Driven by the NHS Long Term Plan (NHS, 2019), the landscape of primary care is changing. The plan further cements the philosophy of primary care at scale. Contractually the ‘at scale’ philosophy is to be achieved through primary care networks (PCNs), which are multiple neighbouring practices working together to achieve population-based care, serving 30 000–50 000 individuals (British Medical Association (BMA), 2019). Alongside this, the Nursing and Midwifery Council (NMC) have updated their educational standards with the publication of Realising Professionalism (2018a; 2018b). These standards see the end of the ‘mentor’ role (NMC, 2008) and introduce practice supervisors, practice assessors and academic assessors (NMC, 2018a). These two drivers could potentially change the context of how learners in general practice are allocated to placements, supervised, and assessed. This article examines how these drivers could impact on the creation of effective learning environments, while exploring the concept of the ‘community of practice’. Could the creation of PCNs offer greater access and ease of placements for local Higher Education Institutions (HEIs) and could PCNs provide greater opportunities to increase the variety of learning environments for the students? But who or what is responsible for this? The simple answer is every single registered nurse, because nurses are all duty bound by the professional code and are therefore responsible for the development and growth of the profession (NMC, 2015).
Communities of practice
Dewey (1897) strongly advocates the idea that learning occurs when individuals are immersed in participation (‘situated learning’) and this is at the heart of Lave and Wenger's (1991) work and analysis of the community of practice. A community of practice can be described as a team of interested, engaged and motivated individuals, all with a similar ethos, who possess a clear aim to share their specialist knowledge. Wenger (1998) described three key elements that are needed to align the community of practice to its core members:
- Mutual engagement
- Joint enterprise
- Shared repertoire.
When a learner—a new junior staff member—joins an established team, they very much sit on the periphery of the network but, over time as they gain confidence and understanding of the tasks and knowledge at hand, they slowly participate at increasing levels, until full immersion in the team is reached, and full participation is achieved (Lave and Wenger, 1991). This very much fits with the novice to mastery ethos of gaining skills over time and through participation, moving from a beginner to an expert (Dreyfus and Dreyfus, 1980). This ethos is something that all learners go through. The theory of creating social networks and learning in social group situations also echoes the social educational theories of the cognitive apprentice and situated learning, where a learner is able to practice their skills in safe environments (Quay, 2003; Woolley and Jarvis, 2007). Lave and Wenger's (1991) model of the community of practice fits very well with the close-knit team (ie individual GP practices), where staff members of a practice are visible to each other on a daily basis. However, if this model is to be scaled up to fit the PCN, it would be essential to consider how multiple nursing teams from neighbouring practices, with their own particular ethos, work ethics and needs, are addressed. From a nursing perspective it is important to consider who will drive this. The theory of the community of practice with several practices mobilising to create a joint educational network could have positive impacts for practice nursing teams.
‘Enabling practice nurses to form broader communities could unshackle this isolation, enable knowledge sharing, knowledge growth and the spread of tacit information.’
The positive stance of the community of practice needs to be counterbalanced and the potential pitfalls need to be discussed, because what is being suggested is the development of a new community of practice that brings new primary care staff together from different GP practices. Pyrko et al (2017) discuss the theory of ‘thinking together’, and how, without this, there cannot truly be a community of practice. In this interpretation, the community has to think and comfortably challenge its members, while maintaining communications, relationships, and working on the mutual engagement as discussed by Wenger (1998). This stance is further backed by Li et al's (2009) literature review, which concluded that simply labelling an environment as a community of practice does not actually constitute one. There is also a note of caution with communities of practice from Levine and Marcus (2010), who suggest that working in a collaborative environment could strip individuals of personal autonomy and creativity. Finally, Wenger et al (2002) also discussed how some communities could hoard knowledge and incarcerate its members, which could stifle innovative thought and the spread of tacit knowledge. From the described perspectives it is clear that careful consideration is needed. The landscape of primary care is being shaped by national policy, which contractually enforces, through financial arrangements, collaborative working; therefore, the ‘thinking together’ is novel and somewhat imposed. The enforced community of practice could be at risk of mistrust and failure (Pyrko et al, 2017).
The community of practice on an at-scale level has positives and negatives but, as networks are developed, how can nurses realistically use what is being enforced to their benefit?
Hub and spoke placements
The NMC (2011) advocated the idea that placement providers could be imaginative in identifying new situated learning opportunities. In addition to this, the NMC (2018a) stipulated that learners need an active leader on placements who can safely and adequately coordinate opportunities in the educational setting. Allowing for the implementation of this framework, placement providers can be creative as long as the students are able to meet the ‘standards of proficiency’ (NMC, 2018b:10; 2018c). A loose model that might be applicable to the formation of the community of practice imbedded in the PCN is the hub and spoke model. There are various forms of hub and spoke models. Roxburgh et al (2012) describe three models:
- The service centred model
- The first-year approach model
- The whole programme approach model.
The model that could be most appropriate in the PCN community is ‘the service centred’ model. In this model, the student is allocated to the service, and spoke placements are provided that follow patient journeys. Applying this to the PCN, the PCN acts as the hub which can then decide how to spoke the student out to the varying micro-environments (individual GP practices) or other environments and services to maximise learning opportunities. This model could potentially enable a deeper holistic stance, by allowing students to experience the total patient journey rather than fragmented aspects. This may be enhanced further as more services move into primary care from secondary care providers. In Roxburgh et al's (2012) and Roxburgh's (2014) studies, it was found that the hub and spoke type placements were positive for learners, allowing them to take charge of their learning, while reducing anxiety and gaining a better understanding of the patient journey. The hub and spoke model that is being presented by Roxburgh (2012; 2014) is not directly transferable to the PCN, so further work and research on understanding the student experience would be needed.
Standards for student supervision and assessment
The new educational roles, as described by the standards for student supervision and assessment (SSSA) (NMC, 2018b), allow those that have not obtained the mentor qualification to have a formalised role in clinical education. It must be noted that research into how successful these standards are is not available to date. One thing that could be considered positive from a primary care point of view, is that the SSSA standards remove the need for lengthy mentorship modules in HEIs, which anecdotally have been a barrier to mentorship and placement capacity in primary care (Heath, 2019). The next few years may be a perfect opportunity to expand the work of the General Practice Nurse 10-point plan (NHS England, 2017) to increase student nurses accessing placements in primary care (Heath, 2019).
Discussion: the potential
Wenger et al (2002) describe how an emerging community moves through five phases:
- Potential
- Coalescing
- Maturing
- Stewardship
- Transformation.
The ‘at scale’ community of practice in the primary care network cannot be restricted to the nursing profession and must include all members of the multidisciplinary team
The PCN community of practice is very much at the potential stage (the merger of individual GP practices into one ‘at scale’ organisation with multiple individual practices providing services under one shared contract). As suggested by Risling and Ferguson (2013), through the development of social networks (mutual engagement) by those with a shared repertoire, there is a real opportunity to expand a learner's exposure to primary care while increasing placement capacity. Individual GP practices are naturally a close-knit team, comprised of numerous multidisciplinary members who all tell each other clinical stories, creating narratives which develop tacit knowledge and identity; which ultimately improves validity and core knowledge (Soubhi et al, 2010). Applying this theory of mutual engagement is not a challenge when considering individual GP practices. Scaling this up to fit a number of GP practices and exposing the teams through increasing social networks could offer new learning environments with greater learning experiences, opportunities and resources, but it has to be recognised that this could be problematic. When scaling up the PCN community, one might need to consider the impact of individual practitioners in the community. Communities are made up of individuals, all with their own competing personalities, cognitive function, needs and demands. As suggested by Fuller et al (2005), consideration of how new members are accepted into a team needs to be addressed. Ultimately, members will challenge the fundamental working and possibly the ethos of the team and the community, which increases its shared and tacit knowledge. One of the benefits of communities of practice is that they enable clinicians to break out of isolative roles (Pyrko et al, 2017). This is extremely important for the practice nurse workforce, because practice nurses are often working in very small nursing teams, frequently in isolation and often without a voice. Enabling practice nurses to form broader communities could unshackle this isolation, enable knowledge sharing, knowledge growth and the spread of tacit information.
The ‘at scale’ community of practice in the PCN cannot be restricted to the nursing profession and must include all members of the multidisciplinary team. This is backed by Fuller et al's (2005) analysis of two case studies; they suggest that learners in any community need individual exposure to multiple learning events, to give a rounded view of the community as a whole. This is important because, to understand the PCN as a whole unit and its operation, learners will need to experience all the various positions and roles that are situated in the community, for example medical, allied health care professionals, management, administrative and reception.
There is a problem with what is being suggested, and that is leadership. In her qualitative grounded theory study, Sayer (2014) strongly agrees with previous work by numerous authors that practice teachers will add significant value to any formed or forming community of practice. Adequate structure to support learners in collaborative learning is also backed by Levine and Marcus (2010), who suggest that leaders should offer support to community members by allowing and facilitating engagement in analysis of their own personal pedagogies, management and relationships. To translate this to the PCN learning environment: members of the community need to be supported to analyse the learning opportunities, the relationships that the community has with learners, and the relationships with other members of the network. In Grealish et al's (2010) qualitative study of students' experience in residential care, it was found that students bring new wealth and knowledge into the community of practice by challenging and developing the status quo. They also found that students bring an investment toward the future development of services. Although not directly translatable to primary care and the development of learning networks in the PCN, the evidence identified points to the value of nurse leadership and to the value of students in practice itself. Nurse educational leadership in the PCN therefore has to be recommended because someone needs to provide leadership to manage learners and their experiences, but leadership to manage the practice supervisors and practice assessors to ensure they are challenged to enable development is also necessary. Alongside these points, leadership is needed to develop the learning environment while showcasing the PCN as a positive learning and employment environment. Ultimately with strong nursing leadership, learners could be allocated to the PCN rather than individual GP practices. Although leadership is being advocated there is an issue with the current proposed structure of the PCN; what is on offer has neglected the nursing workforce by not explicitly suggesting that nursing leadership is vital in the clinical structure and clinical management of the PCN. However, because something is not stipulated, it does not mean it cannot be done; there are numerous nurse clinical directors of PCNs in appointment across the country.
Given the multiple challenges that newly established PCNs may encounter, it has to be recommended that each PCN should identify an educational lead for nursing and nursing development as a priority, but the NHS has failed to recognise this and the vital work the profession does in primary care. Strong nursing leadership could enable appropriate direction to the organisations' placements, the community itself and offer support to all nurses whether they are or are not practice assessors or practice supervisors in the network.
Conclusion
This article has explored a fraction of the literature surrounding communities of practice in relationship to the everchanging landscape of primary care, alongside the introduction of the NMC (2018a-c) Realising Professionalism. The introduction of the enforced community without mutual engagement and ‘thinking together’ could pose a threat to the development of the emerging communities. However, through visible nursing leadership, collaborative working and commencement of the new educational standards, the community of practice with the PCN could be fruitful, allowing innovative and imaginative ways of developing student nurse placements while promoting the evolution of creative learning environments. The current raft of changes will be challenging but exciting and may help forward the role, standing and visibility of the practice nurse. The nursing profession needs to lead some of this work, understand the networks, political will and guidance that influences the contracts and business models.
The practice nurse must continue to evolve; we must voice how valuable we are, we must forge our own networks for our personal growth and development, and we must embrace these changes that are coming our way. Without accepting students in our communities our profession is surely in danger of becoming stifled, especially as the current practice nurse workforce ages and retires. Only we can bring new blood into our profession, only we can train the next generation and only we can develop the scope of our practices. It has been said before: ‘lets stop being done to, lets find our voice and lets develop our profession and lets start leading’ (Heath, 2019).
KEY POINTS
- Primary care networks could enable student nurse placements in greater numbers, thus increasing capacity
- Collaborative working with our peers from differing GP practices may enable us to break free from our isolatative modes of working
- Working together as a network for student nurse places may lesson the burden, increase the educational benefit, spread local tacit knowledge and identify our future nursing leaders
- Student nurse placements in primary care should involve the whole primary care community: GPs, allied health care professionals, back office support teams and others