After eliciting students’ views on what makes a good practice placement, one trust is now working to make sure students feel able to raise concerns
Student nurses at Guy’s and St Thomas’ Foundation Trust participated in pilot work for the local education and training board to ensure clinical placements were fit for purpose. This article looks at how they recognised a good practice placement and which themes emerged to highlight what they felt led to an effective learning environment. Feeling valued and being able to raise concerns in a transparent, open culture was important to them. The trust is working to ensure students can raise concerns in a supportive environment.
Citation: Ramage C et al (2015) Encouraging student feedback on placements. Nursing Times; 111: 10, 20-22.
Authors: Colin Ramage is practice development facilitator, Mags Jubb is clinical education manager, both at Guy’s and St Thomas’ Foundation Trust; Susan Aitkenhead was project lead for assuring quality in practice placements, Health Education South London and is now interim assistant chief nurse, NHS England (London Region).
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
The training and education of our workforce, whether initial under-graduate training or via continuing personal and professional development, reflects how healthcare delivery is moving; the closer education and training is to real-life working experiences, the better prepared the individual (Health Education South London, 2013). However, in the real-life working environment, significant changes are occurring after several high-profile failures of care. The Department of Health’s (2014) response to the public inquiry into failings at Mid Staffordshire Foundation Trust identified that ‘education and training are critical to securing the culture change necessary for the best patient care’.
As such, Francis (2013) and the DH’s (2014) response urge clinical placement providers to stop taking on students or learners in areas that do not comply with fundamental patient safety and quality standards.
Sir Bruce Keogh’s (2013) review into the quality of care and treatment provided by 14 trusts in England often refers to the value of learners, stating they are potentially “our most powerful agents for change”. It highlights that learners are capable of providing valuable insights, but too many are not being valued or listened to.
HESL is a local education and training board that ensures the provision of high-quality, future-focused workforce education and training. One element of its work to achieve its Workforce Skills and Development Strategy (HESL, 2013) has been to develop a set of standards to assure placement quality (HESL, 2014). This has been submitted as evidence to Health Education England’s Shape of Caring review (Box 1). The clinical education team (CET) at Guy’s and St Thomas’ Foundation Trust (GSTFT) has participated in this work by hosting a teaching forum with a cohort of student nurses to discuss what they considered to be conducive to high-quality practice placements.
Box 1. HESL and the Shape of Caring review
- Health Education England and the Nursing and Midwifery Council have undertaken a review of nursing education entitled the Shape of Caring. The review will recommend evidence-based improvements under the key question “How can we ensure the education and training of nurses and care assistants is fit for purpose to support them in delivering high-quality care over the next 10-15 years?”
- The review has called for evidence from stakeholders on eight themes. Health Education South London has submitted as evidence its work on quality assurance for practice placements under theme five: assuring high-quality practice learning environments which support the development of the future workforce.
GSTFT encourages pre-registration student nurses to feel part of the organisation from day one, and so was keen to participate in HESL’s work. Students are treated as the future workforce with an expectation that they sign up to delivering the trust’s values and pledges from their first patient contact. The aim is to ensure a strong “brand” of student nurses at GSTFT, and for all students to feel a sense of belonging to the trust and its ethos of patient care and experience.
The trust actively promotes openness and transparency. Students can express their views and concerns through various channels; these include a forum each term with the chance to feed back to the chief nurse about experiences across the trust. A weekly teaching session with an expert speaker is also an integral part of the student experience. This gives students regular opportunities to raise any issues with the education team or their link lecturers.
In July 2014’s forum, the 100 students answered questions about identifying high-quality practice placements (Box 2). Discussion was broad but a number of factors emerged about what they considered made a good placement experience (Box 3). They also identified that pre-placement preparation was key, which ensured the areas were expecting them and an appropriate induction pack was available. On starting, the most important thing was a friendly welcome from an inclusive, supportive team.
Box 2. How to identify a good placement
- What makes a good placement experience?
- How quickly do you know whether a placement is good or not?
- What strategies can we put in place to improve placement experiences?
- Can you think of any ways that make it easier for you to provide feedback in a safe and timely manner?
Box 3. Good aspects of practice placement
The following were highlighted by students as things that would positively impact on their practical placements:
- A warm welcome – makes a good impression and sets the tone
- Good mentorship
- Mentors who want to be mentors – not those who do it as a necessity for career or banding progression
- A variety of challenging learning opportunities
- Being able to provide timely and candid feedback in a safe environment
Mentorship emerged as a recurring theme. The quality of mentoring was a priority with some students, suggesting not all nurses were capable of it; students said it should not be an essential part of career or banding progression. Some students also felt more importance should be placed on protected time to effectively deliver the mentoring role; another view was that mentors had difficulty completing their assessment documents and that this was sometimes done in the mentor’s own time.
The learning opportunities available were also important, with students wanting a variety of challenging learning experiences. It was suggested that the opportunities available should be clearly signposted in a comprehensive induction pack and there should be an opportunity to work with a practice educator to enhance the experience. It was also proposed that there should be a chance to visit areas linked to the placement by, for example, shadowing a clinical nurse specialist or spending time in a specialist link area.
Students were asked to write down their comments and encouraged to identify themselves so they could be credited for their feedback and referenced in HESL’s final report. However, approximately 50% of attendees did not add their names so it could be assumed that, despite a strong desire to promote an open culture, some students still felt reluctant to be identified.
The CET felt this was a useful exercise, which showed the students that GSTFT values their opinions and, with the regular student forums, offered a channel for them to express their views. It was important to the CET that, as well as the feedback strengthening the HESL standards work, any comments were acted on locally. Students’ comments did not identify specific placement areas but information was fed back to key mentors at the key mentor workshop in October 2014.
The themes highlighted by the students directly correlate to those identified by Emanuel and Pryce-Miller (2013) in their literature review, which concludes that supportive clinical teams are critical to student wellbeing. All students attending the forum agreed feedback on their clinical learning experience was vital and should be candid and given without fear of repercussions.
Students’ feedback about clinical areas being aware and prepared for their arrival is something the CET has tried to tackle by creating a “Help me on placement” email address. Students and mentors are encouraged to contact the CET using the email address if they are unsure of placement details. In place for a year, this has greatly reduced the number of students who arrive on a ward or unit that is unaware or unprepared for them It is also another easily accessible channel for students to raise any concerns or give feedback.
Mentors can request support via the email channel for the tasks they have to do with students, such as writing action plans or having difficult conversations. It is important that they also have a voice and are supported when there are challenges.
Providing learning opportunities for students requires a team approach, and GSTFT has developed a 2.5-day course spread over three months for nursing assistants so they can be more effective when supporting pre-registration student nurses. All staff at GSTFT are entitled to five days study leave per year; this means delegates can do the course in “work time”. The course gives an overview on learning styles, teaching techniques, assessment methods, constructive feedback and communication. This not only provides important learning but also values and acknowledges the input nursing assistants have in the training of pre-registration students.
Fostering supportive teams
Welcoming and supportive teams are fostered at the trust by nurses who take on the “key mentor” role. This is given to motivated, experienced staff, who are there to promote a high-quality learning experience and support the mentors in the area. The CET links closely with the key mentors and offers biannual forums to update them on current education initiatives and strategies.
Students mentioned the welcome they receive and the importance of everyone taking responsibility for it. Ward clerks are considered central to this as they may be students’ first point of contact. Before the email system was introduced, ward clerks were often unaware of when students were due to start placement. Informing them of upcoming student attendance, especially for first-year students, and helping them understand the important role they play in welcome and support has been facilitated successfully by the CET.
Protected time for mentors
The issue of mentors having protected time to sufficiently fulfil the role was raised by students. The HESL standards for placement quality assurance aim to develop a more fundamental culture of learning within all organisations (HESL, 2014). This should also:
- Place more value on the role of the mentor;
- Highlight it is an essential component of student learning;
- Acknowledge the time and ability required to undertake it effectively.
Local feedback has shown that these roles work best when there is protected time to undertake them. GSTFT is currently exploring ways to improve this in the placement areas.
GSTFT has found that gaining senior nurse support for the trust’s mentor, key mentor and sign-off mentor roles has been vital in raising the profile of all the work that is undertaken supplementary to the clinical care these staff deliver.
Confidence in raising concerns
The CET was keen to address the number of students who still lacked confidence to add their names to their comments. The reason for this might be that they felt it may in some way be detrimental to their placement experience. In 2013 the team attempted to address this anxiety by creating an algorithm on raising a matter of concern (Fig 1, attached), which clearly identifies the process and the support that is offered to the students during any possible investigations. This information is disseminated to all students on their annual trust induction and is promoted again throughout the year at the weekly student teaching session, where a member of the CET or a link lecturer is available to discuss any concerns in confidence.
The algorithm has been successfully used to investigate all concerns since its implementation and has provided both staff and students with a consistent approach to raising a matter of concern.
Building a strong workforce
Working to develop an open and transparent culture at GSTFT reassures students that they will be listened to. This encourages them to stay with the trust after qualifying and will help to build a workforce that is accustomed to raising concerns.
The aim of producing a strong brand of student nurse during pre-registration training that, on qualification, is equipped and ready to work with their colleagues at GSTFT is reflected in the high numbers of students who chose to remain here. Retention figures demonstrate that 80% of our newly qualified staff have remained with the trust after a year of employment.
Safer staffing, patient acuity and the development of new services adds to the demand for high-quality nursing staff in the trust, and the recruitment of newly qualified staff who are familiar and confident with the organisation goes some way to address this. To be able to recruit this essential group to the workforce is fundamental, and retaining them is equally important.
It is widely recognised that there has been a culture in some areas of the NHS in which students feel they do not have a voice and will not be listened to if they raise concerns. It has, likewise, been identified that further national work must be undertaken to ensure students feel safe and confident to raise concerns. Our work has identified the importance of students feeling valued and having the ability to raise concerns within an open and transparent culture. Comments from it have been submitted to the Shape of Caring review.
Feeling valued and listened to have been recognised as important qualities that impact on students’ decisions when they are trying to decide whether to remain with an organisation upon qualification.
- Practice learning environments are one aspect of the national Shape of Caring review
- A welcoming, supportive team is essential for high-quality practice placements
- Students want good mentors and challenging learning experiences
- Helping students to raise concerns is part of an open, organisational culture
- Students who feel valued and able to raise concerns are likely to stay their trust
Department of Health (2014) Hard Truths: The Journey to Putting Patients First.
Emanuel V, Pryce-Miller M (2013) Creating supportive environments for students. Nursing Times; 109: 37, 18-20.
Francis R (2013) Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry.
Health Education South London (2013) Workforce Skills and Development Strategy 2013-2018.
Health Education South London (2014) Standards for Assuring Quality in Practice Placements. London: HESL.