Educational institutions, alongside practice learning partners, should ensure students experience the variety of practice expected of registered nurses if they are to meet the holistic needs of people of all ages, the Nursing and Midwifery Council (NMC) (2018a) has said. When nursing students arrive in practice placements, they often find they settle in best in areas where they are considered not simply ‘the student’ but are acknowledged and called by their name. Tutors, visiting placements from higher education institutions, have noticed that being referred as ‘the student’ can cause students to withdraw and try to blend into the background of the practice environment almost like a chameleon (Levett-Jones and Lathlean, 2008; Melincavage, 2011).
The aim of this paper is to explore the significance of offering a meaningful welcome to a practice placement and how this is integral to influencing a positive learning experience.
A preregistration nursing curriculum should provide an equal balance of theory and practice learning (NMC, 2018a). The duration of placements can vary, which inevitably means students can have a rather nomadic existence, adapting to new staff, styles of working and environments. Emanuel and Pryce-Miller (2013) considered that, in undertaking various placements, student nurses have to adjust between one area and the next and fit into the social and professional environment of that placement. This can be challenging and increase the pressures student nurses feel.
Encouraging student nurses to feel part of the team from the outset of a practical placement has benefits for all concerned. Cohesive teams have a positive impact on the quality of care patients receive and on staff wellbeing. When students feel they belong, they become purposeful earlier on, in terms of both the care they deliver and the depth and breadth of their learning (Levett-Jones and Lathlean, 2008).
Students themselves emphasise how much time and effort they need to invest in fitting into a team before they can turn their attention to learning about the area of practice. Yet they feel this time is worth investing because, once they are included, they gain access to more meaningful and complex learning experiences (Gilbert and Brown, 2015).
In areas where a culture of belongingness is embedded, students feel they are respected as potential future colleagues (Kern et al, 2014). This motivates them to persevere in mastering the more complex and technical elements of the care environment. It also boosts their opinion of the suitability of the area as a place to work once registered (Bradbury-Jones et al, 2011) creating a win/win situation for the student and the clinical area.
Undergraduate nursing programmes in the UK are transitioning to the new NMC standards framework for nursing and midwifery education (NMC, 2018b; 2018c; 2018d). This will also mean adjustments for those who support students in practice learning environments. The mentor role is to be superseded by two new roles: the practice supervisor and the practice assessor (NMC, 2018c). Practice supervisors will be responsible for providing inclusive, tailored learning experiences that enable students to meet their learning outcomes. It is important that this inclusive approach includes making students feel welcome and valued as a member of the healthcare team. In view of these new titles, the term practice supervisor rather than mentor will be used throughout this article.
You're welcome
Timely notification of a student being allocated to a placement is essential so the clinical area can prepare for their arrival. Once the name and year of study of the student are known, who will supervise the student will then need to be carefully considered. Foresight is imperative when deciding on a supervisor.
A supervisor should ideally be available for the majority of the placement, rather than someone who is due to have an extended period of time off. This will provide consistency to the student-supervisor relationship and facilitate a greater validity and reliability in the feedback the supervisor gives to the practice assessor (Royal College of Nursing (RCN), 2017). Having a named supervisor as soon as possible, preferably before the placement starts, can be reassuring to the student. If the supervisor is not available in the first few days or week, it is preferable that a named member of trained staff is allocated to the student as a second supervisor (NMC, 2018c). In a time of transition, being able to put a face to a name and having someone who they can approach can instil a greater certainty and can aid introduction to the new clinical practice placement (Abrams and Davis, 2017).
As well as expecting a student, making provision for them in the form of having a roster of shift patterns is imperative (Vinales, 2015). It enables them to plan and offers structure, which can facilitate student wellbeing. This is an important consideration; the average age of a student nurse is 29 years so they will have a number of important primary and secondary roles outside the healthcare setting, such as being a parent or a carer, or having another job. How this is configured can vary from being formal to allowing students to organise their own roster; however, nurse:student ratios for each shift need to be considered to ensure sufficient support at all times.
Doyle et al (2017) identify two components for a successful placement for nursing students, which are ‘happy to help’ and ‘happy to be here’ (to be discussed below). The happy to help component is more valued in terms of satisfaction rates because it relates to the culture of the placement and the affirmation and welcome students receive. If this is positive, students feel comfortable and therefore are better able to learn (Williams and Palmer, 2013).
A preliminary interview with the student is essential and should take place as soon as possible. Emphasis should be on effective two-way communication and a thorough understanding of the student's perception of their clinical environment (Brown et al, 2011). This can facilitate a student-centredness that can respond to student needs (Lindahl et al, 2009). Box 1 lists what the preliminary interview should include.
Starting a new placement can be stressful for a student. A smile and showing students where they can leave their belongings may seem small gestures but are important to someone who is inevitably anxious.
Induction programmes
To aid the transition into a placement, many clinical practice areas run an induction programme. There are a wide variety of these, and they can be organisational and departmental. These are time efficient if a large number of students are starting at the same time who can offer peer support for those attending.
If placements do not have the time to deliver an induction programme, alternatives such as induction booklets given to students before placement or on the first day can be useful for the student. An online induction package to welcome students on placement can be implemented (Reynolds and Kaur, 2016). This approach addresses the difficulties of students having placements at different times of varying durations and at different areas; attending an induction programme could be problematic if the student has to travel a long distance.
Goose (2009) described how an induction programme (Box 2) was introduced for nursing students. A part of this was orientation, which included a ‘warm welcome’, with an emphasis placed on the student being an integral member of the team. Other key features include students highlighting their hobbies and interests, previous placements and their expectations and fears for the placement. It also enables staff to identify students' expectations. This dialogue is an important introduction.
Some areas have found that an induction programme facilitates a quicker transition, particularly in a more acute environment such as the operating theatre. Cowen et al (2016) considered how simulation as part of an induction programme can enable students to practise skills and communication. Although a high-acuity placement can cause anxiety, offering close supervision can lead to a range of invaluable skills being developed (Williams and Palmer, 2013).
Creating belonging moments
The nursing student enters new placements where relationships are established and routines well known. Starting a placement can be stressful for a student and this can impede learning both before and during a placement (Williams and Palmer, 2013).
Grobecker (2015) considered how ‘belonging’ is a fundamental human need and that, if a student feels they belong, this has a positive effect on their learning, motivation and confidence. Vinales (2015) highlighted how belongingness is essential to the success of a student and identifies attributes of a good role model and how these can influence whether the student fits in. Carr and Walton (2014) have shown that inclusive working environments share a number of characteristics that increase a sense of belonging and togetherness (Box 3).
| Create a ‘hello’ culture |
|---|
| A culture in which everyone is greeted with a smile and a ‘hello’ makes a big difference |
| The first ice breaker signals genuine willingness to include students in the team |
| De-escalation of student anxiety starts here |
| Make unique introductions |
| Tell the student an interesting snippet about each person to help them become memorable |
| Non-verbal cues are important in demonstrating mutual respect and trust behaviour between team members |
| Provides a series of connection and security, which enhances two-way communication |
| Be interested |
| Ask the student some questions about themselves and actively listen to their answers |
| Seeking a student's views about aspects of care shows their contributions are welcomed |
| Creates a feeling of having a valid voice in the team and encourages deeper reflection |
| Foster participation |
| Early on, give students jobs to complete alongside team members rather than in isolation |
| Later on, delegating meaningful roles signals to students that they are trusted team members |
| Sharing a common sense of purpose encourages greater perseverance and engagement |
| Acknowledge contributions |
| Actively give feedback when a student has done a good job to increase feelings of ownership |
| This only needs to be a short comment, such as ‘good job’, to boost role satisfaction |
| Students will begin to believe in themselves and be motivated to tackle more complex elements of care |
| Share stories |
| Tell the student stories about yourself to illustrate how we learn from each others' experiences |
| Listening to stories prompts release of cortisol and oxytocin, which helps to boost feelings of empathy |
| Storytelling is a powerful way to foster social cooperation and develop bonds |
A few relatively simple actions, which require little effort to achieve, can have a big impact on student nurses. Here are six ways to create ‘belonging moments’.
Create a ‘hello’ culture
The ‘Hello my name is …’ campaign (Grainger and Pointon, 2014) has made a huge contribution to humanising the first contact between patients and healthcare workers. The authors suggest that this excellent meeting and greeting practice ought to be extended to all students, who can often feel equally bewildered and anxious when entering a new environment, albeit for different reasons (Melincavage, 2011). A culture in which everyone greets the new student with a smile and ‘Hello, how are you?’ makes a big difference to the first impression of how welcoming an environment is. This first ice breaker gives an important psychological signal to students that there is genuine willingness to bring them into the team (Wesselmann, 2012). This immediately begins to reduce students' anxiety, and helps them to become embedded into the environment much more efficiently.
Make unique introductions
Students should be introduced to team members in a memorable way. People are social beings and need to make connections; This is easier if they are given cues to help them remember individuals (Abrams and Davis, 2017).
One way to achieve this is, when making introductions, to tell the student an interesting snippet that is unique to each person rather than just their name and role. An example could be: ‘This is Penny, our physio—she is our resident marathon runner.’ Using the word ‘our’ in the introduction is key as it increases the sense of being in a team.
Non-verbal cues used during the introduction are important Knapp et al (2014); leaning slightly towards the person, nodding faintly and keeping hands and arms relaxed and open can demonstrate that team members have mutual respect and trust one another (Smith et al, 2010). Such introductions give the student a sense of connection and security so they feel more able to communicate with team members.
Be interested
Start by asking students some simple, genuine questions about themselves; this shows that you are interested in them as a person not just as ‘the student’ (Rogers and Smith, 2011). Follow this up by listening to the answer and making an appropriate response. This type of active listening indicates to the student that their contributions will be valued during this placement. These strategies significantly improve a sense of inclusivity for new team members (Watson, 2015).
As the placement progresses, seek the students view's about aspects of care and show them their opinions have been heard by following up with some relevant questions. They will then sense their voice is valid within the team and feel included in group decision making (Van Zyl, 2014). This will encourage them to think more deeply about the care they are delivering as they know their views may be sought at any time. Such an inclusive approach encourages students to be engaged, reflective practitioners.
Foster participation
Dale et al (2013) pointed out that students want to feel their presence is valued and this happens most effectively when they are genuinely working together with others to fulfil goals. Early on in the placement, giving students relatively simple tasks to fulfil alongside the rest of the team, rather than in isolation, can make a big difference to their perception of whether they are considered useful team members (Carter, 2012). Later, delegating meaningful roles to the student signals that they are a reliable team member who is trusted to have a positive impact (Bradbury-Jones et al, 2011). Sharing this common sense of purpose helps students to develop a social and psychological bond with the team (Kalisch et al, 2010) and encourages much greater levels of perseverance and engagement, including when they are faced with challenging new experiences.
Acknowledge contributions
Feeling someone has noticed when you have done a good job increases a sense of ownership and satisfaction. This spurs students on to replicate good work and ‘go the extra mile’ to further improve their practice and become more self-directed in their learning (Levett-Jones and Lathlean, 2008). Even a short comment such as ‘good job’ can make the difference between a student feeing their contributions have been overlooked, and feeling appreciated (Uren and Shepherd, 2016). The more people take notice and comment, the more the student will sense they are making a valued contribution that the whole team acknowledges (Morrison and Brennaman, 2016). This motivates the student to tackle more complex and challenging aspects of care because they begin to believe in themselves.
Share stories
Kluger (2017) pointed out that storytelling is a powerful way to foster social cooperation. Sharing stories about yourself sends a message that you care about your student enough to tell them about your own slip-ups and successes during your career. It also shows the student that people can learn from each other and generates a feeling of partnership; creating such a connection encourages the students to become a role model because they can see the nurse before them has been on a similar journey (Vinales, 2015).
Storytelling has a second powerful purpose. Listening to stories prompts the release of cortisol and oxytocin in the brain, which boost the ability to empathise and connect with others (Zak, 2014). Sharing a story is a powerful way to bond with others.
Creating a safety net learning environment
For a student to thrive in any learning environment, they need to feel safe. Facilitating an environment that offers a freedom to learn boosts confidence and self-esteem.
Attitudes of nursing staff are important in creating an atmosphere. Doyle et al (2017) identified the ‘happy to be here’ environment in their study. This concerns the atmosphere, culture, work ethics and team morale of a placement. If these are positive and learning opportunities maximised, this leads to greater student satisfaction (Lamont et al, 2015).
Thomas et al (2015) examined students' first placements and described how they can be subjected to rudeness, treated harshly or ignored. This is alarming given that nursing is regarded as a caring profession and the authors would like to emphasise if we cannot look after our own, how can we look after patients? The House of Commons Health Committee (2018), in its Nursing Workforce: Second Report, highlighted that more needs to be done to stop the 30% attrition rate on nursing courses and, given it takes three years to train a nurse, retention is a significant factor; facilitating a conducive learning environment is arguably an important factor in this. This is especially the case given that the RCN (2018) has highlighted that student nurse applications have fallen and retention has never been so important. Ensuring a student is happy can only facilitate this.
Conclusion
Within nursing, there is a workforce crisis. Newly qualified nurses now have a wealth of employment opportunities. Students remember good placements as much as they remember those that were not so good. The welcome a student receives while in a practice area and the induction that helps them to settle in quickly and feel that they belong could motivate them to return to the area as a newly qualified nurse. Rather than blending into the background, a student can be a central part of the team.
There are several recommendations for practice that arise. First, that students should be expected, and welcomed when they arrive. Second, students should be called by their name by all staff. Third, pre-placement orientation. which introduces the student to key staff and provides an overview of the placement, should be arranged. Overall, the placement area should have a philosophy of inclusivity, which covers students and other short-term visitors. Placement evaluations should review if an inclusive and welcoming environment has been created for students. It is the role of everyone working in that learning environment to contribute towards the making and not the breaking of the future workforce.