The nursing profession globally is facing unprecedented times owing to the coronavirus outbreak (COVID-19) (Leigh et al, 2020) that has been labelled a pandemic by the World Health Organization (2020). A pandemic describes an infectious disease where we see significant and ongoing person-to-person spread in multiple countries around the world at the same time.
The Nursing and Midwifery Council (NMC) recognises the important contribution that nursing students are making to the national response to the COVID-19 pandemic and the impact that the pandemic is having on those who are studying. They have therefore produced an emergency set of education standards enabling students to complete their pre-registration undergraduate or postgraduate nursing programme while also supporting the healthcare workforce (NMC, 2020). Supporting the workforce includes students opting into a paid or deployed role in clinical practice while being appropriately supported and supervised and having protected learning time. These NMC standards are temporary and will no longer apply after the emergency period.
The authors of this article are educational leaders working across four Greater Manchester universities and its partner healthcare organisations and who have created a Greater Manchester Supervision and Delegation Framework. The framework provides practical guidance for students and practice staff (practice supervisor/practice assessor and registered nurse) on how to support student nurses who have opted into a paid (deployed) healthcare role. The practical guidance operationalises NMC emergency standards, Health Education England (HEE), NHS Employers and The NHS Staff Council guidance. Guidance includes information provided to employers regarding job description and banding for the deployed student (NHS Staff Council, 2020). The principles underpinning the framework are transferable to trainee nursing associate and student midwives; however, the proficiencies referred to in this article relate to pre-registration undergraduate or postgraduate nursing programmes.
NMC Emergency Standards for Nursing and Midwifery Education
Tables 1 –4 provide key information taken from the NMC Emergency Standards for Nursing and Midwifery Education (NMC, 2020). The standards are then explored in terms of the implications for deployed students, considering and operationalising HEE, NHS Employers and NHS Staff Council guidance on the job description and banding for the paid placements.
| NMC Emergency Standard | Rationale | The NHS Staff Council job banding and job description |
|---|---|---|
| Standard E1: Students in the final 6 months of their pre-registration undergraduate or postgraduate nursing or midwifery programmes may complete their programmes in clinical placements, while ensuring all learning outcomes are met | Removed is the requirement that programmes have a 50% split between practice and theory. All programme outcomes need to be met | Grade Band 4 |
| E1.2 Students finishing their programme in placements under standard E1 will be provided with protected learning time. The level of supervision a student needs is based on the professional judgement of their supervisors, taking into account any associated risks and the students' knowledge, proficiency and confidence | Supernumerary status of students is removed. Students must still get the support and supervision they need to learn; protected learning time must be provided |
| NMC Emergency Standard | Rationale | NHS Staff Council job banding and job description |
|---|---|---|
| E2. Students may spend no more than 80% of their hours in clinical placements and 20% of their hours in theoretical learning | Students continue their studies on a programme that offers flexibility for the workforce |
Band 2 or 3 |
| E.2.1 Students continuing their programme in placements under standard E2 will be provided with protected learning time | Students continue to have theoretical learning for 20% of their programme |
| NMC Emergency Standard | Rationale | NHS Staff Council job banding and job description |
|---|---|---|
| E3. Students may spend 100% of their programme in theory/academic learning | Clinical placements can be paused for the duration of the state of emergency. Encourage students to continue with their studies, focusing on the theoretical aspect of their learning |
|
| NMC emergency standard | Rationale |
|---|---|
| E5. All students will receive support, supervision and assessments in line with the Standards for Student Supervision and Assessment (NMC, 2020) | All of those programmes which have not yet moved to the Standards for Student Supervision and Assessment will need to immediately adopt these standards, allowing greater flexibility, by allowing any registered health or social care professional to supervise students |
| E5.1 Exceptionally, 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 | As an exception in the present circumstances, the NMC is allowing a practice supervisor to also fulfil the role of practice assessor for the same student. The rationale is to facilitate both supervision and assessment during a time of crisis |
| E6. Theoretical instruction can be replaced with distance learning, where appropriate, to support student learning, which meets the required theoretical hours and learning outcomes | This standard reinforces that institutions may undertake theoretical instruction through distance learning where appropriate |
To summarise, this group of students who opt in to becoming part of the workforce are employed full or part time, with no supernumerary status provided. Although working under contract of a healthcare organisation, they remain students, requiring supervision and assessment, enabling all NMC pre-registration undergraduate or postgraduate nursing programmes learning outcomes to be met. Table 1 provides the NHS Staff Council information regarding the grade banding and guidance on what should be included in job descriptions, with individual healthcare organisations adapting to meet local needs. Local contacts are issued to students. The NHS Terms and Conditions of Service Handbook contains the national agreements on pay and conditions of service for NHS staff under the NHS terms and conditions of service (Agenda for Change).
The NHS Staff Council also provides guidance on what should be included in a job description for the third-year student (final 6 months, on temporary register). They call this a band 5 pre-graduate nurse.
To summarise, this group of students who opt in to becoming part of the workforce are employed part-time (up to 80% practice/minimum 20% academic), with no supernumerary status provided. Although working under contract of a healthcare organisation, they remain students, requiring supervision and assessment, enabling all NMC pre-registration undergraduate or postgraduate nursing programme learning outcomes to be met. Table 2 provides NHS Staff Council information regarding the grade banding and guidance of what should be included in job descriptions, with individual healthcare organisations adapting to meet local needs. Local contracts are issued to students. The NHS Terms and Conditions of Service Handbook contains the national agreements on pay and conditions of service for NHS staff under the NHS terms and conditions of service (Agenda for Change).
Greater Manchester Supervision and Delegation Framework
The aim of the Greater Manchester Supervision and Delegation Framework is to provide clear guidance for students and practice staff working within Greater Manchester healthcare organisations regarding the supervision, assessment, safe delegation and how to support protected learning time for deployed student nurses. The framework operationalises HEE Standard Operating Procedure for the Deployment of Nursing and Midwifery Students in the North West of England (HEE, 2020a). Exemplar documents include practical ways that students can demonstrate progress towards meeting their NMC pre-registration undergraduate or postgraduate nursing programme. Although north-west centric, the principles of the framework are transferable across other universities and healthcare organisations.
Protected learning time
When considering this important area, it is necessary to be clear on what protected learning time might be. Creating a working definition minimises any ambiguity and provides the practice supervisor/practice assessor with consistency of terminology, ultimately supporting student's timely completion of their pre-registration undergraduate or postgraduate nursing programme. This also empowers the student to manage their own learning and assessment requirements.
Greater Manchester's definition of protected learning time is offered below, adapted from the Greater Manchester Trainee Nursing Associate (TNA) Working Group. Protected learning time (linked to the TNA definition) is defined as time within the working shift during which the practice supervisor/assessor facilitates opportunities for the student to achieve agreed goals/objectives and to provide student feedback and an opportunity for reflection within the working day. At other times while on duty, the student will work under the supervision of a registered nurse (this is not protected learning time). During protected learning time the student and practice supervisor/practice assessor will identify appropriate learning needs/goal(s) that support timely completion of the practice learning requirements, thus enabling the student to continue their student journey. Academic assessors also contribute to this process, having oversight of the student's progress in theory and practice. A key aspect of their role is to support students to develop professionally, working in close collaboration with the students practice supervisor/practice assessor.
On the 23 April 2020, in an email to all north-west service providers and directors of nursing, among others, HEE reported that 779 nursing students had been confirmed as deployed across the north-west of England (HEE, 2020b). This number of deployed nursing students is now even higher. In order not to overwhelm the practice supervisor/practice assessor, Greater Manchester has not attached a period of time to their protected learning time definition, such as 3 hours per week, although some healthcare organisations have chosen to do so. Greater Manchester encourage the practice supervisor/practice assessor, and student to think creatively and flexibly, especially around the assessment process.
Examples of creative and flexible approaches to the assessment include providing and facilitating opportunities for students to practise skills such as medicine administration and injection technique. Sharing knowledge with the student, demonstrating how to put that knowledge into practice, for example through discussion after handover is a different approach to take. Observations can be used as an effective method, with the practice supervisor/practice assessor, providing constructive feedback on student performance in the practice assessment document. Supporting students to reflect on learning is a further assessment approach that can be applied.
During the protected learning time, the practice supervisor/practice assessor should facilitate opportunities to achieve that learning need/goal, providing timely feedback. Students should also provide evidence to the practice supervisor/practice assessor of what they have learned, collating and documenting evidence from the range of health professionals and staff with whom they have worked.
By the end of the identified protected learning time allocated, students should ask the practice supervisor/practice assessor to sign either via the electronic practice assessment document or using a paper-based feedback sheet, when they have observed the student undertaking an episode of care. Table 5 provides practical examples of how students can demonstrate what they have learned and what protected learning time may look like by applying the creative assessment approaches previously discussed. An electronic blank template of Table 5 could be created so that students can use this in times when the electronic practice assessment document is unavailable or inaccessible to the practice supervisor/practice assessor. The practice supervisor/practice assessor should agree the skills and procedures to be assessed as these will be specific to the university programme and NMC nurse standards.
| This feedback sheet supports the student in collating evidence from the staff with whom they have worked. They should ask the practice supervisor/practice assessor to complete this when they have observed the student undertaking an episode of care while undertaking protected learning time | |||
|---|---|---|---|
| Name of student: | |||
| Overview of care delivery observed | Comment on student performance (eg motivation, teamwork, communication and actions for development) | Print name, signature and designation | Date |
| Worked alongside for 12-hour shift caring for a group of 8 patients, handover, multidisciplinary team meeting, medications | Was extremely confident and capable in the delivery of care and managing elements of the team. Great communication skills. However, needs to work on prioritisation elements when doing medications | Staff Nurse Nightingale | 01/05/2020 |
| Documentation of care | Used the electronic patient record system well in a correct manner, following correct procedures | Staff Nurse Smith | 02/05/2020 |
| Administration of medicines under direct supervision for 4 patients | Articulated and followed policy and five rights. Knew how to use British National Formulary. However, lacks knowledge around common medications, which needs to concentrate on | Staff Nurse Nightingale | 02/05/2020 |
| Professional standards | Professional, on time, caring nature and adhering to uniform policy | Staff Nurse Nightingale | 03/05/2020 |
| Managed safe discharge of patient back to nursing home | Safely followed all procedures correctly for checking of prescription, communicated well to appropriate multidisciplinary team meeting. Needs further direction on booking of transport and ensuring relatives aware | Staff Nurse Jones | 04/05/2020 |
Supervision for deployed students
The authors advise that practice staff must be clear about the NMC's expectations for deployed students' supervision during the emergency period. For example, the NMC expect students to be supported to learn, with the decision on the level of supervision agreed between each student and the practice supervisor/practice assessor (NMC, 2020). The level of supervision can decrease with a student's increasing proficiency and confidence. Complying with NMC Emergency Standard 5.1, the practice supervisor can also fulfil the role of practice assessor.
The exact nature of the practice-based role or activity to be undertaken and the level of direct or indirect supervision required will be dependent on the individual student's experience (timing in their NMC programme and practice learning experiences).
Below are Greater Manchester working definitions of direct and indirect supervision:
The students focus and aim should be on building their confidence in managing groups of patients, using the electronic systems to record factually accurate, clear and concise documentation, improving their delegation skills, leadership skills, strong multidisciplinary team working, good communication skills and time management, while seeking opportunities to build on clinical skills where possible, and only if they have received the necessary theoretical programme components.
Despite being employed, all practice hours need to be recorded in the practice assessment document and it is the student's responsibility to ensure that this occurs. If a second-year student, third- and/or final-year student on their first 6 months of study and first-year postgraduate student chooses to work less than 30 hours per week, only the hours worked clinically should be recorded.
Assessment of deployed students
Guidance on assessment of deployed students for practice supervisors/practice assessors and practice staff is summarised in Box 1. Experience from across Greater Manchester has found that providing as much guidance and help to practice staff as possible positively supports the student assessment.
Delegating to deployed students
Created and adopted across Greater Manchester are principles for registered nurses to consider when delegating roles, activities or tasks to deployed students. Principles for students to following when considering accepting a delegated task are also offered. Both sets of principles form part of the Greater Manchester Supervision and Delegation Framework.
The NMC define delegation as ‘the transfer to a competent individual, of the authority to perform a specific task in a specified situation’ (NMC, 2019:3). The key message in the delegation part of the framework is how the registered professional is accountable for all aspects of their practice, including accountability for what they choose to delegate.
The NMC defines accountability as ‘the principle that individuals and organisations are responsible for their actions and may be required to explain them to others’ (NMC, 2019:3).
It is essential that students are delegated roles or activities by the registered nurse that they feel proficient and confident to carry out, always remaining within their scope of practice. Box 2 provides principles that the registered nurse must take account of when delegating a task or activity to the student.
Equally, each student should consider all the options before accepting a role or activity delegated to them by the registered nurse. Student delegation principles include considering if the role, activity or task is within their current scope of practice. If the delegated role, activity or task is beyond their current scope of practice, the student should question the appropriateness of this delegation with the registered nurse. The student should acknowledge any limitations of proficiency with reference to the role, task or activity to be performed and provide appropriate feedback to the delegator. It is useful is to refer to resources from the Royal College of Nursing (https://tinyurl.com/p7z8upk) and the NMC to support safe delegation: (https://tinyurl.com/y9e5y4j7).
For students to meet their nursing programme outcomes and register with the NMC, it is useful for the practice supervisor/practice assessor and student to consider the types of learning activities that the student may need to achieve. This information can then be used to inform the delegation decision-making process. Table 6 provides examples of pre-registration undergraduate or postgraduate nursing programme knowledge and skills that students may already have gained, are maintaining or are working towards. The examples are taken from the four Greater Manchester universities student electronic practice assessment documents. Proficiency and confidence should be assessed on an individual basis before delegation and should reflect the level of direct or indirect supervision required. The practice supervisor/practice assessor are advised to ensure adequate questioning, review of student's feedback and observation for each student.
| Year 2 knowledge and skills (dependent on university attended) | Useful delegation questions | Year 3 knowledge and skills (dependent on university attended) |
|---|---|---|
| Consent and capacity |
|
Whole body assessment and person-centred care, respecting culture and diversity |
| Self-harm | Consent and capacity | |
| End-of-life care | Record keeping | |
| Communicating care and treatment | Working in partnership with people families and carers | |
| Care planning and record keeping | Communication skills to support therapeutic interventions | |
| Skin integrity and wound care | Recognising signs of deterioration in physical and mental health | |
| Nutrition | End-of-life care | |
| Neurological observations/seizure management | Specific nutrition and hydration needs | |
| Management of falls | Specific elimination needs | |
| Respiratory assessment, airway management | Manages procedures in assessing, providing and evaluating care | |
| Venepuncture and cannulation | Communicating care and treatment | |
| Sepsis | Self-care | |
| Positive risk taking | Medicines management | |
| Inserting, managing and removal of urinary catheters | Working within scope of practice | |
| Cardiac assessment | Understanding members of the multidisciplinary team and scope | |
| Resilience | Quality improvement | |
| Discharge planning and transfer | Accurate risk assessments and escalation processes | |
| Anxiety and de-escalation | Evaluating quality of people's complex care applying appropriate inventions if/when necessary | |
| Medicines management | Breaking bad news and difficult conversations | |
| Manage and monitor blood component transfusions | Safe discharge and transition of people with complex care needs; acting as advocate where appropriate | |
| Management of parenteral devices (under direct supervision) |
Conclusion
This article has provided practical guidance for practice staff (practice supervisors/practice assessors and registered nurses) on how to support student nurses who have opted into a paid (deployed) healthcare role. Creating a protected learning time working definition removes any ambiguity and provides the practice supervisor/practice assessor with the consistency of terminology and practical and consistent local application. It is advised that practice staff are clear about the NMC's expectations for deployed students' supervision during the emergency period and that the level of direct or indirect supervision will change depending on the student's proficiency and confidence. Providing as much guidance and help to practice staff positively supports the student assessment.
Finally, the key messages around delegation is how the registered professional is accountable for all aspects of their practice, including accountability for what they choose to delegate. It is essential therefore that students are delegated roles, activities or tasks by the registered nurse that they feel proficient and confident to carry out, always remaining within their scope of practice.