The shortage of healthcare staff in the NHS is widely acknowledged. General practice nurses (GPNs) are a vital part of the primary healthcare system. A review published in June 2022 by the Health Foundation’s REAL Centre (Shembavnekar et al, 2022) warns that without urgent policy action, the NHS in England could face a shortage of between 6400 and 10100 full-time equivalent (FTE) GPNs by 2030/31. It is, therefore, essential that we work together to retain existing nurses, and attract new ones into general practice.
One way of attracting new nurses to general practice is through education programmes. Most nursing degrees do not provide enough primary care experience to students. In a 2015 Queen’s Nursing Institute (QNI) survey, only 22% of respondents had observed a GPN during a pre-registration placement (QNI, 2015). The QNI (2015) survey also observed that only 27% of general practices offer placements to undergraduate student nurses, compared to 61.5% offering placements to undergraduate medical students. If we are to recruit new nurses to general practices, it is imperative that their pre-registration education programmes provide exposure to the role.
Placement barriers
Organisational barriers
Health Education England’s (HEE) General Practice Nursing Workforce Development Plan outlined some of the challenges GP surgeries face when supporting student nurses (HEE, 2017):
- GP surgeries claim that they do not receive sufficient remuneration for student nurse placements, although the tariff has been reviewed recently. When funds are available, they are not nearly enough to compensate for the GPN’s time spent supervising the student. This is in contrast to the £350 weekly tariff GP educators receive for each medical student placement
- The intensity of workload currently being experienced in general practice is not conducive to providing a high quality learning environment for a student. GPNs find it difficult to adhere to the tight schedule of their clinics while also providing sufficient supervision and support
- As general practice placements are relatively scarce for nurses, there is little evidence on the outcomes. This makes it difficult to create a robust rationale for general practices to host student nurses.
Challenges general practice nurses face
For a GPN, student supervision is not a task embedded in their role. A 2014 study by Bennet and McGowan highlighted that many mentors felt that mentoring ‘was a new responsibility for which they lacked experience’. Some mentors stated that they didn’t feel adequately prepared ‘to effectively assess students in practice’ (Bennett and McGowan, 2014).
Andrews and Wallis (1999) showed that mentors who had taken shorter-form mentoring courses did not feel as prepared to mentor students compared to those who had taken longer, more formal courses (like the ENB 998 qualification). Andrews and Wallis (1999) also showed that while mentors viewed mentorship as a positive activity, they found they were stuck in a ‘role conflict’, without enough time to ‘achieve optimum mentor supervision’.
Challenges students face
Brand (2020) outlines issues student nurses may face while on placement in general practice. For those who are on their first placement, it is obviously a time ‘of high emotions’, where ‘expectations and anxiety levels may be high’.
Students may also feel neglected if their assigned mentor is too busy with other responsibilities, which is often the case in the busy and unpredictable world of GP surgeries. This often leaves the student with little time to see their mentor and complete mandatory documentation and interviews, and the nurse with little time to deliver high-quality education.
The contrast between the structured learning environment students are used to at university and the intense activity of general practice can be stressful; students noted that ‘learning opportunities in practice occur often without notice, and that they felt they had to be in the right place at the right time’ (Brand, 2020).
For the purposes of this article, the ‘mentor’ role referenced in older literature refers to the ‘practice supervisor’ and ‘practice assessor’ roles introduced in the Nursing and Midwifery Council’s (NMC’s) Standards for Student Supervision and Assessment (SSSA) programme (NMC, 2018).
Local placement challenges
South East London Training Hub (SELTH) is committed to supporting workforce planning and retention, and student nurse GP placements are part of this offer. Placements are an opportunity to expose student nurses to a potential future career option. A survey sent to practice managers and GPNs in South East London, inviting them to identify specific barriers in hosting student nurses, provided the data shown in Table 1 and Table 2. Table 1 shows the results from 250 responses from practice managers and Table 2 shows the results from the 144 responses from practice nurses.
Table 1. Barriers to hosting student nurses: managers’ perspective
| Reason for not taking students | Number of managers for whom this was a reason |
|---|---|
| The tariff being only £70 per week | 11 |
| Not enough time available to support students | 12 |
| Redirects resources away from targets (eg QOF) | 3 |
| Partners/clinical directors don’t want students | 1 |
| Not enough clinical rooms | 8 |
| Supervisors already supervising other students | 4 |
| No practice assessor/supervisor on site | 3 |
| Staff shortage or skills gaps | 5 |
| The extra workload of preparing for and supporting a student is too straining | 5 |
Table 2. Barriers to hosting student nurses: nurses’ perspective
| Reason for not taking students | Number of nurses for whom this was a reason |
|---|---|
| Not enough time available to support students | 83 |
| Managers won’t allow it | 7 |
| Not qualified enough to support students | 15 |
| Supporting students is too much extra work | 39 |
| Supporting students would add too much stress to the workload | 18 |
| Not confident enough to support a student | 5 |
| Staff shortage or skills gaps | 5 |
There were many challenges that were outside our control, for example practices being understaffed. The survey also highlighted commonly held misconceptions about the impact of having a GPN student placement in a GP practice. Many managers thought that the student would need their own clinical room, or drastically overestimated the supervision the student would need. Many GPNs did not feel confident in their ability to host, supervise and assess a student. We knew we would have to employ a multi-faceted approach to tackle these challenges, as the problems surrounding student nurse placements did not pertain to one specific area. The rest of this article will discuss the support SELTH have developed for practice assessors and supervisors hosting student placements.
Making placements possible
SELTH has built on the NMC’s SSSA programme, streamlining a lot of the process to enable better support of supervisors and assessors, students and the universities involved. We want supervisors and assessors to enjoy taking students, and we want to help alleviate as much of the extra workload and pressure brought on by hosting a student. We are also aiming to increase our GP placement capacity, and therefore need to make the process as appealing as possible to potential new GP practices.
Keeping records
We maintain a database of GPNs in South East London, including their work place and whether or not they are a SSSA-approved supervisor and/or assessor. We keep this up-to-date as more people complete the training, keeping track of who has completed the half-day workshops and the e-learning. This lets us quickly identify supervisors and assessors for potential placements, but also helps give us an idea of which practices have been active in helping support students. Identifying practices that don’t have supervisors and assessors can help us increase placement capacity by offering targeted support to these practices, and hopefully getting them on board.
Simplifying documentation
We have made a 1-page information sheet about the SSSA programme. This is meant to condense the information into something more digestible than the official Pan-London Practice Learning Group’s (PLPLG, 2022) resources. Our information page clearly highlights all the steps needed to complete the training, which e-learning modules need to be completed per role, and links to register onto our training sessions. We want to make the process as easy as possible for nurses to complete and having all the information needed on one page is much quicker than reading through the PLPLG website. This makes it far easier to approach new practices, as we can give them all the information they need in one go.
Assessor and supervisor training
We host monthly training sessions based on the PLPLG’s curriculum. The supervisor session (3 hours) and assessor session (2 hours) are held 1 week apart. These sessions are held virtually, but we try to keep them interactive by getting nurses to tell us about their experiences (as a student and as a supervisor) and completing quiz questions during the presentation. Attendance (and absence) is tracked on our database for all applicants.
Once someone has completed both the half-day workshops and the e-learning, we record the new supervisor and/or assessor on our database and send them a certificate. Supervisors and assessors are then offered bi-monthly support sessions, where they can come and chat with one of the directors of practice nursing for South East London and other experienced nurse supervisors and assessors. We offer our experience to try to help guide those who are newer to supervising students. They can ask questions or raise concerns about their students and how best to support them. We also act as an intermediary between the university, the student and supervisor/assessor when the need arises. We are also offering electronic practice assessment document (ePAD) training to help our supervisors and assessors operate the ePAD, which is becoming more popular with local universities.
Starting in 2023, we are updating our SSSA programme. Many previous SSSA assessors and supervisors had issues accessing and completing the e-learning modules. To help remove the barrier that the e-learning poses, we are making the teaching sessions longer, incorporating the e-learning content into the taught sessions. Prospective SSSA students will no longer need to complete the e-learning modules.
Resources to support placements
We have also prepared some resources to support the supervisor, assessor and the student while the student is on placement. For the supervisor/assessor, we have devised a handbook to help them with tips on how best to organise and run the placement, and a blank draft timetable for them to fill out with their student during the initial meeting.
We worked with The University of Greenwich to redevelop workbooks previously written by Louise Ashwood and Zoe Leroy. There are three workbooks, one for each part of the undergraduate nursing programme. Each workbook has exercises appropriate for the level of study and reflects the expected learning the student should be experiencing in general practice. These workbooks are designed to give the placement some structured learning by providing topics that they can focus on. The workbooks can also provide some respite for the supervisor/assessor during the day, as they can ask the student to go and selfstudy the relevant section for a few hours.
Tailored tuition
Our practice education team has also curated a teaching course specific to general practice for the students to attend weekly while they are on a general practice placement. The course is split into 3 hour sessions covering a range of topics relevant to general practice nursing, including diabetes, asthma and COPD, and heart failure, among others. These topics are mirrored in the student workbook, which reinforces the structure that students expect while on placement. Students can attend the session, which will introduce a potentially new topic to them. They can then go into practice and focus their learning on the topic covered in the training sessions, and supplement that learning with the content available in their workbook. The teaching sessions also provide more respite for the supervisor and/or assessor, as that is a whole afternoon session that the student will be out of practice during the placement.
Reaching out
We are in the process of developing a directory for out of practice placement opportunities for each of our boroughs. These placement opportunities could include anything from spending a day with the diabetes nurse specialists, colposcopy team or a tissue viability nurse, to clinical outreach days with charities for domestic violence, homeless shelters and the NSPCC. While collating this we have made contact with the relevant departments asking for their commitment to taking student nurses for half a day or day. With this information, we hope to provide a timetable for the students with days out integrated into their placement. This will not only give the student a more varied and meaningful experience but it will also give the very busy practice assessors and supervisors time to run their clinics and complete their administration tasks. Finally, we ask all who have completed our training to provide some feedback. The feedback is a short, multiple choice survey with some room for optional extra comments. This feedback has, so far at least, been generally positive, but we frequently ask for and reflect on feedback with the aim of improving our process and catering it to the needs of the GPNs and students in our region.
GP route placements
To promote the role of the GPN to more students, we have worked with the University of Greenwich to redesign the placement programme for those undertaking a community nursing degree. For students on the GP route, up to 75% of their clinical placements will be in a general practice setting. SELTH have worked with universities and GP practices to facilitate students returning to the same PCN throughout the 3-year programme. This ensures continuity of learning, enables students to build professional relationships and develop a skill set more suited for working in general practice. In comparison to the 22% of students nurses that have the opportunity to observe a GPN (QNI, 2015), the GP route gives students a unique pre-registration experience in that a majority of their placement hours are in a GP practice. We believe this course aligns with our goals of workforce development and retention, and endorses general practice as a viable career option for the next generation of nurses.
Conclusion
Overall, our SSSA process is designed to take as little time and energy from the nurses as possible. Having multiple GPNs (who are also assessors) working in our team has helped us understand the challenges nurses face on the ground. We understand the day-to-day workload pressures of a GPN are immense, and we do not want to burden them with extra responsibilities. We want them to have everything they need to hand, and want to provide enough information to answer as many of their potential questions as possible. Offering this much support seems to have paid off, as we have trained 76 new supervisors and assessors, and offered 36 general practice student nurse placements since January 2022.
Key Points
- Without urgent policy action, the NHS in England could face a shortage of between 6400 and 10100 full-time equivalent general practice nurses (GPNs) by 2030/31
- Most nursing degrees do not provide enough primary care experience to students
- South East London Training Hub has built on the Nursing and Midwifery Council’s Standards for Student Supervision and Assessment programme, streamlining a lot of the process to enable better support of supervisors and assessors, students and the universities involved
CPD Reflective Practice
- Do you supervise students in practice? What are the benefits and disadvantages of this?
- What barriers to hosting students do you perceive in your practice?
- How could these barriers be overcome?