The Humber and North Yorkshire region is considered a ‘cold spot’ that faces a strong competition to attract nursing graduates and healthcare professionals. Also, due to the large geographical spread of the region, communities are heavily reliant on general practice to deliver a considerable proportion of their healthcare provision (Humber, Coast and Vale Health Care Partnership; Long Term Plan, 2019–2024).
Historically, student nurse placements have always been at a premium and more so for specialist training (NHS Employers, 2022). This alongside the lack of qualified nursing assessors, has put strain on Higher Education Institutions (HEI) and healthcare providers to find suitable learning disability practice-based placements to accommodate clinical learning as part of their undergraduate programme.
Learning Disability nursing placements are limited and often shared with other nursing disciplines that may not highlight their significant and specialist contribution to patients with a learning disability (Beckman., et al 2022).
People with a learning disability have poorer health and a lower life expectancy than the general population. The annual health checks for people with a learning disability differ from NHS health checks and include a more specific and detailed examination of a person's physical and mental health. Carrying out these checks ensures that health issues are identified early, support can be provided promptly, and the person's health action plan is up to date (NICE, 2019). With the necessity to undertake annual health checks within this vulnerable group, this puts considerable strain on an already stretched general practice service to accommodate and achieve the Quality and Outcomes Framework (QOF) for learning disability patients (NHSE, 2019).
With the continual need to expand placement provision in undergraduate training, and for general practice to achieve the QOF for annual health checks with Learning Disability patients, an opportunity for placement expansion in Learning Disability training seem plausible.
However, the challenge of accessing qualified assessors can be still limiting not just in general practice but across all placement areas.
The long arm approach to supervision refers to the process of supporting students in placements in line with professional body requirements (Knight et al., 2021).
The model encourages a supervisor or assessor to be located at a distance to the clinical practice learning area, yet accessible for support for a student.
This means that the long-arm practice supervisor or assessor will not be with the student continuously whilst they are on placement but meet intermittently for supervision and assessment.
Equally, students need to feel empowered to take responsibility for their own learning, and to self-direct where appropriate. This provides opportunities to develop and consolidate clinical expertise that promote independent practice and reflective learning (Rolfe et al., 2001). Clinical placement models such as the long arm approach has been used in undergraduate health professional education to foster positive perceptions and experiences, which support the development of self-efficacy, confidence, and skill enhancement (Bandura 1982).
NHS England in partnership with Coventry University Scarborough Campus as part of the Coventry University Group were funded to pilot and set up two 3rd. year Learning Disability student nurse led clinics in differing primary care practices to undertake annual health checks with people with Learning Disabilities. This was to examine the impact on student confidence and the quality of care delivered in those specific sessions. These areas were the hub and spoke placements within community settings to test, consolidate and expand skills learned and to examine transferability.
The transformation was a process which was aimed at the Clinical Expansion Programme (CPEP) to be hosted in General Practices (GP) working with National Health Service (NHS) community services, for a more co-ordinated and pro-active services through the support of two appointed Higher Education Peripatetic Educators that focus on learning disability education and care, aiming to promote high quality active living in Learning Disabilities (LEAP, 2022).
Additionally, the metric of increased confidence was viewed as an important evaluation in evolving role identity and managing change which are major factors in the preparation for registration and joining the healthcare workforce (Whitehead et al., 2016).
The main aims of this pilot study were to examine if confidence and self-efficacy increases with third year student nurses running nurse led Learning Disability annual health checks, utilising the long arm supervision process. Additionally, to raise the profile and awareness of the specialist role of Learning Disability Nurses, integrating their knowledge, competency, and skills in primary care settings by promoting best practice and consistency in supporting people with Learning Disabilities and avoiding hospital admissions.
2.0 Methodology and Methods
Hermeneutic phenomenology was used to explore the theoretical underpinning for the study (Ho et al., 2017). This approach was considered appropriate to examine the phenomena of confidence and self-efficacy in 3rd year Learning Disability nurses undertaking health care checks within a primary care setting.
2.1 Ethics statement
This study received ethical approval from Coventry University Project Reference Number: P149731
2.2 Recruitment
This was a purposive sample taken across five primary care facilities and one educational establishment who participated in the 10-week clinical placement between late January and early April 2023 and were in direct clinical and educational contact of running the student nurse led Learning Disability clinics for the pilot study.
Following ethical approval, the study participant information was mailed to all participating partnerships from the identified placements (See Figure 2) and the two Learning Disability Nursing students who took part in the Health Education England pilot project. All were invited to contact the researcher, by email or telephone. This was followed by arranging a mutually convenient face to face meeting for further discussion and to obtain written consent to be interviewed. A cohort of seven healthcare practitioners including the two Student Nurses (See Figure 1) consented to take part in the study and were questioned about their understanding and experiences around self-efficacy and confidence related to care of people with Learning Disabilities and student supervision.
2.3 Consent of Participating Partnerships and Data Collection
Consent and participation were voluntary, and all had some experience in the specialist area of Learning Disabilities. At least one person was recruited from each placement to gain their perspective and their philosophies of Learning Disabilities care in the workplace. Figure 2 is representative of the participating partnerships and the activities undertaken by the student nurses on placement.
The two Learning Disability Nursing Students were placed into a Hub Placement (One North Yorkshire and One in Humber region), and each accessed two or more spoke placements in accordance with their timetabling.
One-to-one semi structured interviews were undertaken to permit the participants to talk candidly and openly in a non-judgemental setting to generate full understanding (Kallio et al., 2016). Interviews were undertaken through either a digital based communication platform or face to face in a secure environment to avoid interruption and maintain confidentiality throughout the interview process. Written informed consent was gained prior to the interview process and an audio was recorded digitally. Recorded transcripts were converted into a written transcript and were analysed and re-analysed to examine and determine themes. All data was recorded and stored in accordance with ethical approval to maintain confidentiality and data storage security.
2.4 Interview Questions
The interview questions were mapped onto Bandura's (1982) four sources of efficacy enhancement model and were consistent with its proposed mechanisms.
This first source of self-efficacy is sometimes called performance accomplishments, and this would assist in exploring the students and supervisors’ views on achievement and failure.
The second source of self-efficacy is vicarious experiences the actions of the people surrounding the practitioner/student and how that impacts the individual's confidence and performance through modelling.
The third source of self-efficacy is the influence from other people's verbal and social persuasion, which impacts on motivation and self-awareness from coaching.
The final source of self-efficacy is that psychological traits and how they impact affect physical and emotional states such as stress and anxiety to investigate emotional regulation, particularly around judgments of one's ability to complete specific tasks. By utilising this model, the key themes and experiences from the project could be identified and evaluated. Each question was open ended to give a depth or richness and exploration of the participants feelings, confidence, and motivation around the study experience. This is expressed in Figure 3.
2.5 Data Analysis
All interview data was transcribed verbatim, and numerically coded to protect the identity of participants. The approach to data analysis was on interpretive analysis, underpinned by hermeneutic reflection. The texts were read and re-read in their entirety, to allow a feel for the data. Particularly significant sentences or phrases were drawn out of the data, along with clusters of sentences that gave meaning to the text. One researcher solely undertook the interview process, and another independently led the data analysis. Both researchers then came together to clarify understanding. This, helped to maintain transparency and rigour and reduce any bias (Aveyard and Sharp., 2017).
A thematic analysis approach was utilised using a pattern recognition for themes from the data. This thematic qualitative analysis with hermeneutic context, permits data to be interpreted for meaning and description (Roberts et al., 2019). Semi-structured interviews were used to gain an understanding of participants clinical confidence and motivations and to examine any reasoning for their observations. Additionally, the interviews considered the external influences, by exploring their experiences to see if this impacted upon their confidence, motivation, physical and emotional states (Devik et al., 2013).
3.0 Findings
The participants in the study had similar experiences around self-efficacy and confidence, within their respective primary care environments and most appeared to be more positive than negative. The main themes identified included, confidence to act independently and assess at a distance, proficiency in skill attainment, mutual sharing of learning and assessment, improved communication and trust with patients and colleagues and an increase in advocacy towards Learning Disability care.
3.1 Confidence to act independently.
Confidence was often described as having conviction in one's ability, particularly when they had a successful performance.
“I found that confidence gets better the more you do it’’.
“Helped me to kind of gain my confidence in allocating tasks to students”.
By having confidence, it gave the individual the drive to achieve their professional goals and enhance motivation to challenge oneself in how a clinical task can be undertaken.
Confidence was not just measured by successful skill attainment, but the ability to speak up, and set a professional boundary when the practitioner and the student felt they may breach their knowledge and skill ability.
“If I’m not comfortable to do something, I won't do it and say so”.
This confidence can enable students and practitioners to act autonomously within their scope of practice and accept their limitations. Through developing confidence, the practitioner gains the ability to exert control over their own motivation, professional behaviour, goal development and work environment (Kanfer and Ackerman 1989).
3.2 Mastery of Skill Attainment
In former placement learning, clinical skills and content were taught for a set amount of time, and a student's aptitude was based on how much they learned in that allotted time.
Using a sustained long arm approach, with supervision available for the whole 10-week placement, students felt that this version of supervision enabled them to be more creative and motivated to master any content or skill more independently and they did not feel time limited. Equally, the practice assessors found student mastery had excelled.
“Every review that I did on my own I had psyched myself up for it and then obviously I went through all the information two or three times because I didn't want to get it wrong. It exceeded my confidence a lot”.
“By the time she went she was fully, she was doing it all. She was great. I think what she really found was her confidence in not only seeing Learning Disability patients but using our systems”. “So, I think it's a real opportunity to have a chance to really take the lead on something and yeah experience that before you qualify”.
“Taking blood pressures and doing diabetic foot checks and all those kinds of things. My confidence in being a third year Learning Disability nurse has boosted massively”.
Additionally, the opportunity to expand skills appears to have offered a deeper and broader understanding of the challenges with physical and mental health aspects that people with a Learning Disability may encounter. This indicated a sense of increased professional value and role identity through developing their skills and competency (Wald et al, 2015).
3.3 Mutual Sharing of Learning, Assessment and Timely Feedback
The opportunity to work with several supervisors demonstrated that knowledge exchange was a two-way process and not a traditionalist approach whereby the supervisor leads, and the supervisee follows. Students and staff stated that they had a sense of value in the work environment through knowledge exchange as well as an opportunity to learn themselves.
“The students know what they're talking about”.
“Explaining to her about the hospital passport. In the hands, it's a brilliant idea”.
“Having Uni staff as part of the assessment interviews in the meetings so that we together we could talk about how she was doing. I found that valuable and supportive”.
“It's made me understand how to learn again. I learnt that by sitting on my hands, she was able to do it”.
Additionally, there was behaviour change through use of long arm supervision approach by letting the student explore, learn, and lead without the supervisor or Peripatetic Educator being prescriptive. Equally, the supervisor learning to take a ‘back seat’ in the process and being comfortable about taking that decision. This helped to develop trust between practitioner and student, each of whom had a skill that the other may like to learn from and share. Therefore, a mutual learning relationship can evolve with both students and practitioner and may strengthen the implementation of the long arm approach, and other supervisory concepts (Clarke et al, 2015).
3.4 Enhancing Communication and Trust
Communication was a featured theme throughout the study, particularly between students and assessing supervisors. The long arm appeared to remove some of the hierarchical barriers and tensions around communication with an effect on individual positivity, confidence, and trust without overly role modelling (Jankelová and Joniaková, 2021).
“So, we can work together and definitely know that it can open that channel of great communication”.
“I learned a lot around the social effect when communicating with patients and their families”.
This had a transformational effect as students were comfortable to explore their communication styles and took time to present their written documentation at the end of the day without feeling fearful of over questioning about care provision.
3.5 Advocacy for people with a Learning Disability
An anticipated outcome from the project was to look at the effectiveness and improvement of the quality of the annual health check for people with Learning Disabilities and this appeared to have a desired effect on the management of the Quality and Outcomes Framework (QOF) and the quality of those patients’ clinical sessions.
“Looking at the whole person in the annual review, their physical science, mental health, social health, just everything and with time. Building a relationship in that time and you add this when you see them regularly over time”.
Additionally, the realisation that the inequalities gap following the impact of Covid with an increasing awareness that people with Learning Disability may have been a neglected and most vulnerable group during that time and still are.
“I don't suppose we'll ever get back to how they were before and within GP surgeries but having somebody lead in the clinic for learning disabilities, who knows what the health and equalities are”.
“I think it would give us more opportunity to see more patients within the surgery at one time with learning disabilities and the students bring knowledge”.
Having the Learning Disability Student Nurses in General Practice, demonstrated there was a value of this speciality being represented in the General Practice setting and could lead to higher quality outputs for students and practitioners with an increase in satisfaction for people with Learning Disabilities accessing healthcare services (NICE 2019).
4.0 Discussion
The evidence from this study suggests that positive feedback between student and supervisor with the support from the peripatetic educator is beneficial in developing and sustaining confidence in undertaking student nurse led clinics.
The influence of this type of supervision is comparable to the technique of verbal persuasion as described by Bandura (1982), in which supervision feedback can negatively or positively influence self-efficacy. As the long arm supervision was approached with regular feedback mechanisms and timings this could have had a significant impact on the student nurse's motivation and protecting any fragility of confidence at the beginning of the placement (Bedwell, et al., 2014). As this was a pilot study the two peripatetic educators were available continuously for the ten-week duration, however the student was encouraged to engage with experiential learning and reflect in and on practice (Kolb, 1984).
Equally, as general practice requires individualised consultation the student nurses were operating independently and trying to practise in a manner to their own specialist philosophy to exercise their Learning Disability knowledge and practice. This autonomy within a consultation room enables the Learning Disability student nurse to provide the care they wish for their patient, which aligns with their professional values and is a protected zone to exercise their skills and specialist knowledge without the potential of interference (Stump, et al., 2012).
Supervision between student and supervisor is often compromised by the clinical environment and the conflict that can occur in hierarchy structures and the needs of the organisation (Bedwell, et al., 2014). Frustration can diminish motivation through limited infrastructure to accommodate autonomous practice through pressure on clinic room availability. Equally, the QOF for Learning Disability patients commences at the beginning of the fiscal year and therefore there could be a limitation on how many Learning Disability annual health checks could be performed by a student nurse on a placement. Therefore, the timing of the placement to undertake a student led clinic that may involve a QOF requires consideration. Also, to be mindful that this type of placement activity can maturate and elicit demotivation if over utilised to ease workload on the Learning Disability QOF.
Scepticism at the beginning of the placement intending to use the long arm approach can raise questions around safeguarding, particularly when working autonomously (Field and Brown 2019).
Therefore, the initial consultation with the student at the beginning of the placement is the appropriate opportunity to support and empower the student to take responsibility for their learning without compromising public protection. The fact that students will be given a longer time to accomplish an annual health check, keeps the emphasis on learning rather than timeframes and therefore may offer a higher quality of care.
Lastly, the students had the opportunity to test their social effectiveness, emotional intelligence, and self-awareness (Goleman 2009) through consultation with Learning Disability patients to gain a satisfactory outcome from the annual health check consultation. This suggests that developing confidence is key in nursing students training and education to assist the transitional phase of student to registrant to engage in ‘real life’ practice (Walsh et al 2021).
5.0 Limitations
This was a small cohort due to the limitation of participants in the pilot study.
However, a sample size of seven participants was considered appropriate for this phenomenological study, where the aim is to obtain in-depth and rich data from a small number of participants (Hays et al., 2012). As this research was an evaluation of a pilot study from the NHS England, data saturation was not considered a significant requirement, but to accommodate a deep dive of exploring the experience and phenomena of occurrence around confidence and self-efficacy using a long arm approach to student supervision. The data that was obtained indicated strong similarity in the findings by the participants.
6.0 Recommendations and Implications for Practice
Strategies related to support, education and supervision are necessary to help students develop confidence and clinical autonomy in their placements in preparation for registration. This with the utilisation of the peripatetic educators is essential to support students and staff within these primary care setting.
Through good preparation and adopting an appropriate supervision model that is aligned with the clinical environment and skill mix, will assist the students and supervising staff to maintain confidence and an opportunity to share knowledge in a positive way that benefits not just both parties but people with Learning Disabilities and their families.
By providing timely training throughout the hub and spoke placements will offer the student to experience and test their flexibility and consolidate any skills acquired in similar care settings. Equally, timetabling for constructive feedback and assessment within the placement can help maintain and develop confidence and further motivation (Gibbson et al., 2011) and helps better identification of the Learning Disability role within the placement partnerships.
Accessible supervisor support enhances trust and an opportunity for sharing without fear, but equally to exchange specialist clinical knowledge to enhance patients experiences during the annual health check review process and alleviate workload around the Learning Disabilities QOF.
Lastly, the transferability of the long arm approach in supervision may have a significant impact on expanding placements within the private, voluntary, and independent sectors.
Conclusion
The third-year student nurse led clinics increased confidence and self-efficacy, which is viewed as a key factor in evolving the Learning Disability Nursing role identity in General Practice.
Additionally, it is important to preserve confidence and trust within students, practice assessors and supervisors to accommodate a productive learning environment and to remain resilient in challenging situations to ensure high quality care and delivery, particularly around the QOF.
As this was a pilot study, further research should be undertaken to explore assessment and supervision utilising the long arm approach within primary care settings and how the role of the Peripatetic Educator may encourage and support 3rd year nursing students to become more autonomous in running specialist clinics that that align with their nursing discipline.