Greater Manchester (GM) has signed a devolution agreement with the Government in 2015 to take charge of health and social care spending and decisions in the city region. The Greater Manchester Health and Social Care Partnership is overseeing this devolution and has taken charge of the £6 billion health and social care budget. The rationale for this is to deliver the greatest and fastest possible improvement to the health and wellbeing of the 2.8 million people of GM (Greater Manchester Combined Authority (GMCA, 2018). This would be achieved through building a clinical and financial sustainable model of health and social care. Since the agreement was signed in 2015, GM has seen changes in how care is delivered, which has included amalgamating large hospitals and NHS trusts into even larger organisations.
Four universities in GM (Box 1) provide undergraduate nursing programmes. Equipping GM nursing students with exemplary clinical leadership skills requires the practical component of their educational programme to take place in a supportive clinical environment in which these new nurse leaders can flourish. Firmly embedding clinical leadership development within undergraduate nursing programmes ensures that the GM nursing workforce has the right leadership knowledge, skills and behaviours required to make sound clinical and non-clinical decisions and will empower nurses and strengthen nursing in decades to come. This in turn will provide the optimum conditions for delivering exemplary patient care.
The GM universities have a strong relationship and history of collaboration. Since 2009, the GM hospital trusts, the four universities and Health Education England (HEE) have worked together as the Greater Manchester Practice Education Group (GMPEG). The aim is to act as the forum for collaboration and governance of practice learning across Greater Manchester. The strength of the GMPEG lies in the expertise and passion of its members, who are committed to providing the best opportunities for student learning when engaging in clinical practice.
It is from this collaborative perspective that in 2016 members of the GMPEG applied storytelling and a strengths, weaknesses, opportunities and threats (SWOT) analysis to identify underlying challenges and opportunities associated with delivering nurse education that would realise the GMCA vision to make Greater Manchester one of the best places in the world to live and work.
From this work, it emerged that support for nursing student development in clinical practice was variable. A key issue was that the mentorship model meant that, while individual support on a one-to-one basis was highly valued, students were not consistently encouraged to take ownership of their learning needs; in line with the evidence base, mentors were often overstretched and struggled to fulfil their role of providing student assessment and supervision while caring for patients (Leigh and Roberts, 2017). In addition, there was a lack of a clear strategy for a smooth transition from student to qualified nurse and for providing the incentives for student nurses to practise in GM hospitals when registered. Other challenges related to delivering on Health Education England's (2016)Quality Strategy 2016-2020 and Quality Framework (2016) for promoting high-quality placements and clinical leadership development. Moreover, the changing landscape of healthcare education, including issues associated with the need to increase the number of registered nurses across GM, made seeking opportunities to change both placement and clinical leadership development models a greater priority.
Influenced by evidence from the 2012 Willis Commission (Willis, 2015) on the future of nursing education, which provided evidence for the Collaborative Learning in Practice model (CLiP) and their own practice, the authors identified coaching as an effective model for student nurse support in practice. In 2016–2017, GMPEG members attended a study day facilitated by the University of East Anglia, which had developed the CLiP coaching model, and visited Lancashire Teaching Hospitals NHS Foundation Trust, which had implemented it.
Seeing the success of this context-responsive model, the authors realised they needed to take a similarly responsive approach in GM. A GM-wide approach to a shared model and governance system was chosen, as the practice placement circuit is shared by the four GM universities and there is a strong history of collaborative working between education and placement providers. This includes use of the pan-Manchester electronic practice assessment document, student practice placement evaluation (P@RE), practice placement audit and shared practice policies and procedures. The authors' vision was clear from the outset that any new model would continue to standardise GM resources while promoting flexibility and freedom in the diverse clinical contexts and healthcare organisations. Given this, it was recognised that a bespoke model had to be created, which would be responsive to the different context and needs of each hospital trust and university involved in the project, thus complementing GMCA priorities.
In this context, a steering group was formed to develop an innovative GMCA model of support for student nurses in clinical practice. Our steering group comprised senior leaders from the GM universities and the healthcare organisations. Key personnel played a vital consultancy role, including three student nurses who had experienced coaching in clinical practice. This ensured that the student voice was heard from the outset (Box 2).
Working together, we developed our bespoke GM Synergy model for student support in practice placements. GM Synergy (Figure 1) is based upon coaching ideologies, placing emphasis on delivering patient-centred care, promoting student nurse clinical leadership development and peer learning.
The typical, traditional student support model is mentorship—the process of a qualified nurse transferring their knowledge and skills to a less knowledgeable student. The Nursing and Midwifery Council's Future Nurse: Standards of Proficiency for Registered Nurses and Realising Professionalism: Standards for Education and Training (NMC, 2018a; 2018b) brought in three new practice learning roles: practice supervisor, practice assessor and academic assessor. These practice learning roles will supersede the current mentorship function.
Coaching in the context of GM Synergy and the NMC standards of proficiency
Whitmore (2009) suggested that coaching is an intervention that facilitates another person's learning, development and performance. The GM Synergy coaching training promotes leadership learning that is student led, less focused on following the directions of a mentor and more focused on students taking responsibility for identifying their learning goals and objectives.
There is a risk with this approach. For example, a student may not be ready for their increased responsibility or the coach in clinical practice may not feel prepared and adequately supported in their role. Ensuring that the student, practice assessor and the coach are all fully prepared for their roles and that effective communication takes place between the coach and the practice assessor minimises these risks. Learning logs, which are completed daily by students and contain feedback from coaches on clinical practice, provide evidence to practice assessors of students' learning and ongoing development.
Leigh and Roberts (2018) suggested that within the context of the new NMC nursing standards (NMC, 2018b), the role of the coach will be undertaken by practice supervisors, who will give students opportunities to take responsibility for their own learning. The role of the practice supervisor, as set out in the new standards, is to: role model and facilitate student learning through independent participation; raise and respond to competency and conduct concerns; supervise, support and provide feedback to students; and contribute to assessment and progress decisions made by assessors.
This in turn promotes optimal patient care, achieved through improved student performance, motivation and empowerment. Again, there is a risk to this approach, so preparation for the role and clear lines of communication with the future practice assessor and academic assessor are key.
GM Synergy: a typical day
GM Synergy placement areas are allocated up to 20 undergraduate student nurses (a combination of first, second and third year students), although not all will be on duty at the same time. Placements are situated in hospitals (spanning adult, child and intermediate care) and attended by students in the adult and children and young people fields of practice. Many practice areas are split into bays and there may be one or more bay that will operate the GM Synergy model at the same time, allowing a large volume of students to be accommodated, compared to non-Synergy areas where student allocation can be as low as one. This high volume of students is required to provide the teaching and learning opportunities.
At the start of the shift, students meet their coach for the day, who could be their future practice supervisor (NMC, 2018b), to discuss their learning needs for the day. The ideal ratio is four students to one coach (Leigh et al, 2018). Students complete their learning log, focusing on specific learning objectives related to their placement learning outcomes. Students provide care to patients with direct support and supervision from the coach. Peer teaching and learning also takes places between the first, second and third year students. At set times throughout the shift, the coach and students review learning based around the students' objectives, critically reflecting on what they have learnt and continuously planning for the next learning opportunity. Other key practice-based education roles that support student learning and placement governance include those of the university link lecturer, the practice education facilitator (PEF) and the practice assessor. Future roles will include the practice and academic assessor (NMC, 2018b).
Here, the authors offer some personal perspectives about how they developed, implemented and evaluated their coaching approach to student nurse clinical leadership development, peer learning and increased practice placement capacity.
Setting up a steering group
Before developing, implementing and evaluating the model, the authors set up a steering group with key stakeholders represented. The constitution of the team and consultants (Box 2) capitalised on its members' diverse experiences of practice-based learning, curriculum development, workforce transformation, educational improvement and providing support for colleagues in healthcare and higher education. Developing the steering group's terms of reference helped its members implement the vision for the new model and kept them on track. From this group, the following important systems were created:
Meeting monthly to begin with and challenging the process, the authors established and maintained harmonious working relationships that not only facilitated the development of GM Synergy but also contributed to the development of group members' leadership skills.
Testing the model
Testing the GM Synergy model before its implementation allowed the authors to identify and manage any issues that would potentially reduce the effectiveness of the model. In July 2017, the authors collaborated with 19 students from all fields of nursing practice and from across the four participating universities in clinical simulations that took place in the University of Salford's simulation suite. Steering group members simulated the role of patients and coach in clinical practice, and students engaged in patient care and shift handover.
We disseminated the evidence of our impact through publishing our truly unique teaching and learning educational improvement opportunity (Leigh et al, 2018). Factors, as well as evidence, that informed the development and implementation of the model included:
Implementation of the GM Synergy model
In September 2017, GM Synergy was rolled out across 13 diverse practice areas in the following GM hospital trusts: Bolton NHS Foundation Trust, Northern Care Alliance NHS Group (The Pennine Acute Hospitals NHS Foundation Trust), Manchester University Foundation Trust (Manchester Royal Infirmary, Wythenshawe Hospital and Royal Manchester Children's Hospital). Placement areas spanned adult acute and community settings as well as children's acute wards.
The GM Synergy team has broken down the silos and organisational boundaries that in the past would have prevented the success and sustainability of the project. For example, PEF champions in each healthcare organisation are using our unique eligibility and readiness framework and GM standardised resources to seamlessly convert student practice placements into GM Synergy placement areas, which has significantly increased student nurse placement capacity from 63 to 168 (a 266% increase). The team is contributing towards a 2017 government strategy to place the extra 10 000 student health professional workforce by 2020 (Department of Health, 2017). Our evaluation is demonstrating the systems that need to be in place to promote student nurse clinical leadership development and these include effective preparation of all involved and careful rostering of students to manage the increased student numbers on placement at one time.
GM Synergy placement areas continue to open, and operational structures allow the scheme to widen its reach within community, midwifery and mental health settings.
Evaluation of the GM Synergy model
Measuring the impact of GM Synergy from multiple stakeholder perspectives is imperative. The authors therefore developed a robust evaluation strategy to measure the impact of the implementation of the model on student clinical leadership development, and this evaluation is led and sits within the University of Salford portfolio for healthcare leadership development and evaluation. Health Education England has funded a project evaluation, which applies realistic evaluation with a focus on the following key areas:
This evaluation work started in 2018 and is ongoing with data influencing future GM approaches to the implementation of the standards for supervision and assessment (NMC, 2018b).
One of the key findings so far is the need for all stakeholders—students, practice staff and academics—to be fully prepared before the placement starts. A standardised suite of tools to inform and guide this preparation is being prepared.
It was also found that, in community settings, the emphasis is placed on coaching rather than increasing practice placement capacity.
Conclusion
Providing clinical leadership development for undergraduate student nurses requires support from educators drawn from clinical practice (nurses), practice educators and academics from universities. Development of multiple personnel removes the single point of failure for student support and significantly increases the likelihood that the model is sustainable.
Partnership working between universities and practice partners is key. Coaching as a model for student support and clinical leadership development is in line with the new NMC standards, with the role of the practice supervisor complementing that of the coach.