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Changing practice

Using supported learning to ensure nurse recruits are skilled to care for acutely ill patients


Nurses often lack the necessary skills to care for patients with acute illness. A trust set up a programme to enable applicants to train before taking up posts



Linda Chapman, MSc, PGCEA, BSc, RGN, is education lead; Julie Blackman, PGDip, BSc, RGN, is head of clinical skills; both at Royal United Hospital Bath Trust.


Chapman L, Blackman J (2010) Using supported learning to ensure nurse recruits are skilled to care for acutely ill patients. Nursing Times; 106: 11, early online publication.   

Recruiting registered nurses to acute care wards can be difficult as applicants often lack the necessary skills to work with acutely ill patients. To overcome this problem the Royal United Hospital Bath Trust set up an acute care training programme.Through partnership working between managers, clinical, education and human resource staff, it provides an opportunity for nurses to develop confidence and competence to meet the needs of the acutely ill.

Keywords Acute care, Competence, Recruitment, Training

  • This article has been double-blind peer reviewed



Practice points

  • The acute care training programme has helped registered nurses to develop confidence and competence when caring for patients in acute settings.
  • Close working between clinical and educational staff and students has helped overcome the many challenges of developing a new programme.
  • An assessment day involving an interview, clinical skills test and team management exercise is key to nurses successfully completing the programme. 
  • Flexibility is essential to enable each student to learn according to their personal learning needs and the demands of their workplace. 
  • An emphasis on students as self directed learners is vital for their ongoing development.



A shortage of competent nurses could jeopardise the government’s plans to modernise the NHS. Nurses are central to delivering healthcare and a crucial resource (Maben and Griffiths, 2008). The changing profile of acute care requires nurses who are competent to respond effectively to the needs of acutely ill patients.

Like many acute trusts, the Royal United Hospital Bath Trust faces a challenge in recruiting enough registered nurses who are up to date and confident in meeting these acute needs. The trust’s recruitment strategy group recognised that many nurses were put off applying for jobs in acute care, or were unsuccessful at interview because they did not have the necessary skills to work with very sick patients. To recruit suitable staff, the trust’s nurse recruitment group commissioned a working group with representatives from education, human resources and nursing practice to develop an acute care training programme.

This training offers supportive learning to enable registered nurses to change their area of practice, and develop knowledge and skills to meet the needs of acutely ill patients cared for in busy wards.Although the transition from acute care to primary care has been supported elsewhere (Clegg et al, 2006), there is no documented evidence of a specifically designed programme for nurses to gain skills in caring for acutely ill patients in an acute trust.

The acute care programme

The programmeprovides an opportunity for registered nurses to undertake up to six months of supported learning to enable them to meet the needs of patients with acute illnesses.

A partnership approach is used to develop and implement the programme, which includes clinical and education staff who design the content and implement training and HR staff who organise the contractual arrangements. The latter includes a fixed term contract for the length of the programme and a substantive band 5 post on successful completion. During the programme each student is allocated a learning partner, who is an experienced registered nurse working with acutely ill patients, and an educational coach from the education department; they jointly supervise and support students.

The learning partners’ role is to provide guidance and enhance clinical skills development. They negotiate learning needs by considering students’ previous experience and the needs of the workplace with the aid of a learning contract (Knowles et al, 2005), which helps individualise each student’s learning. Learning partners give feedback to their allocated student on progress and constructive comments on aspects of practice that need further development. Students are encouraged to express difficulties and skill gaps identified in the workplace.

Educational coaches help students and learning partners understand the requirements to pass the programme successfully. They organise a schedule that includes taught sessions, led by experts in the trust, and facilitate work based learning sessions. The latter promote sharing of incidents from practice, encourage reflection, and provide opportunities for learners with similar concerns and difficulties to come together and support each other.

The programme places significant emphasis on students being self directed learners. For the first two weeks, students have supernumerary status and are given protected learning time throughout to attend study days and undertake independent study and work experiences. This is essential to enable them to complete required clinical competences and collate evidence for the development portfolio, which is assessed.

Students are expected to be proactive in seeking learning opportunities such ase-learning,in-house training or working in alternative teams for short periods. They are also responsible for demonstrating they have achieved their agreed competences and skills by successfully completing a learning contract and portfolio of evidence. Those who do not complete the required competences are not offered a substantive post at the end of the programme.

Challenges and solutions

The working group had to resolve several difficulties before and during implementation of the initial programme. Choosing candidates who are suitable to work in the hospital and motivated to develop skills is a major challenge. Sisters and matrons prefer to choose candidates who are suitable to work in their areas based on matching their past experience and preferences to the requirements of the post.

There is an assessment day for each cohort, which aims to enable candidates to demonstrate their knowledge and potential to develop. It also enables clinical staff to assess candidates’ suitability for their practice areas, whichinvolves one to one interviews with ward sisters. An assistant director of nursing gives a presentation on the trust’s expectations and a member of the education team outlines the programme’s structure.

Candidates participate in a series of activities such as a clinical skills test and team management exercise. These give applicants an opportunity to demonstrate their problem solving and team working qualities. To encourage as many potential applicants as possible to attend, these assessment days are held on Saturdays. 

As applicants have a wide variety of different experiences and skills, learning opportunities have to be flexible to meet their individual clinical needs and the needs of the areas where they will work. In developing the programme, education staff considered the difficulties in assessing work performance and clinical skills. Clinical staff do not want to have to complete long and complex documentation as evidence of students’ skills. National Occupational Standards competences developed by Skills for Health (2010) are already used in the hospital to assess practitioners and many clinical staff are therefore familiar with them. The working group identified four compulsory competences from the NOS that they felt all staff should achieve when working in acute care. Additional optional competences are negotiated between students and their learning partner. This allows appropriate competences to be met according to patients’ needs in the wards where students are working. The required competences to complete as part of the programme are summarised in Box 1. 

The use of the NOS competences has proved successful in helping students improve performance and as an assessment tool.  A nurse working with the student witnesses the successful achievement of the competences. Learning partners and educational coaches check portfolios reflect students’ achievement. Although the portfolio is not assessed at higher education institution level, progression opportunities to gain credits towards an academic qualification are available within the trust.


Box 1. Competences to complete during the acute care programme

  • Trust induction programme, including basic life support;
  • Four compulsory competences:
    - Physiological measurements;
    - Discharge arrangements;
    - Medication administration;
    - Infection control;
  • Two further options relevant to students’ area of work and own development gap. For example: supporting patients through the process of dying; carrying out extended feeding techniques to ensure nutritional and fluid intake; intravenous and subcutaneous therapy workbook; blood transfusion. 


Other obstacles

Some ward sisters and charge nurses are apprehensive about accepting acute care students onto wards which have staff shortages. It is difficult for existing staff to provide additional support as busy wards do not have time to facilitate learning and skills development for newly recruited staff. To overcome this, two students have undertaken their acute care training programme on a ward with sufficient staff to support them and then moved to another ward of similar speciality towards the end of their training period and before their substantive post.

To allow students to settle in to the ward, get to know team members and observe new skills and practices, two weeks of supernumerary practice is included. For some this has still proved insufficient, especially for those who work fewer than three days a week. As a result the programme is not suitable for students who cannot commit to working a minimum of three days a week in clinical practice while undertaking training.

Outcomes and benefits

The acute care programme has been running for a year andtwo cohorts of five students each have participated, with more planned for autumn and spring.

Through the evaluation process, learning partners and students have outlined positive benefits for professional development. Students have appreciated being given the support and time to adjust to changes in practice and the pace of acute care nursing; in particular, developing their clinical practice and ensuring they are working within current policies. Before undertaking the training most students expressed apprehension and a lack of confidence in being able to nurse in an acute setting. They have been surprised at how their confidence has grown and how quickly they have been able to achieve their competences.

Flexibility in the programme enables students to complete it in 3-6 months, depending on their ability and work pattern. After successfully completing it all have been given permanent work contracts. So far most students have completed the programme successfully within 3-4 months, and only two have taken nearer to six months. Two left during the early stages of training due to unexpected changes in their personal circumstances.


The success of the acute care programme relies heavily on learning partners and managers, education and HR staff and the determination of students themselves.The trust is fortunate to have dedicated staff who provide excellent support for this programme. As it is proving to be a positive factor in supporting recruitment to our registered nurse workforce, it continues to be offered twice a year with cohorts of up to 10 students at a time.



  • Many acute trusts struggle to fill vacant positions for registered nursing staff due to a shortage of candidates, both in terms of number and calibre.
  • The introduction of the acute care programme is part of a localstrategic approach to recruit sufficient nurses.
  • Nurses need colleagues’ support within the organisation to enable them to develop necessary skills.




Readers' comments (9)


    The nurse 2000 does not train nurses in fact it educates them, i feel that the move to university to educate the nurse was a big mistake. when nurse 2000 was implemented , we used to call these nurses paper nurses. as they can only nurse on paper .they can not actually cope with the hands on care. sorry that this statement sounds a little uneducated i have been retired a while now and have lost my skills

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  • As a newly qualified (6m ago) nurse, who got a job on an acute ward and was way over my head, this is a brilliant idea. If all nursing is going to degree level ( and I have one) it should be 4 years, with one of those being pre-employment, fully supported, hands-on nursing with on the job learning. The combination of theory and practice in Uni just makes both dilute. Although I had supernumery status for 2 weeks, the ward was so busy and short staffed, I had no training days and preceptership and feedback were non-existant. It made me consider leaving nursing but I have stuck it out. I have learned lots, but could have learned so much more.

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  • Perhaps I am getting too old, I qualified in the late '70's. I thought this was all part of nurses training (infection control, medication administration). Discharge planning is part of student nurses management placement. This article suggests to me that both universities and studen mentors are not performing thier roles effectively.
    Changing roles from a student to a trained nurse is difficult, especially these days when the pace of work is so fast. Newly qualified nurses should be able to work with support of a preceptor during this period, without having to go back to basics.

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  • I feel that this programmme is a good opportunity for newly qualified nurses/ nurses new to that area of practice to consolidate and transfer their existing nursing skills in a new area. Health care is constantly changing environment (Darzi, 2009) and nurses strive to stay up to date with clinical skills and evidence basing their own practice. Nursing research demonstrates that transition between the student role and registered nurse and can be difficult, with nurses suffering emotional highs and lows, in addition to feeling lost and deskilled (Evans, 2001). Therefore support and preceptorship is vital for role acquisition registered practitioner. There are so many areas of practice and specialisms in healthcare to date and it is difficult for nurse education to provide practice placements in all clinical areas. Instead, the NMC have provided standards which student nurses must attain prior to registration. Thus education and mentors in practice need to be proactive in supporting learning in practice and recognising students who are not achieving expectations and outcomes, throughout their training (and not just being highlighted at the end of their management placements) and failing these students so that only competent nurses are being registered (Duffy, 2004). There have been huge debates over nurse education, ranging from the theory practice percentage split and many changes throughout the years. Although it can be questioned whether or not nurses are better equipped to care when nursing becomes graduate in 2012, Nurses have a wealth of theoretical knowledge which underpins their practice and undertake huge responsibilities and are accountable for these actions. As the majority of other allied healthcare roles are all graduate programmmes, nurses need to be educated and rewarded in their pay in line with these other professions.

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  • Like others, I too think this can only be a good thing.

    But I also think that it should be incorporated more into the actual training.

    I disagree with Sandra Odells coments, we are not paper Nurses without hands on skills. We have skills, as the mix between uni and placement is quite good, so most of us rely on the actual placements to learn and develop these skills.

    I actually agree with the degree for Nurses, but what is currently on the academic program just isn't fit for purpose.

    We need less ethics, politics/sociology, management, communication modules and other 'soft' subjects. We need MORE medications and pharmacology, more A&P, more pathophysiology, and more CLINICAL SKILLS labs!!!!

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  • Whilst I think that this idea can only lead to better patient care. I also think that student nurses spend ample time in the clinical environment working with current RN's to learn patient care, recognition of the sick patient etc. This coupled with the theory coming from the university should be enough to provide excellent nurses.

    It will always be difficult to adapt from being a student to becoming a RN because responsibility and accountability is suddenly on their shoulders. The newly qualified nurses that I have worked with over the last couple of years have had the knowledge and skills but have just lacked the confidence, with a bit of reassurance they perform very well.

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  • Well god help us all...
    We are now educating nurses...are we ?
    I find this article a very sad reflection on nurse education.
    Surely, if a nurse completes a course to enable entry to the register then one must assume they have reached an overall level of competence. Sadly, this is not the case.
    I too, as previously mentioned, was very sceptical of project 2000. My concerns are now clearly demonstrated.
    I fear nothing will improve until the wheel goes full circle and we return to a good "old fashion training" with the bulk of it carried out on the wards, under the remit of the formidable ward sister.
    Thats how I was "trained" in 69 -- 72.
    Then along came nurse research. What did I do.... I read research articles but luckily my brain was able to critique so that I made appropriate choices for the good nursing care that I still deliver.
    One question... If a Doctor, on qualifying, could not care for acutely ill patients what would WE think of them and would they have the RESPECT that nurses appear to be craving.

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  • Judith Willis, I'm sorry but I have to completely disagree with you. You may have trained that way 40 years ago, and it may have worked for you, but guess what, times have changed and so have Nurses. A lot of the problems I have faced on the wards during training have come directly from older Nurses with views such as your own, who think everything should hark back to the 'good old days' as they sneer at students. Older Nurses who think that a student Nurse should be broken in for three years doing nothing but making beds and washing patients and are simply unwilling to teach us anything above that.

    Now I agree that observation of patients during washing and caring for them is extremely important and we need to know this. It is one of the first things we learn and we do it constantly throughout training. But guess what, we also need to know how to do obs and understand the pathophysiology behind them, we need to be able to catheterize, to insert NG tubes, manage enteral feeds and fluid therapy, manage medications and understand to pharmacology, diagnose changes in a patients condition, change dressings, care for a stoma, etc etc etc etc et bloody c.

    Now luckily I have met a few decent Nurses alongside the bad ones I mentioned earlier, and they taught me the practical skills I mentioned earlier amongst many others. I also learned the theory behind them at uni, or at least some of it when they weren't forcing ethics or sociology modules on us!

    Nursing has changed, we are more educated, more highly skilled and more autonomous. The training has adapted, unfortunately not a lot of the older Nurses have.

    As for your question, most newly qualified Doctors rely heavily on senior Nurses when they first qualify to get their sea legs so to speak, much in the same way as a Leiutenant in the Army fresh from Sandhurst relies on the experienced Staff Sergeant. In the same way, newly qualified Nurses are highly skilled and knowledgeable, they just haven't had the time or experience to hone those skills yet. But they will. And in 40 years time I can imagine a Nurse with that level of training, knowledge and skill, plus that amount of experience, being pretty damn good at what they do. Dare I say it a lot better than the Nurses ready to retire now.

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  • In my final year and have just started a placement in an acute medical ward. Quite frankly, most of the time staff are running about like headless chickens-too many patients and not enough staff. My supernummery status is completely out of the window and really its not about learning as it doing. The majority of nurses are trying to help but in a lot of cases, I'm left to get on with it (so much for being supervised).
    In the last few weeks, there has been a number of sick people that I have cared for and the thing is, without the education from the University and reading, I would be so out of my depth.There isn't time for mentors or nurses to explain to me about patients conditions or side effects-kinda of need to just do it.

    Being able to make beds and help wash patients is not the only thing to being a nurse and quite frankly, I'm not sure that's kind of nurse that's needed in an acute ward

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