Next steps for student supervision and assessment

In 2018, the Nursing and Midwifery Council (NMC) released its updated educational standards that will see the abolition of mentorship as we know it today. Mentorship, in its current guise, will slowly be faded out from September 2019, and mentors will be replaced with practice supervisors and practice assessors (NMC, 2018a-d). This article will ask what this means for our current mentors and how it will affect general practice nurses who may want to get involved in student education. It will also consider pre-registration placements in light of the NHS Long Term Plan (NHS, 2019) and the development of Primary Care Networks (PCNs).

The NMC are driving these changes and the 2018 standards relinquish some of the rigid controls of the NMC (2008) Standards for Learning in Practice (SLAIP), placing the development of pre-registration programmes securely with the Higher Education Institutions (HEIs) and placement providers. Key to the 2018 Releasing Professionalism standards are four documents (NMC 2018a; 2018b; 2018c; 2018d):

• Standards framework for nursing and midwifery education (NMC, 2018a)
• Standards for student supervision and assessment (SSSA) (NMC, 2018b)
• Standards for pre-registration nursing programmes (NMC, 2018c)
• Future nurse: Standards of proficiency for registered nurses (NMC, 2018d).

Current supervision and assessment

Point nine of The Code states:

‘Share your skills, knowledge and experience for the benefit of people receiving care and your colleagues.’

(NMC, 2015)

This clearly means that all registered nurses—including practice nurses—are expected to support learners, junior colleagues and the future nursing workforce. Therefore, we are responsible for creating appropriate learning opportunities and educational environments to support learning in clinical practice. If nurses do not support each other, as well as their learners in clinical practice, there is a risk of stagnation within an existing team (Wenger, 1998). Alongside this, there is a real danger that we, as professionals, neglect career succession planning, which will ultimately impact negatively on recruitment and possibly retention. However, and most importantly, the wonderful insightful and creative work that practice nurses perform in primary care would not be promoted outside of our existing networks.

There has been tremendous work over the past few years since the publication of the General Practice Nurse 10 Point Development Plan to increase student nurse placements, but there is so much more that could and should be done (NHS England, 2017). Accepting students in your workplace creates and develops the workforce, stimulates learning and fosters ongoing development (Grealish et al, 2010). Students are a wonderful source of inspiration and will bring with them new ideas while contributing to the evolution of our services, profession and professionalism (Grealish et al, 2010).

The NMC standards have addressed some of the problematic issues with the facilitation and mentorship of learners. First and foremost, mentorship training was arduous, often based in HEIs and required the writing of academic essays. A triennial review was required, and both of these demands could have been demotivating and off-putting for some practice nurses. Alongside these requirements, students needed to spend 40% of their time with the allocated mentor, and there was a need for sign-off mentorship during the final management or destination placement (NMC, 2008). Sign-off was supposed to address ‘failing to fail’, but it could be argued that this should have been addressed much earlier in the students' educational journey; however, as discussed by Duffy (2003), failing students is multifactorial: lack of skills and training; the differing agendas between the university and clinical setting; passing the responsibility to the next mentor; and experience and confidence in the mentor's decisions.

The 2018 standards are not so rigid. Once implemented, mentorship and sign-off mentorship in this form will no longer be required.

The new standards

The SSSA (NMC, 2018b) potentially offers opportunities for learners, placements and registered professionals who want to become involved with teaching and learning in clinical practice. The governance and training structures are far less rigid, and for practice nurses, the standards could help shape ‘at scale’ working that the new PCNs require. Working at scale could assist practice nurses in coming out of isolation within their roles (Pyrko et al, 2017) and create an ‘at scale’ community of practice (Lave and Wenger, 1991). Lave and Wenger (1991) describe a community of practice as being made up of individuals who share a common interest and a common goal. It could be said that, as a profession, practice nurses certainly have this common thread. A community of practice needs the three following factors (Wenger, 1998):

• Mutual engagement
• A joint enterprise
• A shared repertoire.

From our profession's perspective, this ethos could easily be adapted for the purposes of ‘at scale’ pre-registration student nurse places. Imagine a world where general practices within the PCNs are audited as a group and students are allocated to the PCN rather than individual practices. This could share the load, share the burden and spread the wonderful learning and challenges that student nurses bring with them, while increasing support and relationships with nurses from within the community.

The SSSA could facilitate this. From the first placement, students need to have both a named practice supervisor and practice assessor for each placement, so immediately practice nurses would be working in less isolative ways. It is important to note that the practice supervisor and practice assessor cannot be the same person. In primary care, this could be a potential issue, but as ties with local neighbouring practices strengthen, there may be an opportunity to share staff and resources. The new standards could support an environment not only where students are allocated to the PCN, but the practice assessors could be borrowed from within the PCN to complete the student assessments as required.

We have a duty to ourselves, our profession and our patients to grow and develop the future generation of nurses

There are no reasons (except being newly qualified) as to why 100% of registered practice nurses could and should not be practice supervisors. We have a duty to ourselves, our profession and our patients to grow and develop the future generation of nurses. Practice nurses must develop our profession, and in doing so find our voices as leaders, advancers and promoters of primary care.

Supervisors and assessors

The SSSA (NMC, 2018b) splits the role of the supervisor and assessor into three positions (Table 1).

• Practice supervisor: this person will be any registered nurse or any other registered health professional (for example GPs, dieticians, physiotherapists, pharmacists and nursing associates) who has undertaken the required training. This person acts as the guide, the facilitator of the placement and the clinical friend. They will ensure that the student is settled in the placement and progresses by allowing exposure to the real-life clinically situated work that we do in our clinics. Alongside this, they will help the student develop their learning outcomes, including the initial assessment and formative assessments, as well as contribute to the mid-point assessments. They will work very closely with the practice assessor, reporting achievements, concerns and work collaboratively on action plans if these are needed. The practice supervisor will not complete the summative assessment
• Practice assessor: this person has to be a first level registered nurse who has undertaken the required training. Their key role is to assess the student summatively. They will need to work with the student, signing off the initial learning outcomes, and they will work with the practice supervisor on the mid-point assessment and complete the final assessment. It will be the practice assessor who countersigns the proficiencies (formally known as competencies), and signs-off the episode of care and the professional values. Ultimately, it will be this person that passes or, in some cases, fails the student on their placement. They will work and liaise closely with the academic assessor who will offer support to the practice assessor and the student, constructing action plans if needed. It is vital that if a student is struggling, prompt liaison with the academic assessor is recommended
• Academic assessor: this person will be a registered nurse but will have links back to a HEI, therefore they could be a link lecturer, practice tutor or another member of the HEI team. This person will liaise with the practice assessor regarding the student's professional ability and competence in the clinical domain, while ensuring that the student is achieving academically. They will support the practice assessor with the struggling student and help develop action plans. They will pass or fail the student in the section or year of the students' programme—this allows or stops the student progressing. This role has been developed to address ‘failing to fail’ by the early identification of the students who do not meet the clinical competence or professional standards to be on our NMC register.

It must be noted that failing requires very early intervention from the academic assessor, and it is the responsibility of the practice assessor to make that contact. Failing a student is stressful for any assessor and getting the right support, for themselves and the student, should make this process easier (Duffy, 2003).

On placements, the role of the practice assessor and practice supervisor cannot be the same person—splitting the role of placement facilitator and assessor. The academic assessor can be the same person in years 1 and 3, but in year 2 the student needs a different assessor.

Current mentors and sign-off mentors

Across the UK, HEIs and secondary providers will all offer different opportunities to convert its current mentors into practice supervisors and assessors. If you are a mentor and are on the local mentor register, all you need to do is attend your annual mentor update—this will convert you to a practice supervisor and practice assessor. Some regions will have online tools, they may be running conversion study sessions through the local secondary care systems, some will offer conversion through the HEIs, and some will offer a combination of these options. Conversion is not arduous and it mainly constitutes of making sure that, as a supervisor or assessor, you understand the new roles and responsibilities (Pan London Practice Learning Group (PLPLG), 2019). Following conversion, it will be recommended that the locality which holds the current mentor register is informed.

As a previous mentor (following conversion) you will be able to perform either the supervisor or assessor role, you could also consider assessing other learners who are not based or placed within your practice (i.e. they could be placed within the PCN). This may help develop and encourage a less isolative workforce and develop the community of practice as previously discussed.

Training for new practice supervisors and assessors

Under the SSSA (NMC, 2018b), the initial training is far less arduous but it formalises what already happens in many learning environments—multiple team members may already be involved in the facilitation of a student's learning on placements. It must be noted that differing regions of the country may offer alternative arrangements for new supervisor and assessor training.

Practice supervisor

The requirements for this role are an e-learning package plus a half day's face-to-face interactive study session. If this training is completed, you can only practice as a practice supervisor. There may be a requirement in some organisations that to fulfil this role you need to have been qualified for a minimum of 6 months.

Practice assessor

The requirements for this role are an e-learning package plus a whole day's face-to-face interactive study session. If this training is completed you can act as both a practice supervisor and a practice assessor.

Academic assessor

The recommendations for this will be set by local HEIs. In all of the roles, annual updates are advisable. Triennial reviews are no longer required, but it would be expected that anyone who is an Assessor or Supervisor discuss this aspect of their duties in annual appraisals and in the triennial revalidation.

Future Nurse

The final piece of the new education standards are the Future Nurse standards (NMC, 2018d). They are the final piece because they lay out the standards for the proficiency of the next generation of nurses. In practice, the new assessors and supervisors will be assessing new and evolving skills, possibly skills that were considered the domain of the qualified nurse. Nurses in 3 years' time will have greater proficiencies than those currently practising. The standards cover seven core areas:

• Being an accountable professional: delivering person-centred care that is delivered by health professionals safely and compassionately. They will be lifelong learners who use critical reflection to aid their personal growth and development
• Promoting health and preventing ill health: delivering care that enables patients to make informed decisions about their care while enhancing quality of life. They will work with all health agencies to promote health and prevent ill health, while reducing health inequalities in the populations they serve
• Assessing needs and planning care: delivering care to patients no matter their mental, physical, cognitive, behavioural, social and spiritual needs. They are able to prioritise patient needs and care while working collaboratively with the patient, other services and agencies
• Providing and evaluating care: delivering evidence-based care while ensuring that delegated care is evaluated, safe and ultimately person-centred
• Leading and managing nursing care and working in teams: leading and managing case loads and teams of nurses, while ensuring quality and evaluating care that is delegated
• Improving safety and quality of care: delivering and contributing to the on-going monitoring of care to improve health outcomes
• Coordinating care: delivering coordinated care to those with the most complex needs. They are able to contribute to service design and redesign through a global awareness of local and national drivers.

These core standards must be applied to the four fields of nursing (general, mental health, learning disability and children). The Future Nurse must be able to meet these standards in all of these fields and must be able to holistically treat people at any stage of their life who have a range of needs (NMC, 2018d). In practice, this will mean that practice nurses may see children's nurses, learning disability nurses and mental health nurses being placed in primary care. When this is embraced, it may develop our own knowledge as information from the other nursing disciplines is shared.

‘In practice, the new assessors and supervisors will be assessing new and evolving skills, possibly skills that were considered the domain of the qualified nurse’

In addition to these seven standards and the proficiencies that are contained in them, student nurses will also have a raft of clinical skills to meet. It is beyond the scope of this article to analyse these in detail, but to name a few and to demonstrate the level of the proficiency of the Future Nurse, they must:

• Undertake venepuncture and cannulation
• Be able to interpret blood gases and electrocardiograms
• Manage infusion pumps
• Undertake whole body systems assessments
• Undertake chest auscultation
• Administer basic mental health first aid
• Manage the administration of intravenous fluids
• Manage and monitor effectiveness of symptom relief medication, infusion pumps and other devices
• Understand and apply ‘do not attempt cardiopulmonary resuscitation’ decisions
• Administer injections using intramuscular, subcutaneous, intradermal and intravenous routes and injection equipment.

Future Nurses will be highly trained with a greater capacity to deliver, interpret, monitor and evaluate care. We need to embrace them, nurture them and develop them and as nurses and we need to show them the currently hidden, exciting and varied world of primary care.

Conclusion

The 2018 NMC education standards could and should be a real opportunity to increase the number of practice nurse supervisors and assessors who can support student nurses in clinical practice. The standards remove some of the barriers that the previous standards had put in place for the nursing profession.

Alongside these standards, primary care is in a position of rapid change with the development of PCNs and ‘at scale’ working. There is an opportunity for the practice nurse profession to capitalise on this and create exciting learning environments, not only for our students, but also for us as we work ever closer together and step away from our previous isolated methods of working. Practice nurses could develop excellent and sustainable communities of practices for ourselves, our learners and our colleagues.

We have to embrace student nurses and we have to accept, adopt and contribute to the development of PCNs; we should not allow our GP colleagues to dictate how we work. It is time the practice nursing profession took charge of its own destiny.

KEY POINTS

• All nurses are responsible for the training, development and progression of our profession
• The term mentor and sign-off mentor will no longer be used
• All practice nurses have the ability (after basic training) to support students as practice supervisors
• Current mentors, after completing a simple conversion course, can act as a practice assessor or a practice supervisor
• Sign-off mentoring has been removed and an academic assessor has been introduced. This is hoped to support assessors and supervisors in failing struggling and under-performing students