGs, so we clarified to both that activities should be non-clinical. This student reported having developed professional skills and found it interesting communicating at patient level with members of the public while doing surveys.
Box 1. Examples of student activities
- Helping to plan PPG meetings/agendas
- Helping with marketing strategies to promote the PPG
- Attending PPG meetings to provide a ‘younger’ perspective
- Supporting the PPG to set up/improve its Twitter feed
- Helping to set up a Facebook page
- Working with the PPG to develop new patient services in the practice
- Helping the PPG to undertake patient surveys, including the Friends and Family Test
- Producing or contributing to newsletters for the PPG or GP practice
- Working with the PPG to improve access to health services
- Helping the PPG to work with other PPG groups
- Supporting the PPG to raise awareness of health matters
Another student met several times with the practice manager and PPG chair, and attended one meeting with all PPG members. She helped prepare meetings and market the PPG; she reported learning about patients’ perspectives of healthcare and which services they found valuable, and believed the attachment helped her develop communication and interpersonal skills.
A third student was asked to review the practice website and Twitter feed, and consider issues for younger patients. The practice has since improved its website and information for patients, increased patient feedback via the Friends and Family Test, introduced blogging and improved its social media communication.
Conference workshop groups
In total, 117 people attended: 45 from PPGs, three practice staff, 25 students (including 18 of the 23 attached to PPGs), and 44 others including staff from Plymouth University, Patients Association and NHS.
Benefits for the practice
Conference participants saw students as providing PPGs with new resources, as well as perhaps different skills (for example, social media) and ideas more in line with those of younger people. There were many suggestions as to what students could do (Box 2).
Box 2. Other suggested tasks for students
- Take on an intermediary/advocacy role: patients may find it easier to talk to student nurses than a PPG or staff member
- Help engage younger people with sexual or mental-health services take-up: students could go into schools to highlight family planning practices
- Explore aspects of health inequalities in practice population
- Help to include hard-to-reach groups
- Help raise the PPG’s profile in the practice population
- Look at preventive services, for example, what is the take-up of flu vaccinations in the practice and what can we do about it?
- Help the PPG plan a health fair
- Help with non-attendance and ascertaining reasons for it
- Gather patient stories
Benefits for the PPG included gaining different perspectives and knowledge (“Helps PPG get better perspective of different professions and ideas from the acute setting” [PPG a1]), as well as the connections they would provide via their university and other students (“Opportunities to share best practice using the students to assist in communication with other PPGs”) [PPG b2].
One participant summarised it:
“You don’t know what you don’t know – there could be all sorts of surprising benefits not yet envisaged. Student attachments… are opportunities for co-production of activities” [PPG f1].
However, another was more cynical, saying it was good for “impressing the CQC!”
Benefits for students
As ‘healthy’ patients appeared more empowered to say what they wanted than those who were ill and in the clinical – particularly acute – care situation, students said they gained different perspectives listening to patients.
They also learned about the health profile of the local community; patient practice issues; social influences on health and wellbeing; and diversity (the wide range of patients accessing general practices).
This learning would contribute to their understanding of health inequalities, public health, person-centred and holistic care, life after hospital for patients and what constitutes good practice.
Participants thought students would improve and develop interpersonal and communication skills, in particular, learning to understand and differentiate between clinical, NHS and lay languages, and knowing when and how to use them. Some saw this as an opportunity for students to boost their experience in the community to help balance the emphasis on the acute setting. It would help them understand the challenges facing primary care and how it differs from secondary care. At a procedural level, they would be able to use their experience from PPGs in meeting criteria for their OARs.
Finally, participants suggested two more personal benefits: students are also patients, so knowing what happens in PPGs and primary care was useful. As many enter nursing for altruistic reasons, working with the PPG should satisfy their desire to meet their social responsibility.
Challenges for students
The main perceived difficulty was insufficient hours in the curriculum – the activity was organised as a ‘bolt on’, making extra commitments difficult. Even if PPG attachment was better integrated in the curriculum, it was suggested that it would require good time management and communication – a challenge and a useful learning outcome for students. Attachments need to be meaningful for students; workshop participants thought that some less-able students might have difficulty understanding the experience.
It was also thought that students needed to be able to choose location (for travel) and specialty (diabetes, general primary care, etc); this would increase motivation and the time spent on activities, not just direct contact hours, but it might not work if PPGs dictated tasks rather than co-producing them with students. This highlighted the need for the university to help to create reasonable expectations of students among PPG and practice staff.
Considerations for practices
Concerns included potential lack of continuity if students were only involved during one nine-week attachment; this could be improved if they remained involved for longer, although it was noted the university might have insufficient attachment opportunities for new students. Perceived additional workload for practice staff might concern practice managers but, to date, little extra work has been created.
There may be problems superimposing student involvement on small PPGs in small practices, as members might not have the capacity to deal with extra activities. In addition, students, particularly less able ones, may need some mentorship by the PPG chair or practice managers, which might require funding.
Other concerns were around clarity of the nature of the attachment and ‘selling’ the idea to practices and students: PPGs had to be clear that this was not a clinical placement, as well as clarify the roles of practice staff and PPG members.
Some participants wondered whether attachments might ‘medicalise’ PPGs, but others argued that students were in the early stages of their careers and joined PPGs in a non-clinical role. Attachments are with PPGs rather than practices, but practices are involved in initiating attachments, so clarity is needed on who manages the student. It was decided PPGs should sign off students’ time, but not be involved in formal assessment.
Challenges and practicalities for the university
For continuity, the university would have to find additional PPGs willing to host students. It would also have to allocate students in a geographically suitable manner. Scaling the pilot up might produce problems such as finding enough PPGs and placing all students, including some who might be less motivated than those in the pilot.
The university was deemed to need a more flexible approach to defining learning outcomes than is sometimes allowed by regulations, standards and quality-control bodies. Outcomes are needed but must be sufficiently broad to encompass very varied activities – co-determined by PPGs and students.
University staff who arrange clinical placements need to know about practice attachments, so they can make allowances and know what students are doing. They must also ensure the curriculum prepares students if PPG activity is linked to practice attachments.
The concept, and all roles, needed to be explained more clearly to practices, as well as the distinction between this role and clinical placements with practice nurses. While such switching is one of the benefits, if not clear in the minds of all parties, there is a danger of ‘mission drift’.
Ideas for the future
Participants had many ideas for expanding the pilot’s scope, including involving other healthcare students and those in different years, and embedding it into the curriculum. As there is considerable public and patient involvement, and engagement in different spheres, it was suggested students could help create links between various groups, such as PPGs, hospital patient advice and liaison services, Healthwatch, public health initiatives in community engagement and expert patient groups.
Engaging with them in non-clinical settings should enhance nurses’ understanding of how patients represent and contribute to health service improvements, as identified by Lord Willis’ review (Health Education England, 2015). However, there is a need to evaluate whether student experiences affect their subsequent professional behaviour.
Feedback questionnaires were completed by 71 (61%) conference attendees (30 PPG members or practice staff, 17 students, and 24 others). Of the 67 who answered the question on whether the attachment was beneficial, most (45/57, 79%) thought it was beneficial for students and PPGs; 10 thought it was for students or PPGs but not both; and two reported it was “not worthwhile”; one commented:
“If nursing student experience of patients away from the doctor or nurse treatment/appointment context is considered appropriate for their studies, better to attach to a practice, not to a volunteer-led PPG.” [ConP 20]
With small numbers, attaching students to PPGs seemed feasible and was considered beneficial to both parties. Strategic and operational barriers to service-user involvement in education has been noted (Gutteridge and Dobbins, 2010), and there will be logistical problems in scaling this initiative for all 500 students per year, given the number of PPGs within a reasonable distance of our university. However, we consider this activity worth continuing and are currently embedding PPG activity as a choice for students.
Our pilot aimed to give students opportunities to work with PPG members in a wider sense, to gain knowledge and experience of how patients participate and work with health providers to improve healthcare services. We had considered boundaries might blur, so students and PPGs were given written information stating students were attached as volunteers for non-clinical work. Stakeholders also identified potential confusion between students’ non-clinical and clinical roles as being a problem.
Practice hours in our nursing curriculum exceed those required by the NMC, so there is leeway for students to engage in PPG activity provided it does not compromise practice placement requirements. We considered whether PPG activities were closely aligned to criteria in the OAR; students could provide evidence of activities for clinical mentors as reflections, statements from PPG members and activity logs signed at the PPG.
With our nursing programme’s current clinical placement allocation, some switching of clinical placement time to non-clinical attachment – reducing clinical placement time by >5% but still achieving the same clinical competencies – seems possible. This is still under discussion. Students could be encouraged to undertake these activities in small chunks across placement periods, ensuring relevant learning and competency development in clinical placements is not compromised. Mentors, however, may be reluctant to release students to engage with PPGs, so losing clinical placement time to PPG activity may only appeal to students who have their clinical work well under control and have free time to dedicate to it.
Students were told that although PPG activities would be non-clinical, they would be working with patients to address health issues aligned and linked to their clinical work and competencies for practice assessment. These perceived benefits were confirmed by students and PPG members. Some activities suggested by conference delegates, such as acting as advocates, possibly raise ethical and role issues for students and, despite offering great learning possibilities, must be planned with care.
Most patients are involved in healthcare curricula as experts on their own medical conditions (Jha et al, 2009); this pilot involved them as ‘healthy advisers’ to the planning and delivery of general practice services. Such attachments should complement students’ clinical placements.
There is considerable scepticism about frequent NHS reforms and concerns that, without appropriate resources, public and patient involvement remains “empty rhetoric and box ticking” (Petsoulas et al, 2015); students may be a useful human resource to counter this.
PPGs might struggle to engage the interest of the patients they purport to represent (Newbould et al, 2015) and may not have the skills (for example, in using social media) to engage younger generations. Student nurses are increasingly developing such skills (Jones et al, 2015), and can help PPGs fulfil their role.
This small pilot study in one university in the south-west of England, where PPGs were willing to participate, might not be generalisable; different health and education systems make replicating the methodology difficult. However, it illustrates how students could be involved in non-clinical patient activities to benefit themselves and patients. Locally, we are convinced this activity is beneficial and are trying to scale it up to offer it to all student nurses.
- Non-clinical attachments focused on wider patient engagement could give student nurses the chance to better understand patients’ needs
- Attachment to patient participation groups can help students to develop their communication skills
- Student nurses have skills and ideas that can benefit the groups
- Activities can be mapped to students’ practice-competency assessment criteria
- Patient participation groups’ activity varies, which must be considered when allocating students
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