Student nurses in the primary care network: a pilot

The year 2019 saw the start of a period of rapid change in primary care. The NHS Long-Term Plan (NHS, 2019) was released which proposed that general practices should form networks to deliver contracts rather than work on an individual practice basis; these networks are known as primary care networks (PCNs). Through the Direct Enhanced Service (DES) specifications, primary care will be striving to hold and run service delivery contracts at the level of the PCN that serve populations of 30 000–50 000, by increased amounts year on year. Couple this with the Future Nurse Standards for nurse education and supervision (Nursing and Midwifery Council [NMC], 2018), this makes it a time of great change in the way we not only deliver primary care but also in how we train and develop the next generation of nurses. In light of the COVID-19 pandemic, growth of our workforce is now more important than ever.

Heath (2019) described how we can use the PCN to bolster the potential throughput of student nurses experiencing the varied work that is undertaken as general practices nurses (GPNs). The core elements of the PCN model are designed to cut down on duplication, replication and time, while decreasing isolative models of working for the GPN community and increasing the community of practice (COP). A COP can be defined as a team of interested, engaged and motivated individuals all with a similar ethos who possess a clear aim to share their specialist knowledge (Lave and Wenger, 1991).Wenger (1998) described that three key elements are needed to align the COP's members to the community: mutual engagement; joint enterprise; and shared repertoire.

In the pilot, the core elements of placing students in our PCNs included:

• Auditing the PCN as a whole rather than each GP practice: each clinical area taking students must have an educational audit in place, which demonstrates the educational merits of a clinical area. The Pan London Practice Learning Group have a shared audit tool which all London Higher Education Institutions (HEIs) use; the tool can be used to audit areas that have a similar clinical interest
• The PCN signs one placement agreement: each clinical area must have a signed placement agreement (a governance structured agreement). Rather than having several signed placement agreements for each practice, one is signed by the clinical director for, and on behalf of, the PCN
• The students are placed in the PCN: the PCN itself decides where the student will be spending their time, which will depend on the student's learning objectives and the skill set of the supervisors and assessors.
• Burden: as the student rotates around the varying practices, their supervisors and assessors feel less of a burden, as there is an increased sense of sharing
• Student experience: as the student experiences a variety of practices, clinical areas and expertise, their exposure to primary care and what it has to offer increases, resulting in potential increased satisfaction
• Communities of practice: as the nursing staff come together in the PCN they start to come out of isolation and begin to form networks of nursing, which could increase the sharing of tacit knowledge and development from within the network itself.
• Payment for placements: the placement tariff is awarded to the network rather than the individual practices. The network itself decides how it is to be allocated among its member practices.

This article looks at how primary care in South East London with funding from Capital Nurse has started work on placing students in this manner.

Project design

The practice education team (PET) for South East London successfully bid for the development funds from Capital Nurse to develop and implement the project of placing students in the PCN rather than with individual GP practices. The bid was warmly welcomed and the funds were transferred to Lewisham Training Hub for invoicing and accounting.

The overarching aim of this project was to increase the student nurse experience of primary care nursing placements, alongside developing an ethos of shared load and responsibility for educating the next generation of nurses from a primary care perspective. There is an ambition that this shared load will positively impact on the number of student nurses allocated to primary care for placements, which is a core element of the General Practice ten-point development plan (NHS England, 2018). The core design of the projected included:

• The recruitment of two educational nurse leads (ENLs): The main objectives of these two roles was to implement and manage the project and its design
• The ENLs identified two PCNs in which to place a minimum of two students within each neighbourhood of practices, the PCNs were offered the nationally accepted tariff for the placement and £1000 for partaking. The PCNs were chosen based on the ENLs' prior knowledge and existing relationships with colleagues. It was important for the project to identify PCNs based on the BMA's description (BMA, 2020), ie serving a population of 30 000–50 000 and the coming together of multiple smaller practices into a newly formed network. Liaising with the clinical directors from the PCN was key. The PCNs were educationally audited as one organisation utilising the Pan London Audit; the clinical director was asked to sign one HEI placement agreement.
• The ENLs were pivotal in gaining, negotiating and communicating with our partner HEIs and their placement teams regarding the project's design
• The ENLs were key to developing the community of nurses in the network, ensuring adequate practice assessors and practice supervisors were trained. Where sufficient numbers were not present learning opportunities were delivered to the Pan London Practice Group practice assessor and practice supervisor standards
• The ENLs supported the named practice assessor from the respective PCN in the design and management of the actual placement, ensuring there was rotation around the PCN and rotation within the PCN's services
• The ENLs supported the practice assessors and supervisors through the duration of the placement
• The ENLs worked with the HEIs to carefully select appropriate students. The number of students was limited to two per PCN. Facilitating more students in each network was not practical nor feasible due to limited capacity of space, assessors and supervisors; this project was a test and learn piece in order to widen out to increasing numbers of PCNs throughout South East London. One of our partner HEIs helped us select two students that were completing a community circuit pathway, the other HEI selected two second-year student nurses. Both sets of students were on a BSc programme. It was agreed due to the complexity of the programme that first-year students were not appropriate
• The ENLs delivered weekly supervision and teaching sessions to the students on placement. The two groups of students were studying at The University of Greenwich and Kings College London. Both groups of students were allocated to the PCN for a 4-week placement
• The student nurses, with the ENLs, delivered an evaluation session to their respective PCN practice nurse forums at the end of the placement. Invitees included representatives from Capital Nurse, the PCN, the HEIs, lead nurses from SEL, and the PET
• The ENLs and project lead, with assistance from Capital Nurse, evaluated the project and considered future recommendations.

Discussion

Given the very early coalescing stage of the PCN, this project succeeded beyond an idea and has not only been rewarding but has also enabled further development of the ethos of nurses working together and belonging to a community of practice and a neighbourhood nursing team. As with any project there were struggles and barriers to the implementation. In this section these enablers and hurdles will be examined from varying perspectives.

PCN selection

The original design of the pilot aimed to start considering how student nurses can utilise primary care at scale, moving away from individual GP practices to larger networks of practices who are working together for a similar population of patients. However, the newly formed networks are and were still at the forming stage (forming, norming, storming). As described by Buckman (1965), the forming stage is one of testing which enables the boundaries of interpersonal relationships to be identified. As the concept of the PCN is new, the partner organisations are developing their working relationships in this new framework. In our pilot, each partner practice was not aligned structurally from a perspective of ethos to deliver this pilot to its full potential. The PCN selection as described above relied on prior relationships between the ENL and the PCN to enable participation. It was also important to maintain regular contact with the management team from each individual practice and the supervisors and assessors (nurturing and developing relationships). Due to these points, inclusion of all member practices proved difficult and resulted in some negative feedback from individual GP practices: ‘It will be too time consuming, what's in it for the GP practice and why should we put in the extra work for not that much money (referring to the tariff)’.

In PCN 1, only 3 out of the 5 practices fully engaged by means of accepting the rotating students and contributing to the educational audit and the signing of the placement agreement. The rational for not signing the placement agreement as a collective was that some practices would not sign an agreement which stated it lasted 5 years. Despite this being changed by the HEI to ‘for the life of the PCN pilot’, some practices would not agree to sign and subsequently lost faith with the pilot. This was in contrast to PCN 2 who agreed to be audited as a whole and signed the placement agreement as one unit; they have also suggested they may continue placements in this manner.

The tight time frames of this project, from the acceptance of the project from Capital Nurse to the actual placing of the students was challenging and the project would not have succeeded without the dedication of the two ENLs. This dedication of an individual working primarily on student facilitation is something that been backed by Heath (2019). The final challenges that were encountered were the timing of the project, just before the end of the financial year, and the previous exposure of student nurses in individual practices. Despite this, and some initial hiccups with some fine details of rota management, the GP practices enjoyed hosting, so much so that some of our GP colleagues could see the benefits of not only hosting placements in this way but the positive impact students in primary care have.

Unfortunately, shortly after this project and pilot finished the United Kingdom went in ‘lockdown’ due to the COVID-19 pandemic, therefore some momentum has been lost in developing this further.

HEI experience

The experience of all our partner HEIs was positive and no overtly positive or negative comments were noted. They praised the efforts of the education team and supported this project in terms of identifying potential students and offered support and guidance when needed; it was important for the ENLs to build personal relationships with the practice learning leads from the partner HEIs. One of the HEIs was very amenable and changed their placement agreement for PCN 1 to include a statement about the length of the agreement. This, of course, was not in the overall plan and has meant that to further continue this model of placing students with this PCN it would require further work and input.

Student experience

The over-arching aim of this model – providing placements in primary care at a PCN level – was to increase student experience, depth of knowledge gained and to spread and share the load of students in primary care and the experiences that they bring. The students from both sites had no previous experience of working in primary care and were not known to the ENLs or the PCN sites: positive experiences were gained in both of the PCN pilot sites. The students benefited from obtaining different patterns of work, differing methods of delivering care and exploration of all the varied work that the general practice nurse workforce has to offer. These clinical sessions were carefully orchestrated, rotated and planned with the knowledge from the ENL. The students had clinical sessions from a variety of professionals including GPs, pharmacist, advanced nurse practitioners and other multidisciplinary team members. Alongside clinical work, the students benefited from weekly supervision with the ENLs. These sessions were designed not only to offer clinical supervision but enabled education to be delivered from a primary care perspective with the outcome of bridging the theory/practice gap. Students from both sites were also supported to write and develop their own feedback, which they presented to the respective GPN forum to whom the practice education team, HEIs and senior nurses were invited. Their comments included the following: the students from PCN 1 felt that actually rotating through three practices (rather than the 5 included) was sufficient on a four-week placement. If this were a model taken forward it would mean that if all practices are aligned to this mode of placement delivery there can still be periods where not all practices within the network would be allocated students, this would then further dilute and spread the educational load. The students felt welcomed and valued in the member practices from both PCNs and the supervision sessions were immensely beneficial to reduce the clinical/educational divide. The staff feedback from the PCNs stated that this model of placing students was much more feasible and practical for future placements.

Barriers and further discussion points

Financial reimbursement for offering placements has been a long-standing issue for all placement providers, especially from in the GP landscape. This has remained a stumbling block in all placements that are offered in South East London, and has been one of the issues with regards to increasing and developing new placement areas. Couple this with the fact that the placement tariff would now (potentially) be split 4–5 ways (depending on the PCN), this could lessen the incentive, and the PCN may have to agree on how to spend and split that money fairly. This issue has not been resolved in this pilot, but in addition to the standard tariff our PCN pilot sites were offered an additional incentive of £1000.

This pilot also had a very short turn-around from the funding being agreed to students starting their placement. This was not ideal and may have increased pressure on staff, the PCNs and individual PCN sites. In addition to this, it was hopeful the PCN pilot would have identified potential future nurse leads from the PCN sites to further this model of placing student nurses. To date this has not succeeded, so without external support this project is in jeopardy of not developing further. This is important to recognise as Heath (2019) suggests that nurse leadership in the development of the PCN is crucial for services and the community of practice.

Enablers

The picture is clear that this hub and spoke type model of placement in primary care has significant benefits for student nurses, practices, networks and the future nursing workforce. Fostering excellent relationships between nurse leads and the network is key to the success of placing students in this manner; however, there is the question that without funding who will lead this model? One of our recommendations is that nurse leads are identified to support and foster pre-registration placements at a network level; we might call this role a ‘PCN champion’. This pilot, through our ENLs, has helped our network of boroughs develop:

• A shared student induction pack
• Rota management templates for each individual network to plan placements with their own PCNs
• Consider how we can support student facilitation supervision and educational development sessions.

Multiple students allocated to one network was also crucial to this project. The students were able to have group supervision, gaining support from one another, resulting in a sense of less isolation. We also found our assessors and supervisors had even less burden and stated they felt good and less stressed by this model of placement allocation.

Ultimately the project has led us to consider how a student nurses' journey should progress from student through to high level educator: this is represented in Figure 1. The student moves through the educational levels and (potentially) at each level increases their impact on nurse leadership and their leadership skills. Therefore, we recommend a staged approach to education, which outlines a strategic carer development pathway with education at its heart.

Figure 1. How a student nurses' journey should progress from student through to high level educator

Conclusion and future recommendations

This pilot has demonstrated that a hub and spoke model of placements in primary care is possible and, as a result, we are recommending that all networks should not only consider this but should actively seek nurses out to lead similar ventures. Funding has been available through Health Education England to support preceptors and to increase assessor and supervisor capacity; in our opinion this should be long-lasting and recurrent year on year. In addition to this, we believe that nurse leadership through a PCN champion is essential to develop our education model; this of course would be much easier to facilitate if funding was sufficient and recurrent to support roles such as these. The PCN champion could work alongside the clinical directors of the PCN making primary care a valuable part of the clinical placement experience that our nurses have. And why stop there, with a PCN champion in place, working with the training hubs and the other professional bodies from the new roles that are being introduced, could Interprofessional Education be advanced?

Our STP is also funding a student nurse education facilitator working part-time across our 6 boroughs. This position seeks deliver education and supervision sessions across our STP to groups of students on placements described in this report. We hope to see a further reduction of the theory–practice gap and an increase in assessor and supervisor support. Our models are striving to support the NMC Standards for Student Supervision and Assessment (2018), alongside supporting and developing the individuals who are aiming to foster the clinical education arena. Ultimately, it would be fantastic to see an increased number of pre-registration students experience the wonderful work that we perform in primary care. Let's develop our profession, let's support students and let's work with and within our networks and influence the shaping of them.

KEY POINTS

• With support from Capital Nurse, primary care in South East London developed a hub and spoke placement pilot to support student nurses in a primary care network
• The hub and spoke type model of placement in primary care has significant benefits for student nurses, practices, networks and the future nursing workforce
• In light of the COVID-19 pandemic, growth of our workforce is now more important than ever

CPD reflective practice

• Do you think working with other practices in your primary care network (PCN) would encourage you to support student placements? Why?
• What barriers to facilitating student placements do you currently face?
• How could these barriers be overcome?