This article discusses the findings of a research project that explored the impact of a coaching approach in preparing pre-registration nursing students for their next stage of learning (or registration) and to determine whether students perceived this approach as helpful in increasing confidence.
The development and implementation of the ‘student coaching in practice’ (SCiP) approach is discussed. The term SCiP was chosen from a range of ideas received from practice partners across three UK NHS trusts and students across years 1, 2 and 3 of their pre-registration nursing programme. The term was felt to encompass the approach of practice supervision proposed. Although not a specific aim of the research project, as part of SCiP implementation, practice capacity was significantly increased.
Background
Coaching is a term that is used across a multitude of disciplines including health care and is not a new concept (Lobo et al, 2014; Clutterbuck et al, 2016). In the UK nursing arena, supervisory coaching as a concept is gaining impetus (Ashworth, 2018). This has been encouraged by the introduction of the Standards for Student Supervision and Assessment (SSSA) (Nursing and Midwifery Council (NMC), 2019), and a need to improve placement capacity for nursing students. Coaching does not require the same level of one-to-one mentorship described in the previous NMC Standards to Support Learning and Assessment in Practice (SLAiP) (NMC, 2008). However, it does continue to promote support and supervision to students in achieving their learning goals.
The various mentorship models have not always encouraged independence in learning and may unknowingly actively discourage nursing students from ‘scaffolding’ knowledge and skills to build confidence in their transition to registration (Gusar et al, 2020). Much of the literature has suggested that mentorship is useful for more junior staff where more intensive demonstration and supervision is required. However, this approach should be adapted as students progress (Gopee, 2018). Although coaching can also incorporate mentorship elements in the learning relationship, it is important that the change in learning philosophy should be embedded within all organisations involved, and all parties understand the aims of this approach (Clutterbuck et al, 2016).
Coaching as a learning philosophy
Coaching is a fundamental element of leadership and incorporates role modelling at its roots. However, role modelling in this instance also constitutes a questioning, probing approach that encourages the learner to think, reflect and reason why. Drawing on an evidence base to work through planning, implementing and delivery of care, in addition to contemplating possible problems and solutions, helps the learner to gain confidence in discussing and proposing their ideas in a safe environment. The coach should be prepared to ‘let go’ to promote independence but be available to consider and support the next and subsequent areas of learning, which the student should identify for themselves (Bachkirova et al, 2016).
Models of coaching supervision include GROW (Goal, Reality, Options, Way forward (Whitmore, 2009) and OSCAR (Outcome, Situation, Choices/Consequences, Action, Review) (Gilbert and Whittleworth, 2009). These models are primarily process driven and can help structure the student/coach sessions, and foster an inquiring learning relationship. These were the models of choice for this project across the three NHS trusts involved and are indicated in Table 1. Students are encouraged to ‘own’ their learning and develop their decision-making skills in a meaningful way to improve practice. Principles of coaching can be adopted by all supervisors and assessors when helping student nurses to learn, but this does require understanding of the aims, process, support and evaluation of the coaching role.
Table 1. The GROW and OSCAR models of coaching
| The GROW model | ||
|---|---|---|
| G | Goal | What do you want to achieve?Objectives |
| R | Reality | Where are you now?Ask for feedbackComplete a self-assessment |
| O | Options | What do you need?Who can help?What can you do to bridge the gap?Brainstorm |
| W | Way forward | What are the action points?Commit to the actionIdentify stepsConsider timing and action plan |
| The OSCAR model | ||
| O | Outcome | Determine the outcome and goals of the session |
| S | Situation | Clarify current situation and feelings |
| C | Choices | Generate choices and consider their consequences |
| A | Actions | Define the next steps and their choices of actions/process |
| R | Review | Develop a plan to review the process |
Source: adapted from Whitmore, 2009; Gilbert and Whittleworth, 2009
Preparation for the coaching initiative
Primary source literature relating to coaching models used in pre-registration nursing programmes is currently limited, with much of the literature being descriptive in nature. When coaching is used as part of peer learning, it has also been found to encourage teamwork and confidence in those who are involved in ‘teaching’ fellow students in practice and those who learn from their peers (Bennett et al, 2015). The Collaborative Learning in Practice (CLiP) and Practice Learning at Northampton (PL@N) models draw on initial research from The Netherlands to implement a coaching approach in pre-registration nursing programmes (eWorkforce Information Network (eWIN) and Health Education England (HEE), 2016). The SCiP approach is based on these models, using GROW and OSCAR as previously discussed. In a study by Knowlton (2017), coaching with peers was also suggested as an effective way of managing perceived stressors identified as part of undergoing a baccalaureate nursing programme.
Previous studies have identified a lack of confidence in newly registered nurses and difficulty in transitioning from student to registered nurse. These areas are often highlighted as student-identified weaknesses on completion of their nursing programme, with resulting national initiatives recommending more effective teamwork and supervision (Morrell and Ridgway, 2014; Willis, 2015; NMC, 2019). Coaching approaches may help to implement a change in approach to student learning, with the literature making tentative suggestions of numerous benefits for both students and staff through implementing a coaching model. These include increased job satisfaction and retention, increased student-led supportive environments, increased confidence in taking part in ward rounds, and preparedness for registered practice (eWIN and HEE, 2016; Clarke et al, 2018). However additional research to evaluate how these approaches are affecting students' perceptions and behaviours is needed to build an evidence base for future roll out of these types of initiatives.
A steering group involving senior academic staff linked to practice areas, work-based learning administration leads, and practice partners from three NHS trusts met monthly to agree a coaching approach, how to prepare practice staff, how to prepare students, and dissemination of project aims/information to the wider multidisciplinary healthcare team. This was fundamental to ensure a whole-systems approach for success and included allied health professionals, doctors, and non-registered staff such as receptionists and porters. A SCiP champion was identified from each NHS trust to promote the initiative in practice through local events and communication marketing. These champions were practice educators/facilitators who were instrumental to the project's success. Workshops were held in placement areas and the university to gather support, discuss ideas, seek solutions to potential problems, and disseminate information. Lessons learnt from both CLiP and PL@N were shared to ensure preparation of staff and students remained the focus of this initiative.
Eight placement areas were initially identified to form the research project setting. Learning environment profiles (practice audits) for these areas were reviewed before they were included. These eight areas covered outpatient, adult acute and community-based placements. Practice staff and relevant academic staff received coaching information sessions and training from an external coaching consultant. SCiP champions, who were predominantly practice facilitators/educators, also co-ordinated in-house training at each trust. The project period was nine months to allow for inclusion of various cohorts of all year groups from the adult pre-registration nursing programme.
SCiP champions from each trust, project leads and allocated academic staff visited placement areas throughout the 9-month project to offer support to students and practice staff in implementing the model and address any concerns raised.
Aims
The aim of this research was to evaluate the impact of the SCiP approach. There were two objectives:
- To determine if SCiP has helped in preparing students for the next stage of practice learning or registration as a nurse
- To determine if students perceived SCiP as helping to increase their confidence in practice.
Ethical approval
Ethical approval for the research project was gained from the university ethics committee.
Methodology
An evaluative survey design was chosen for this study using a mixed-method strategy. This is defined as ‘the collection of information from a sample of individuals through their responses to questions’ (Check and Schutt, 2012: 160). This reflects the purpose of the research and the purposive recruitment of participants to ensure representativeness (Ponto, 2015). A social constructivist approach underpinned this research, whereby individuals are understood as constructing meaning in the contexts in which they are situated.
Second- and third-year students will have experienced previous models of mentorship. The assumption is that these groups of students will have shaped their understanding of this learning process and been influenced through the culture they have been exposed to. First-year students may not have been exposed to previous models of mentorship or supervision, which will also affect their responses and understanding of how the SCiP model informs their learning journey.
However, interpretation of the environment around us is fluid and identity is not fixed, with Crotty (1998) describing this as a constant state of ‘becoming’. Therefore, it is acknowledged this research project will only present findings of participant responses at this particular point in time, with views and perceptions continuing to emerge and develop as future events are experienced. The findings from this project are not proposed to be generalisable, but may be transferable.
Method
First, participant information sheets were distributed to all adult field students allocated to the identified placement areas during the research period. This consisted of 97 students in total. Consent forms were collected from those who agreed to take part in the study. These were anonymised and only coded in terms of year group for the purpose of analysis. Questionnaires incorporating closed and open questions were administered to all students to evaluate their experience of SCiP. Questions focused on their experience of the approach in developing learning and skills, preparing for the next stage of practice/registration, and perceived effects on confidence. Responses were placed in a sealed envelope and returned to the project lead.
Questionnaires give an opportunity for participants to record their experiences and give reasons for their answers in a safe, confidential way. Using both open and closed questions encourages respondents to develop a narrative and provides further insight into closed question responses, prompting additional thinking around answers given. It was acknowledged that further probing and clarification of responses would not be achievable with this method of data collection. However, it was felt that individual interviews may be intimidating for nursing students and may not necessarily encourage them to be completely frank in the data needed to provide a full analysis of their experiences and perceptions. It is also acknowledged that questionnaires may have a low response rate and may therefore not be representative of the population sampled. To mitigate this, questionnaires were personally handed out to students by the project chair, allocated link academics and practice facilitators during the last week of the students' placement allocation.
Sample
A purposive sample was used for the study. Eight placement areas including outpatient, acute medical, and community hospital areas were identified across three NHS trusts to implement the SCiP approach. These placement areas only offered placement opportunities to those nursing students studying the adult field programme. All student nurses allocated to these placement areas over a 9-month period were invited to take part in the project. One placement area withdrew early in the project due to a reconfiguration of services and staff reallocation.
From the remaining seven placement areas, 97 eligible pre-registration nursing students were allocated to these areas and invited to take part in the research project. In total, 70 students (72%) returned the questionnaires, consisting of 20 year 1, 23 year 2, and 27 year 3 students. This can be seen as a good response rate and representative of the sample population (Parahoo, 2014).
Data analysis
Descriptive statistics were used to present quantitative data collected from closed questions. These indicated each student year group and the number of yes/no responses. From a social constructionist framework, multiple realities exist with all responses accepted as each student's construction of reality. Braun and Clarke's (2006) stages of thematic analysis were drawn upon to generate meaning from open question responses, using an inductive approach. These were: familiarisation with all the data, generating codes, identifying themes, reviewing themes, defining and naming key themes and, finally, writing up themes into a report. This method is consistent with a qualitative approach in questionnaire response analysis.
All data were managed manually to allow the author to immerse herself in all responses received so as to understand and reflect on the data. No data were reviewed until all responses had been received up to the deadline date for submission, to minimise bias towards a particular narrative (Silverman, 2016).
Rather than looking for certainty in data results, participant meanings and interpretations are the focus in qualitative research, with Polit and Beck (2018) suggesting that researchers' accounts will only be representations of that reality, rather than reproductions of it. It is acknowledged that another researcher could undertake this study and interpret responses differently, and others' perspectives are equally valid. Therefore, validity as a term may be better understood as confidence in the interpretation and representation of the data. Student participant checks of their responses were not seen as a process that would increase the validity of this study in interpreting meaning so were not undertaken.
Three themes were identified from the qualitative responses received: peer and staff support, increasing confidence, and preparation for registration.
Results
The following quantitative findings are presented in Figures 1–3 from the closed questions posed:
- Has SCiP been beneficial in developing your learning and skills in practice?
- Has SCiP helped prepare you for your next stage of practice learning or registration?
- Has SCiP helped to increase your confidence in nursing practice?
Qualitative findings are presented within themes that were generated by responses given to open questions asking students to explain the reasons for their answers to the above questions.
The findings suggest that the majority of participants across each year found SCiP beneficial in developing learning and skills in practice, helped prepare for the next stage of learning or registration, and helped increase confidence. However, it was also noted that most positive responses came from students from year 1 and year 3. Qualitative comments indicated below probe the reasons for these responses.
Peer and staff support
Students were asked how SCiP had helped to support their learning and were asked for examples of how this had been achieved. Students across year groups were positive of the peer learning encouraged through the use of the SCiP approach, with first-year students in particular feeling more able to ask fellow students questions, rather than asking registered staff. Third-year students also benefited from this peer learning through developing their skills in teaching and coaching fellow students. This is supported in previous literature, suggesting peer learning is of benefit for students in the clinical setting (Bennett et al, 2015). Student comments included:
‘It was great to have other more senior students to talk to and ask questions. You don't feel stupid asking something that I wouldn't ask a qualified nurse.’
Year 1 student
‘The first few weeks were great as we had second- and third-year students who were extremely helpful and had time to show me skills and explain them in detail. I felt really supported and knew my coach was overseeing things.’
Year 1 student
‘I didn't want to be placed here when I knew it was going to be a different model to what I had been used to, but it's really helped me to learn about coaching and how I can use it to help other students learn. A first year I had been working with said she's learnt so much from me today … it felt really good.’
Year 3 student
Although many second-year students also reported that SCiP had been a positive experience, they raised concerns that they did not always get an opportunity to participate in some learning activities to develop their leadership and coaching, although they did feel supported by their coach in practice. This may also have been attributable to their understanding of leadership as a concept, with it being associated with leading a team or taking charge, rather than leading effective planning and delivery of care. Leigh et al (2019) suggested that coaching and leadership, although different concepts, should be understood as linking together to achieve maximum effects. Student comments included:
‘I think as a second-year student, I missed out a bit on developing my leadership skills as the third years tended to take this role, but I did work well with first-year students and we helped each other in planning care for our identified patients. My coach was really good in helping us to question our thinking.’
Year 2 student
‘I didn't feel SCiP really helped me in terms of learning any more than the previous system. I felt, at times, there were too many students in this placement so I didn't always get a chance to participate in some of the things that I would have liked to … such as taking charge of a bay of patients.’
Year 2 student
As discussed earlier, the preparation of staff has been seen as imperative to ensuring success. Despite strategies to ensure this project was disseminated and understood by all staff, it did become apparent from the participants' responses that, in some cases where new clinical staff had joined the SCiP placement area, understanding of the approach was not always evident. However, the majority of participants reported a positive coaching experience from staff. This does suggest that ongoing support for all staff involved in the SCiP approach must be maintained to ensure ongoing success and reflects experiences of other institutions involved in the initial CLiP project (eWIN and HEE, 2016). Student comments included:
‘Students were split up on different sides of the ward area, so it meant we didn't work together much. Some newer staff didn't really understand how SCiP was meant to work, which meant it varied depending which staff or coach you were allocated to.’
Year 2 student
‘My coach was brilliant! She really challenged me to develop my practice skills and my understanding of these. I would love to work on a SCiP area when qualified.’
Year 3 student
‘It has helped me develop my leadership and delegation skills in practice. My coach gave me more responsibility, which was scary at first, but I am glad she did. SCiP is obviously new to this ward and some staff really embraced it and were really into it, like my coach, but I think some staff struggled with it.’
Year 3 student
Increasing confidence
Across all year groups, an increase in confidence was apparent among the majority of respondents, particularly among year 3 students. This may suggest that year 3 students are expected to be more knowledgeable and skilled in their final year of a pre-registration nursing programme, and participants may have felt they ‘should’ respond as being more confident, as this is what would be expected. Nevertheless, examples shared of how their confidence had increased demonstrates understanding and reflection on reasons for their responses:
‘It has made me step up and be responsible for my own learning. I feel so much more confident now. You don't rely on your mentor for everything like I did on previous placements because you are questioned and challenged by your coach, you think about the answers yourself. I planned a discharge for a patient, organised medications, contacted the community nurses and family, everything really.’
Year 3 student
‘Because I was encouraged to lead the care for a bay of patients, plan what staff would do, evaluate with my coach, it felt as though I was trusted. The coach was always there to ask but it gave me confidence in my own ability.’
Year 3 student
Year 1 and year 2 participants also gave a majority of positive responses, although year 1 students acknowledged that this was only their first placement and did not feel confident in general. However, some students felt that working with more senior students actually lessened their confidence because they realised how little they knew compared with some of their peers. This is in contrast to much of the previous coaching and peer learning literature, which predominantly reports positive feedback from adopting this approach. Student comments included:
‘It has made me realise how much I do know when I am given a chance to deliver care with a team of students and other healthcare staff. The coaches are there but you are given more freedom and that has increased my confidence.’
Year 2 student
‘As a first-year I still feel I have a long way to go when I see how much knowledge second- and third-years have. I have felt my confidence is increasing through asking more questions and learning from other students but I don't feel more confident in my nursing care yet.’
Year 1 student
‘The coaching system is much better in helping you learn and I hope all wards do this in the future. My coach helped me to increase my confidence through letting me do things and encouraging me to give it a go. Obviously we talked things through first, she asked me what I felt was the best way, rather than telling me what to do.’
Year 2 student
Confidence is notoriously difficult to measure (Eraydın and Karagözoğlu, 2017) and these findings must be viewed as the respondents' own interpretations of what confidence means to them. It is acknowledged that this research does not postulate a definition of confidence or provide a working definition of this concept to respondents. However, it does provide some insight into students' own perceptions of how the SCiP approach contributed to their perceived confidence during their individual experiences.
Preparation for registration
Respondents were asked whether they felt their experience of SCiP prepared them for the next stage of their learning and whether, in their final year of study, it had prepared them for registration. Many stated that they felt prepared for their next stage of learning but some respondents from years 1 and 2 found it difficult to articulate the particular impact of SCiP in these responses. Some stated that confidence had increased, and peer learning had helped their progression, repeating responses identified in the first two themes. However, year 3 students did indicate they felt SCiP specifically helped them in their preparation for registration.
‘It has definitely helped me prepare for registration as a nurse, mainly improving my teamwork and working relationships with a range of people.’
Year 3 student
‘SCiP has helped me improve my teaching skills and thinking about how I explain things to others. I think this is essential as a new staff nurse as I will be a role model for student nurses, so it's definitely helped me prepare for registration.’
Year 3 student
‘SCiP has made me feel much more prepared to qualify as a nurse. I have learnt more about organisational skills and co-ordination of care from my coach. I have felt able to have a voice and justify my decisions. I wasn't able to do this on my previous ward placement, even though I was a third year. The coaching approach is something I want to develop further as a qualified nurse.’
Year 3 student
Respondents from year 3 were very keen to develop their own coaching role as a registered nurse and could see the benefits of the SCiP approach in preparing them for their own role as supervisors and assessors for future nursing students. They were positive in taking these initiatives forward to share with colleagues and peers, which correlates with previous literature suggesting coaching can increase confidence, job satisfaction, and increased supportive environments for students (Bennett et al, 2015; Clarke et al, 2018). However, as with any managed change, momentum must be maintained to encourage the initiative to be successful. Additional comments from respondents highlighted the need for sharing experiences to motivate other practice areas to adopt the SCiP approach. Year 3 student respondents, in particular, saw themselves as helping lead these changes in their new registrant roles.
Other findings
As a result of introducing the SCiP approach, an additional 58 placements were made available for students. This was because a larger group of students can be overseen by a coach rather than the traditional one-to-one mentor approach. Students were able to work and learn from each other to plan, discuss and deliver patient care under direct supervision from their allocated coach. A different coach/supervisor can be allocated each day so it does not require the same member of staff to oversee an individual student for the duration of their placement experience. Students are empowered to be directly involved in patient care and take responsibility for their own learning.
Limitations
This was a small research study over a limited time period, consisting of three trusts in one regional area. It was not the aim of the study to make generalisations to student nurse populations, although it is acknowledged that some of the findings may be transferable to other student nurse populations and institutions sharing similar characteristics. It is acknowledged that these findings relate to adult field students only.
It is acknowledged that students involved may have felt obliged to complete a questionnaire as part of this study.
Conclusion
SCiP, as an approach to student learning, appears to be successful in increasing student confidence across the three years of a pre-registration nursing programme and preparing students for their next stage of learning and nurse registration. The findings from this study support previous literature advocating peer learning and also suggest that coaching supports growth and empowerment of student nurses in preparing for their next stage of learning or registration as a nurse. Although increasing placement capacity was not the primary aim, the impact was noticeable, with an additional 58 placements offered to students in these areas during the project. This demonstrates a measurable impact and suggests that using a coaching approach provides an opportunity for considerable placement growth for future cohorts of nursing students.
With coaching approaches being adopted to meet standards of supervision and assessment in undergraduate UK nursing programmes, it is fundamental that the impact of these approaches is further studied to provide a robust evidence base for future implementation.
Recommendations
Hospitals and trusts adopting the SCiP approach must prepare support staff who will be providing the coaching in the initial phases of implementation.
Students must be adequately prepared in the higher education institution (HEI) setting to understand their role in becoming a proactive learner and the expectations of the coaching approach.
Further research to replicate this study in other HEIs and practice areas, including primary care and independent sector placements, would add to the body of knowledge currently available.
KEY POINTS
- A coaching approach was shown to be beneficial in developing learning and skills in practice
- Students who participated in the scheme reported that it helped to improve their confidence
- In this study, the coaching initiatives were implemented in both acute and community settings
- The use of a coaching approach can help to increase placement capacity
CPD reflective questions
- Consider how you currently support student learning. How does this compare to a coaching approach?
- Consider the suitability of your clinical area in adopting a coaching approach. Discuss with your colleagues if this would be something you could adopt and identify what support you would need
- Consider the differences and similarities of a coaching approach compared with mentorship. Discuss this with your colleagues to generate debate