Community nursing placements: student learning experiences during a pandemic and beyond

Navigating the COVID-19 pandemic in community nursing environments has posed, and continues to pose, many difficulties and challenges. Established ways of working have needed to be reviewed to ensure that both staff and patients continue to adhere to Government public health guidance. Continuing to plan and deliver high-quality, effective nursing care for patients remains paramount (Jackson, 2020).

Lessons have been learnt from the initial COVID-19 wave in 2020, and while restrictions continue to be in place and may well be reinstated in the future, new ways of working are being considered, which may well shape the future of community nursing.

Maintaining learning capacity to increase the nursing workforce

One area that has continued to raise particular challenges in community nursing is maintaining the level of student learning capacity, supervision and assessment to the extent of pre-pandemic levels. Pre-registration nursing students enjoy a wealth of learning during community placements, develop invaluable knowledge and skills and gain exposure that may help them consider this dynamic field of practice for their future nursing career (Williamson, 2020). Student nurses from both adult and mental health programmes consistently rate a community experience as being valuable to understand holistic care and gain insights into the nursing, living and social care needs of diverse populations. Applications to study nursing have increased by 32%, with interest in the profession seeing a rise across all age groups. Universities and College Admissions Service (UCAS) data suggest that 60 000 people have applied to study nursing in the UK for autumn 2021 (Council of Deans, 2021). This increase in nursing applications provides a superb opportunity to generate interest in community nursing as a future career, if students are afforded a placement opportunity. Ensuring the continuation of pre-registration nursing programmes is essential for the future nursing workforce, and Health Education England (HEE) expansion plans reiterate this need. Expanding community nursing placements can help to address future workforce deficits, developing students' understanding of this particular aspect of nursing as a future career and also encouraging registered staff's professional development in supervising, assessing and being part of the students' learning journey.

As community nursing teams have negotiated approved office space for team meetings and administration requirements in line with Government and public health guidance, the addition of student nurses in these spaces has been difficult to accommodate. Similarly, Government guidance around the use of car sharing has seen individual trusts/provider organisations and community nursing teams having to make difficult decisions as to whether they consent to a student sharing their car to visit patients. This has resulted in many student nurses forgoing a community experience at this time due to continuing restrictions.

The community nursing workforce, indeed, the nursing workforce as a whole, has also seen increased staff sickness in many areas, as well as the required periods of self-isolation in line with their employing organisation and Government guidance. This has resulted in a reduction in practice assessors and practice supervisors in many areas, contributing to reduced capacity for student nurse placement experiences. To try to compensate for the possible depletion of the nursing workforce in many areas, and to encourage continuation of student nurse learning experiences, the Nursing and Midwifery Council (NMC) has reinstated one of the emergency standards implemented earlier in 2020, where a practice assessor can also act as a practice supervisor for the same student in exceptional circumstances, as described below:

Emergency Standard E5.1: the same person may fulfil the role of practice supervisor and practice assessor during this emergency period. The assessment is to be conducted by a registered nurse, midwife or nursing associate with suitable equivalent qualifications for the programme the student is undertaking, and who is not on a temporary register (NMC, 2021).

Many lessons have been learned from the first lockdown period in March 2020, with recent reports suggesting that student nurses continue to have a positive experience in placement. HEE (2021) reported on the impact of COVID-19 on students, suggesting that student learning in practice changed significantly during the first wave of the pandemic, although 90% of respondents stated that ‘clinical placements were of a high quality and a good learning environment’. Many students felt they should be in practice, helping their registered nurse colleagues, and this was borne out by the numbers of students opting into paid placements, wanting to feel ‘useful’ (Townsend, 2020). Conversely, many students felt a sense of guilt for not opting in, compounded by the constant ‘hero effect’ portrayed by the media. However, during this recent wave, the NMC has been clear that the introduction of paid placements would be for third-year students, and programmes of study/placement experiences should continue as normal where possible. The aim for all students to complete their programmes of study on time and join the nursing workforce is of great importance for future care delivery. As stated earlier, the community nursing workforce needs to expand to ensure effective care for an increasing ageing population. Maintaining and increasing student nurse experiences in the community setting is seen to be fundamental to achieving this goal (King's Fund, 2016).

Alternative ways of supporting students in community nursing practice

Considering alternative ways of working in community settings has afforded the opportunity to develop new and innovative ways of supporting student learning. Challenges are becoming catalysts for change, and initial frustrations are now prompting transformation. It is important to share developments and consider how these approaches could work in individual teams. The following suggestions and examples are not exhaustive, but include aspects of learning that community nursing teams may want to consider. One size does not fit all, with transformation success being reliant on the leaders and staff implementing the ideas with a robust underpinning strategy and evaluation mechanism, where preparation is key (Blane, 2017) (Figure 1).

Figure 1. Aspects to consider when planning student learning experiences.

One particularly challenging aspect of maintaining student placements in community settings relates to car sharing, as mentioned earlier. Government guidance should always be followed and risks assessed (UK Government, 2020). This guidance should be reiterated to all students:

• The transport should be shared with the same people each time
• Small groups of people should be kept to at any one time
• Windows should be open for ventilation
• People should travel side by side or behind each other, rather than face to face, where seating arrangements allow
• People should face away from each other
• Seating arrangements should be considered that maximise distance between people in the vehicle
• The car should be cleaned between journeys using standard cleaning products; it should be ensured that door handles and other areas that people may touch are cleaned
• The driver and passengers should wear a face covering.

Higher education institutes (HEIs) should be informed of the approach to this guidance being used, in order that allocations can be considered with individual community nurses who are able to offer a placement opportunity. It should be explored with the HEI if there are other suitable means of transport, as not all student nurses drive cars.

Patient acceptability is key to facilitating student learning. It is understandable that many patients may be anxious if more than one person is attending to their nursing needs in the current climate. However, patients' experiences of household isolation also need to be acknowledged (Brooke and Clark, 2020). This requires sensitivity, explanation and appropriate planning. Patients should not feel pressured into accepting a student nurse into their home, but, with appropriate social distancing measures, student nurse involvement may be acceptable in some circumstances with patient consent. Student nurses can observe direct care from a distance, or a more experienced student nurse could deliver care with the community nurse observing from a safe social distance. Methods of communication are a key focus area to discuss with students, particularly in relation to the impact of wearing of masks/personal protective equipment.

Simulated practice is one way to promote community nursing knowledge and skills in a safe environment. If used creatively, realistic scenarios can be used to good effect in translating learning into clinical practice (Gunowa et al, 2018). This requires collaborative working between the HEI and practice partners to ensure that relevant learning outcomes are incorporated and reflection is encouraged. Telephone and video consultations should be considered where a member of the community nursing team could act as a patient. These types of consultation have increased at a rapid pace during the past year in GP practices and are likely to become a ‘normal’ method of interaction in many wider healthcare interactions, including community settings (Thornton, 2020).

Office space is at a premium, and social distancing requirements could mean students may not be allowed into these spaces. Alternative arrangements should be considered, where staff and students are rostered for office time. This could include hot desking and using corporate spaces/meeting rooms. Students could complete mock or simulated administration tasks from home and discuss with their practice supervisor/practice assessor the following day or at the end of the day via phone or virtual technologies. This could include reflecting on a case study/episode of care, where confidentiality and anonymity are maintained. Although this does take time to prepare to ensure that relevant competencies are included, it can be used again for future students. Liaising with the organisation's practice facilitator/educator and HEI will help to inform this practice and ensure that all regulations are met. With any virtual technology used, Governance arrangements and data protection must be adhered to in order to protect patient confidentiality and ensure that appropriate computer malware protection is in place.

Multidisciplinary working is a requirement of the NMC's educational standards for nursing students (NMC, 2018), so this is a good way of increasing student experiences. Planning student placements to include these opportunities with a variety of health and social care professionals provides a learning space for all team members. Voluntary agencies, charities and specialist services should also be considered, as they may be able to facilitate student learning in face-to-face clinics or via online formats. The trust/organisation's IT policy for online home working should be checked. Students could be provided laptops with appropriate intranet access for offsite working, which includes remote secure desktop support. This type of access can also be considered for students within a university setting.

Corporate placements are excellent learning experiences for final-year students. Team leaders and operational managers should be asked if students can spend a part (or all) of their placement time with corporate teams to understand and develop their leadership skills. This could include attendance (virtual or otherwise) at director meetings, strategic governance discussions, workforce meetings, audit reviews and, stakeholder meetings.

Using the full range of shift patterns can help to increase the number of students accessing a community experience. These can be scheduled to ensure that students experience all shift patterns at different times. An example of a student's learning journey over a week can be seen in Table 1. Another student could have a plan incorporating these activities at opposite times and including weekends to accommodate both students' learning opportunities.

A blended learning approach can be incorporated as a long-term strategy, in addition to being a short-term solution in the present climate. Face-to-face learning, virtual learning and directed/self-directed learning can be used together effectively to facilitate a superior community nursing experience for students. Preparation is key, with initial planning needed to:

• Develop robust scenarios
• Schedule activities/days with team members
• Organise rotas
• Ensure IT systems are available
• Develop virtual student forums for peer networking
• Access relevant virtual learning tools to share with students
• Adopt a coaching approach
• Schedule regular phone/virtual discussions to monitor progression.

In addition to drawing on local HEI resources, e-Learning for Healthcare has some useful learning materials to support student placements. There are numerous webinars available, where students can gain relevant transferable knowledge and information, which they can subsequently disseminate to the community team as part of a teaching session. Social media journal clubs, which can be peer led, can also encourage groups of students to engage in critical appraisal skills and review the relevant best evidence (Ferguson et al, 2017). Final-year student nurses can present a teaching session online to other students/staff as part of their episode of care.

Practice facilitators/practice educators can be invaluable sources of support to facilitate student learning. Student forums can be scheduled and implemented by these individuals across community team areas to reflect on learning and discuss specific aspects of community care. This could include case study reviews and student presentations, either virtually or within NHS trust/organisation education centres. Identified ‘student links’ can be considered, which involves a named individual being the lead for student support in a neighbourhood team/area. These support links would work with practice facilitators/practice educators to help enable student learning and identify new ways of working. This also facilitates continuing professional development for staff members.

Collaboration with the HEI is necessary, to ensure that students are prepared for the types of experience they are likely to encounter in the community setting. Preparation for clinical practice should start within the HEI setting and continue as part of the student's induction within the first days of practice. It is important that the information students receive is up to date and reflects the reality of the setting. Students should know what will be expected of them, the opportunities available and the possible changes to their learning experiences.

Conclusion

Planning and preparation for student learning is always important, but even more so during the pandemic. Students can bring a wealth of transferable skills and look forward to a community nursing experience with motivation and enthusiasm. Therefore, it is paramount for community team leaders and all staff to continue to facilitate student placement opportunities to the best possible extent. This requires thinking and working differently within the bounds of Government and organisation guidance/policy. The benefits of having students in these settings are numerous, and a positive experience will contribute to the future community nursing workforce. Sharing of ideas is needed to promote innovative practice across regions. It is recommended that teams share the implementation of strategies through regional HEE quality leads and trust/organisation workforce meetings as well as with HEIs in order to disseminate these strategies and realise their impact over a wider area.

KEY POINTS

• Community trusts should continue to facilitate student learning experiences during the pandemic to encourage exposure to community nursing as a possible future career
• Creative ways of working can be implemented to facilitate student learning in community settings
• Including the multidisciplinary team and corporate placement experiences can expand learning opportunities for students
• A blended-learning approach can be embedded in all community nursing placements
• Preparation and collaboration with all stakeholders/higher education institutions is key to successful implementation of these initiatives.

CPD REFLECTIVE QUESTIONS

• Consider how you engage with your local higher education institution in implementing educational innovations in practice
• List all the possible student learning opportunities available across your area. How can these be incorporated in a placement experience?
• Reflect on the advantages and disadvantages of blended learning and how you can implement some of the suggestions above