This article explores how GPN educators can facilitate safe practice to allow student nurses to flourish in primary care as safe, and increasingly semi-autonomous practitioners. To promote students in semi-autonomous practice, this article explores educational theories and conceptual frameworks. The theories are linked to worked examples that have successfully been used in clinical practice.
There is a continued lack of clinical placements within primary care; successive policies have made some headway, for example, the GP Forward View and the GPN Ten Point Action Plan, both of which set priorities to increase placement capacity (NHSE 2016; NHSE 2017). The lack of placements may be caused by common misconceptions, such as perceptions that students will get in the way and hinder service delivery, the practice's knowledge on what they can, or cannot do, time pressures for assessment, and low tariffs in comparison to medical students. Corneck et al (2023) and Hawkes (2019) point out that students really value placements and the unique perspectives of healthcare on offer in primary care. There are other rationales as to why there is a lack of enthusiasm for student nurse placements; but one question GPNs should consider is, how can the GPN workforce develop placements to ensure they are positive for the learner and allow them to practise semi-autonomously. Increasing the numbers of registered nurses through the development of quality educational (placements) is a key demand within the National Health Service's (NHS) long-term plan (NHS 2019, V3.0) and within the NHS's workforce development plan (2023); this plan suggests that nursing positions in primary care should be increased by an additional 5400, by 2036/37.
GPNs are autonomous or semi-autonomous practitioners, functioning and working behind closed doors; but should we allow our pre-registration student nurses to see patients alone? Anecdotally, students observe and contribute to care on the fringes, never fully being allowed to explore autonomous practice, which is a requirement for year-three students (NMC 2018). Comparing primary care to secondary care placements, we should reflect that students may be left alone with patients, in a bay on a ward, or behind closed curtains, where personal and intimate care might be offered. We should reflect on our own experiences and the individual conversations that we had when we were students whilst working on busy wards. Those individual conversations were pivotal moments that facilitated unique opportunities for learning; we practised finding our own words, developed our own styles of communication and in those moments, we might have tested giving health care promotion, completed observations, or held the hand of a distressed patient. Surely, that curtain or bay in the hospital is the same thing as our closed offices and clinical spaces? Safe supervision of students is paramount, safe debriefing is absolutely essential, and safe learning and educational experiences are essential to running effective clinical environments. What is being described is an approach to education known as, ‘heutagogy’, which sits within the conceptual framework of experiential learning.
Heutagogy is an educational ideology that empowers the student to take control of their learning, with the support and guidance from supervisors; it fosters self-determination. Heutagogy in nursing is of particular importance because learners are often faced with unpredictable situations, and work at the limit of their current knowledge and competence (Bhoyrub et al. 2010). In autonomous practice, we must encourage the learner to practise decision-making. Froberg et al's (2017) qualitative study suggests that the pedagogy of students working autonomously with close, but not direct supervision, is valued by students, this sentiment was reiterated by Rolfe and Sampson-Fisher's (2002) literature review. In their review it was found that independent experiential learning is essential for personal growth and development. However, equally important to autonomy is the counter-perspective of safety, which can be achieved through the process of ‘in action’ guided reflection (Rolfe and Sampson-Fisher 2002).
The Nursing and Midwifery Council's (NMC) Standards of Student Supervision and Assessment (SSSA) do not explicitly state that students cannot practice autonomously; however, they stipulate that students must be allocated an assessor who has oversight of their practice; assessment should be provided at a level in line with the individual's stage of learning (NMC 2018). Students should be encouraged to be proactive in their learning; it would be important to recognise that the support and supervision required for a first-year student nurse would be greater than a student coming toward the end of their program. A student in:
The approach of increasing autonomy is in line with Benner's (1983) Novice to Expert model, in that, as skills and knowledge develop within clinical practice, this could lead to a reduction (but not complete withdrawal) of supervision. This can be further aligned against the General Practice Nurse Core Capabilities framework (Health Education England [HEE] 2022). The framework suggests that, as individual skills advance, the defining boundaries between roles and career advancement begin to blur, see Figure 1 (Health Education England [HEE] 2022). In the framework we could simply replace one of the stated registered nurse roles with, first, second, or third-year student. As a registered nurse, or as a student, it does not matter what stage of learning an individual is at, because each educational journey is unique and contains a continual blurring of boundaries; therefore, the need for support, development and education change overtime as, confidence, skill and capability increase.
A further concept to be introduced is Vygotsky's ‘zone of proximal development’ (cited in Cole et al. 1978) (see Figure 1). This concept allows a learner and an assessor to identify the self-stated tasks that can be done competently and independently by a learner; however, it also suggests that there is a window for development by using guided support and direction. The area of where guidance is needed can be seen as a potential for autonomy; it is this ‘potential’ that can be labelled as the ‘zone of proximal development’. This model is helpful, because it allow the GPN assessor and learner to identify current levels of competence and the next steps or focus that is needed for continued growth. Within the zone of proximal development, it would be crucial not to set targets beyond the capacity and capability of the learner, as this would have the potential to knock confidence, and may pose issues around patient safety and clinical governance.
There will always be a need to increase student nurse placements within primary care. It should be considered that the vast majority of patient contacts in the NHS are undertaken in primary care (Moulton, 2016). As GPNs, we need to highlight the work that we do; but how should GPNs allow students to practise and grow in our environments, in safe, but autonomous manners? Dewey (1897) famously discusses that the assimilation of knowledge occurs in real life situations, this is known as ‘experiential learning’. It can be argued that constantly and directly supervising our students is not real-life, and therefore, does not allow the student to find their inner voice. Constant supervision may give rise to the student deferring decisions, and so, they do not practise the decision-making skills that are needed by the registered practitioner. The next aspect of this article offers ideas and suggestions that the GPN can use to facilitate student semi-autonomous practice. It is crucial to remember that learning activities must be set uniquely for an individual after initial assessment. It would also be important to consider the year of study that the student is in and ensure that patient safety is maintained.
Students working semi-autonomously
The introduction and background have set out the value of allowing students to work autonomously through experiential learning. Discussed in the remainder of this article are conceptual frameworks and suggestions that could help supervisors and assessors facilitate this pedagogical approach. The suggestions are not definitive, but offer an opportunity for readers to reflect to develop personal practices as clinical educators.
Work-based assessments through ‘Entrustable Professional Activities (EPA)’
Entrustable Professional Activity (EPAs) is not a new concept, first introduced in approximately 2005, and is useful because they define a task and the discrete stages that must be achieved in order for autonomous practice to occur (Cate et al. 2015). The theory of the EPA aligns with Benner's (1984) Novice to Expert Approach, Vygotsky's Zone of Proximal Development (Vygotsky, cited in Cole et al. 1978) and Gagné's (1961) method of instructional design. Instructional design will be discussed later, but this theory defines tasks into explicit ordered instructions; each stage must be completed in the order stated (Gagné 1961). The purpose of using an EPA is to bring theory from the classroom into the clinical environment (Cate et al. 2015). there are five defined stages for autonomous practice (Cate and Sheele 2007):
Permission to practise and to supervise juniors, i.e. student-on-student supervision. For example, we might consider how a third-year student nurse coaches a first-year student on a particular topic or experience. This student-on-student approach to coaching and supervision is used in the Collaborative Learning in Practice (CLiP) model (Markowski et al. 2022). Williamson et al. (2023) found that when introducing the CLiP model into primary care it was welcomed positively; students of all stages valued the chance to hold their own clinics and practise ‘Enhanced ‘Responsibilities, and also, third-year students acting in the role of a ‘coach’ found they were able to practise, model and rehearse leadership skills. A question for the future is, could this model be considered more widely in primary care?
Entrustable Professional Activities (EPA): The EPA is split into three tables, each describing a different but supportive element. Tables 1, 2 and 3 describe an example of an EPA tool that was developed to support autonomous practice for learners completing an NHS Cardiovascular Disease Health Check. The EPA tool can be adapted to allow for local guidance, personal preferences and other clinical tasks.
| Title | NHS Cardiovascular Disease Health Check (routine care) |
| Specification and limitations |
|
| Required Experience, knowledge, skills, attitude and behaviour | Knowledge: |
| Assessment information sources to assess progression and ground a summative entrustment decision | Observation and assessed in 5 independent NHS health checks |
| Entrustment for which a level of supervision is to be reached at which stage of training | Indirect supervision at year 3 of pre-registration nurse training. |
| Level: NHS Health Cardiovascular Disease Checks | Stage of career |
| 1. Observe Only | Pre-Registration (Year 1,2 or 3)/Qualified Registered Nurse (RN) |
| 2. Act with direct supervision (supervisor or assessor directly present) | Pre-Registration (Year 1,2 or 3)/Qualified RN |
| 3. Act with indirect supervision (supervisor or assessor available on request) | Pre-Registration (Year 2 or 3)/Qualified RN |
| 4. Act with supervision not readily available (distant oversight) | Pre-Registration (Year 3)/Qualified RN |
| 5. Provide guidance to other learners | Qualified RN only |
| EPA: NHS Cardiovascular Disease Health checks | ||||||
|---|---|---|---|---|---|---|
| Assessment Date | Assessment Date | Assessment Date | Assessment Date | Assessment Date | Comments | |
| Observation and participation | ||||||
| Competency | Milestones and Dates | |||||
| Patient Care: Measurement of BP (automatic), Pulse rate/rhythm, height, weight and BMI | ||||||
| Patient Care: Point of care testing (Hba1c and lipids) or venous phlebotomy | ||||||
| Knowledge: Applies NICE guidance regarding BP (theory to practice) | ||||||
| Knowledge: QRISK3 and relative risk (theory to practice) | ||||||
| Interpersonal and communication skills: Can confidently communicate risk and findings | ||||||
| Referrals and limitations: recognising own limitations and refers appropriately | ||||||
| Systems: Can record data | ||||||
The EPA begins with Table 1, the ‘Specification’. The specification outlines the clinical task to be performed, limitations, knowledge and the assessment process. Table 2 outlines the framework and stages of supervision and the person specification; these are benchmarked against the learner's stage of development. Finally, Table 3 demonstrates the clinical assessment and the ‘sign-off’ process.
Structure of the Observed Learning Outcome (SOLO)
This concept sits comfortably with the theory of constructive alignment; this ideology uses constructivism to produce social learning activities that enhance the learner's ability to assimilate meaning (Biggs 1996). A key concept within constructivism is that students are encouraged to view concepts from their unique and individual perspective, so there is an expectation that ‘errors’ in practice must be seen as an opportunity for reflection (Biggs 1996). The concept of constructive alignment is therefore associated with autonomous work, providing that patient safety can be maintained. The conceptual approach of the ‘Structure of the Observed Learning Outcome (SOLO)’ agrees with constructivist theory and suggests that a learner's development is enhanced through autonomy. Autonomous practice increases the acquisition of skills with a goal of achieving mastery (Biggs and Collis 1982, cited in Biggs 1996). It is suggested that there are five levels of ‘mastery’:
To use SOLO in practice, we could look at how medical student education facilitates safe, but some autonomous practice. Undergraduate medical programmes are written with the expectation that students consult and learn from (and with) real patients. Students might be expected to consult, in groups, alone or under direct supervision, this might be achieved in various guises. Some examples of techniques include, observed clinical consultations to support mastery, fishbowl exercises, interviews with patients, recorded and then reviewed consultations, or direct observation of performed skills. These approaches could be used to facilitate student nurse education.
One option to explore is how we could use our trusted and reliable patients who are living with long-term conditions. Patients could be approached and asked if they would mind talking to the junior semi-autonomous student about their health, their long-term condition, their coping strategies, the impact of the disease on their personal, social and mental health wellbeing, as well as, discussing their social situation and support networks. The patients would need to be instructed that this exercise is a learning experience, and therefore be aware that it would not be appropriate to raise new clinical problems. Students could be provided with templates of questions or coached to create their own questions that follows the biopsychosocial model. It would be important to reflect that students with greater clinical experience and knowledge may feel more confident with an exercise like this and be able to assimilate meaning more easily. The final element of this work could encourage the student to use their clinical assessment, knowledge of the patient and the patient medical records, and formulate a plan of care. The plan could benchmark current standards of care (against national and local guidance) and include items such as, screening, routine review, routine bloods, signposting to voluntary services, and quality and outcomes framework targets. This manner of work might be considered as a project, taking weeks for the student to complete; the student would need to get to know the patient, read and digest multiple strands of guidance, and consider how the guidance and current care impacts the patient from a holistic stance. Learners would need to be closely supervised and directed through a project of this nature. It would also be recommended that a GPN contact any patient after any student assessment, to offer the opportunity and space for the patient to discuss any problems encountered. The student should be encouraged to write-up the project and present their findings to the assessor or peers. Finally, the learner could be benchmarked against a ‘SOLO’ structure demonstrated in Table 4.
| Prestructural | The student fails to demonstrate evidence of effective communication, with no clear documentation of the patients' medical problems, issues, complications, plans or goals. There is no evidence nor consideration that local or national guidance around disease control or monitoring has been reviewed. The care plan lacks structure from the patient and medical perspective. |
| Unistructural | The student has used some (but minimal) evidence of the patient's needs or challenges (as above) and has demonstrated minimal review of the literature. The care plan is segregated and disjointed but does contain increasing evidence of effective communication. |
| Multistructural | The student has collected information from the patient and documented this, they have also reviewed the current literature for one or more of the patient's long-term condition(s), but there is a failure in linking patient needs to the guidance. |
| Relational | The student has collected a good history from the patient and has started to understand their needs, medical conditions, plans and goals. They have reviewed the guidance and are able to link and demonstrate this in a holistic and patient-centred care plan, then considers the variables that might arise alongside the patient's personal preferences. They would have also considered what might happen when things are deteriorating. |
| Extended Abstract | The student demonstrates the relational standard but in addition is able to link multiple long-term conditions together as a whole, whilst prioritising the patient's needs. The student is able to demonstrate clear thought processes as the patient's needs and goals adjust to arising challenges. They would have considered and planned for periods of deterioration and is able to apply the theory of care planning to multiple situations. |
Task Analysis
The final concept for discussion is Gagné's (1961) Instructional Design and Task Analysis. Gagné suggests that when learning a task, it could be helpful to consider the task as a defined set of ordered logical steps. Some steps within a logical sequence might be seen as ‘conditional’, i.e, the outcome of one step in a sequence needs to be understood, processed and acted upon, before progressing to the next step. It is imperative that the learner understands and is able to act appropriately on any conditional step. Table 5, demonstrates Task Analysis in action, the task is a sequence of steps that a second-year medical student needed to perform to become autonomous in the administration of an annual influenza vaccine. The table may not have exhaustive steps, but it is demonstrated to guide and prompt reflection.
| Task | Conditional procedure | Learning Objective |
|---|---|---|
| Check vaccine storage and fridge temperatures – current, maximum and minimum temperatures. Reset thermometers and record findings. If stored to the desired standards proceed, if not consult with senior nurse | Yes | Intellectual and cognitive – applying knowledge regarding fridges and vaccine storage, also decision making if temperature range or storage is out of the given criteria |
| Call patient into the clinical room | Communicating | |
| Introductions | Communicating | |
| Ask the patient to sit and to prepare | Communicating | |
| Discuss the purpose of the flu vaccine and answer any questions | Communicating, Intellectual and cognitive – the student will have to draw on knowledge and may have to answer unprepared questions and use decision-making skills | |
| Complete the vaccination checklist | Yes | Communicating and cognitive – the student will need to use decision-making skills by deciding if it is appropriate and safe to proceed |
| Discuss side effects of the vaccine | Intellectual and communication – the student will need to draw on their knowledge on how vaccines work within the human body | |
| Remove the appropriate vaccine from the fridge | Intellectual (vaccine choice) | |
| Wash hands or use alcohol gel | Motor – demonstrates effective infection control procedures | |
| Put gloves on | Motor | |
| Ask the patient which arm they would like the vaccine and ask them to expose their upper arm | Communicating | |
| Locate the central deltoid region | Motor | |
| Remove the safety cap | Motor | |
| Administer the vaccine | Motor – able to administer the vaccine smoothly and safely | |
| Cover injection site with cotton wool | Motor | |
| Place used sharp into the sharps bin | Motor | |
| Offer a plaster or alternative if allergic | Yes | Motor, cognitive and intellectual – the student will need to ask about allergies and decide on fixings |
| Invite the patient to get dressed | Communicating | |
| Say goodbye and repeat on side effects and aftercare | Intellectual and communicating | |
| Record on the patient's records, batch number, expiry date and site | Intellectual and communicating | |
| Feedback | Cognitive and communicating – accepting and assimilating feedback | |
| Repeat stages 1 – 22 for the next patient | Intellectual |
Conclusion
This article has explored how educational concepts and theory can be used to facilitate semi-autonomous practice. This article was written after the author completed the final assessment of a first year, first-placement student. Within the student's final assessment, it was suggested (and documented) that she needed to find her inner voice, see some patients alone, write some notes by herself (with a registered nurse at hand to check, and correct her work). On catching up with the student several weeks later whilst she was on her next clinical placement, she said, ‘oh they don't let me do anything, I sit in the corner and watch’. The new assessor even stated that the suggests of having some autonomous practise was ‘maverick’, the new assessor stated, ‘we play by the rules here’. The discussions in this article are not maverick, they might be seen as progressive for nursing placements in Primary care; but the concepts are an attempt to allow students to find their inner voices, in safe and supported environments. Of course, patients, learners, clinicians, and services need to be protected and kept safe, but demonstrated are models that have successfully been used in practice; these models facilitate, structure for the learner, structure for the assessor and structure for assessment. The tables included are not exhaustive, but it is hoped that they will facilitate creative thinking. There will be other models and concepts available to help learners increase their autonomy; our job as GPN educators is, to support and develop the next generation of autonomous registered practitioners. We must remember that by a student's third year, they should be practising with minimal supervision; we just need to ensure that this can be facilitated safely and that we always showcase our profession and work in a positive rewarding manner.