Practice learning facilitators as roaming assessors

The World Health Organization (2013) recognises the importance of increasing the number of health professionals who have the appropriate knowledge, skills and capabilities for the populations they support. This expansion is supported by the NHS Long Term Workforce Plan, which calls for a significant increase in the number of students (NHS England, 2023).

Practice learning is recognised as being central to developing proficiences and identity during training, and good placements are required to ensure students achieve well in their future careers (Immonen et al, 2019). Supervisors and assessors are central to a good experience; however, fewer skilled nurse educators are available to undertake practice supervision and assessment (Warne et al, 2010) because of increasing clinical pressures, shortages of nurses and changes in the way education is delivered (Fawaz et al, 2018).

As the demands on health and care systems continue to increase (Pandit, 2020; Propper et al, 2020; Willan et al, 2020), it is critical that these pressures do not result in the next generation of nurses losing out on the training they need to provide high-quality care to their patients (Ozdemir, 2019; Alqahtani et al, 2020; Walsh et al, 2020; Mlambo et al, 2021). One aspect of ensuring that student nurses are prepared for their professional role is the use of effective and appropriate assessors so they meet the required standards (Immonen et al, 2019; Manetti, 2019).

The Nursing and Midwifery Council (NMC, 2023a) Standards for Student Supervision and Assessment (SSSA) changed the approach to practice assessment (Pearson and Wallymahmed, 2020). The SSSA resulted in a move away from mentorship and the separation of assessment from supervision NMC (2023a). The academic assessor role was created, and there was a move from competencies to proficiencies.

Many organisations provide support for students in practice including clinical educators, practice learning facilitators (Pollard et al, 2007; Ironside et al, 2014) or preceptors who support newly qualified nurses throughout the transition to practice (Whitehead et al, 2013). These roles are in addition to the requirements and prescriptions of the NMC SSSA.

In Derbyshire Healthcare NHS Foundation Trust's (DHCFT) clinical placement areas, clinical educators or practice learning facilitators provide the assessment function as a separate service as a roaming assessor (RA). RAs may act as practice supervisors or practice assessors, or have a role in supporting people performing these functions. This role is particularly useful in small teams where there may not be enough people to take on the practice assessor role or where individuals have not undertaken the required training, or where there may not be capacity.

The assessment criteria in each part of the programme change and increase in complexity as students progress and require a higher level of practice for successful achievement. Guided participation in care and performing with increasing confidence and competence are sought in part 1, active participation in care with minimal guidance and performing with increased confidence and competence in part 2, and practising independently with minimal supervision and leading and coordinating care with confidence in part 3 (Pan London Practice Learning Group, 2018).

Students work towards completing competencies and proficiencies. These terms are often used interchangeably but they have different, distinct meanings. Competencies are a broader set of abilities, knowledge, skills and behaviours that are essential for effective performance in a professional role. They encompass not only the technical skills required for a specific job but also cognitive, emotional and social skills. Proficiencies are generally developed over time, as a professional gains experience and expertise in specific areas, and these are assessed through practical demonstrations of skill and expertise. Proficiency concerns a high level of expertise or mastery (Halcomb et al, 2016; Nehrir et al, 2016; Leigh and Roberts, 2018). Preregistration nursing programmes usually involve a range of assessments on aspects of proficiencies (Table 1).

Practice learning facilitators and roaming assessors

A practice learning facilitator is a health professional who plays a key role in supporting and facilitating the learning and development of student nurses and other healthcare students during their clinical placements. Practice learning facilitators are responsible for creating a supportive, educational environment in which students can gain hands-on experience and apply the knowledge they have gained in their academic programmes.

The role of the practice learning facilitator can vary depending on the context and setting, but they typically work closely with students, clinical supervisors and academic staff to help ensure students receive a high-quality clinical education. This may involve providing guidance and feedback to them, facilitating reflective practice and helping to coordinate assessment activities.

In some cases in DHCFT, practice learning facilitators may also be involved in student assessment, either by working with academic staff to carry out assessments or by acting as RAs, who observe students in practice and provide feedback on their performance. Practice learning facilitators tend to be employed by health or care organisations.

An RA is a health professional who is responsible for observing and assessing students' performance and progress in clinical practice. RAs typically move from one student to another rather than being assigned to a specific student for the duration of a placement, hence the term roaming. However, students may receive support from the same RA on more than one occasion. This could be because the student has been allocated to a team the RA is supporting or if learning and development issues have been identified.

In the context of nursing education, roaming assessors are typically nurses who have been trained to provide assessment and feedback to students. They may be employed by an academic institution or by the health or care organisation where the students are placed. Their role is to ensure students receive high-quality clinical education experiences as well as timely assessment.

RAs observe students as they perform clinical tasks and procedures, provide feedback on their performance, and help them reflect on their learning. This helps students identify areas where they need to improve and develop their clinical reasoning and judgement skills. RAs can also help to ensure that assessments are consistent and standardised and that students receive a comprehensive and well-rounded educational experience, especially if multiple students are being assessed. RAs are essentially practice assessors but are independently located, mobile and can assess across whole health and care systems and beyond rather than being limited or restricted to a particular clinical environment or service.

These roles are governed by the NMC's (2023a) SSSA, which guides the expectations and responsibilities of those involved in the supervision (sections 2–5) and assessment (sections 6–10) of student nurses and midwives in the UK in addition to defining the roles of practice supervisor, practice assessor and academic assessor (Table 2).

The SSSA are designed to help ensure that students receive a high-quality education experience that prepares them for entry to the NMC register and their future careers in nursing and midwifery (section 1).

The RA role has similarities with other clinical educator roles which, essentially, involve education in practice (Hesketh et al, 2001; Higgs and McAllister, 2007a; 2007b) but is different and distinct from it. While clinical educators support students to become competent practitioners, ready to enter the workforce (Higgs and McAllister, 2007b), their remit is usually broader and encompasses the full range of learning and development students need; the RA role is focused mostly on assessment in practice. RAs may, therefore, provide more opportunities for standardised, fair and consistent assessment.

The RA role was borne out of changes to the NMC's (2023a) SSSA, and its development was accelerated by the COVID-19 pandemic where many students experienced stress in addition to making less progress than expected because placements were interrupted and fewer supervisors and assessors were available, which resulted in the suspension of placements and service disruption (Masha'al et al, 2020; Swift et al, 2020; Casafont et al, 2021; Suliman et al, 2021).

Study aim

This article aims to explore the use of practice learning facilitators as RAs for student nurses in the UK. It also aims to examine the potential benefits and limitations of this approach and explore its implications for the future of nursing education.

Derbyshire model of roaming assessment

In 2021, DHCFT used clinical placement expansion project funding to invest in the development of two RA roles. DHCFT works in partnership with Derbyshire Community Health Services and covers the whole of Derbyshire, providing a range of primary and community services including children's services, integrated community services, GP services, health, wellbeing and inclusion services, planned care and specialist services (DHCFT, 2024).

Derbyshire covers an area of approximately 1000 square miles and has a population of just over a million. There are a few population centres, including Chesterfield, Derby and Buxton, and a number of towns and villages spread across the county, leading to a dispersed distribution of services. Derbyshire also covers the Peak District. This also provides challenges in terms of service provision and transport. Because of this, DHCFT provides a wide variety of services across many centres and places across Derbyshire.

Student nurses are placed in most of these services and originate from the University of Derby, the University of Nottingham, Nottingham Trent University and Sheffield Hallam University. Student nurses are often placed in teams across DHCFT where numbers of registered professionals are small, which means that most are required to act as practice supervisors. This prevents their ability (because of the requirements of the NMC SSSA) to be practice assessors because the practice assessor cannot simultaneously be the practice supervisor and academic assessor for the same student. Therefore, DHCFT, in partnership with the high education institutions, developed the RA role to support the assessment of students in practice.

DHCFT employs two RAs who undertake practice assessments for student nurses across Derbyshire. These RAs are the first point of contact for nurses undertaking the practice supervisor role. They also handle enquiries about NMC (2023a) SSSA training and from supervisors who need support or guidance regarding practice assessment.

RAs also provide support with delivering high-quality supervision and assessments and work with the universities to ensure students are assessed in a timely and appropriate way. RAs monitor the student experience in practice areas and have developed a support network for practice assessment across the county.

The roles were initially funded by the clinical placement expansion project via Health Education England (NHS England, 2020). They have been continued for another year supported by placement tariff funding (a central funding mechanism whereby organisations receive financial support from NHS England to accommodate students on placement).

RAs support practice supervisors and provide additional support for learning in practice through the provision of drop-in sessions for specific skills or knowledge development. Their primary roles are to support students in clinical areas struggling for assessors, assist teams to return to pre-COVID-19 student numbers, placement expansion, increasing compliance with supervisor and assessor training, and maintaining adherence with the NMC SSSA.

The RA also works with academic assessors and link lecturers (academic staff identified to support particular organisations or clinical environments) across the university network, working proactively to promote effective and reliable assessment for students in practice. They provide support, develop action plans and work alongside academic assessors to support practice supervisors in ensuring and promoting student achievement and progression (NMC, 2023a). Conceptually, the RA works across the practice domain of the SSSA process, performing the practice assessor role when required working alongside the academic assessor (Figure 1).

Impact and activities of the role

DHCFT appointed two RAs on a 12-month fixed-term basis, who have supported more than 300 students as of February 2023. They have trained 30 assessors from 10 teams with more sessions being planned over the coming months. Six per cent of teams in the trust have returned to pre-pandemic placement numbers with RA support.

In the academic year 2021-2022, 62 placement opportunities were not offered for a variety of factors including that no practice assessor was available. Since the implementation of the RA role, no placements have been cancelled. It has also been possible to place students at short notice because of RA support (because RAs could provide trained practice assessment capability where there previously was none, and completing training would have taken time). There has been a 2% increase in placements offered since the introduction of the RA role. Knowledge of the RA role has increased across the county and demand for the roaming assessor function has increased.

RAs have also supported students who are struggling with progression in practice because they have needed more time to train, practise or gain proficiency. These situations can arise when staff are unable to dedicate enough time to support students; however, the RA may have time to support this. In one case, the RA provided additional support and training towards proficiencies as well as objective advice on how best to achieve goals. The impact of this was the successful completion of the placement by the student. The RA has also supported new teams to accept students for the first time, thus expanding placement capacity.

RAs have also allowed virtual placements to be arranged for nearly 100 students at the University of Derby as part of their programme. Virtual placements are curated learning experiences consisting of online learning, case-based learning as well as virtual patient and real patient encounters where students can engage in directed learning based on specific competencies or proficiencies, while receiving support and contact with practice supervisors and practice assessors (Verkuyl and Mastrilli, 2017; Taylor et al, 2021; Wagg and Morgan, 2022). RAs provided the practice assessor function for these virtual placements as well as providing some teaching and role-play scenarios.

Feedback from staff and students

Feedback on the RA role has been received both formally and informally, from students, supervisors and via placement evaluations. Although statistical feedback has not yet been collected, anecdotal feedback has been positive, reflecting how the role has given students opportunities, particularly if their supervisors have been in busy clinical areas. Students have said the role has enabled them to learn and be assessed at a faster rate than previously, and that RAs make the assessment process smoother because of their experience and time available to undertake assessment. This has improved the rate of practice assessment documentation completion and therefore programme completion.

Clinical teams have anecdotally reported that RAs allow staff to focus on the student experience and their learning opportunities, removing the time-consuming aspect of assessments. Although teams recognise the importance of assessment, the process of undertaking an assessment thoroughly can take time.

Clinical teams have said they feel able to contact RAs if they need practice assessment support. They have also contacted RAs on how they can provide better learning opportunities for their students.

The RAs have developed resources with clinical teams to provide additional information about practice assessment and using the tools of assessment tailored to a student's stage in the programme.

The team also said it was beneficial to have an external assessor who could provide an objective perspective, particularly in cases where there was uncertainty or difficulty in reaching an assessment decision. RAs expressly seek to neutralise psychological biases in the assessment process such as Hawthorne, Halo and Horn effects (West, 2007; Kondrasuk, 2012; Hull and Sevdalis, 2015).

The Hawthorne, Halo and Horn effects represent significant biases that can influence the assessment and learning experience of students. The Hawthorne effect refers to the phenomenon where students alter their behaviour because they are aware they are under observation. This might lead to an improvement in a student nurse's performance that does not necessarily reflect their true capabilities but is a response to being closely monitored by their supervisors. This could result in an overestimation of their abilities in everyday clinical practice. The Halo effect occurs when an assessor's overall positive impression of a student, possibly influenced by just one positive aspect, leads to a biased overall assessment. For example, a student nurse with exceptional communication skills might be perceived as being competent across all areas of nursing, which could mask areas requiring further development. The Horn effect is the opposite, where a single negative trait or incident disproportionately impacts the assessor's perception, potentially leading to an undervaluation of the student's overall abilities and potential.

RAs, who operate across a variety of clinical settings, can play a pivotal role in mitigating these effects. Their broader exposure and experience in different environments allow them to offer a more objective and diverse perspective. Unlike assessors who might regularly work with the same students in one setting, RAs are less likely to develop biases based on frequent interactions or isolated incidents. Therefore, their assessments may provide a more balanced and unbiased view of a student nurse's competencies and areas for improvement, enhancing the fairness and effectiveness of the learning and assessment process in nursing education. These issues contributed significantly to the separation of the assessment function in the NMC (2023a) SSSA and RAs are able to take this separation even further.

Benefits of the roaming assessor role

Assessment is a challenging and complex process (Crow et al, 1995; Helminen et al, 2014) and is a vital component of nursing and student learning in practice (Bisholt et al, 2014; Immonen et al, 2019).

Failing to fail, where students obtain pass grades but do not display satisfactory clinical performance, is a well-recognised issue (Duffy, 2003; Docherty and Dieckmann, 2015; Hughes et al, 2016; Hunt et al, 2016). The reasons for this are multifactorial including a lack of support for supervisors and assessors, a lack of confidence on the part of assessors, time requirements and the psychological impact of failing a student because the assessor has invested emotionally in them (North et al, 2019). The RA role can circumvent these issues by providing time, confidence, trained support and minimal emotional investment in students. Therefore, the RA could potentially prevent failure to fail by removing potential psychological biases within the assessment process, which is a recognised phenomenon (Narayan 2019; O'Sullivan, 2023).

Assessments are a highly stressful element of a student's learning process in what is already recognised to be a stressful occupation (Gebhart et al, 2020; Pires da Rocha et al, 2013). RAs have the opportunity to reduce stress by providing support throughout the assessment process.

As identified previously, student nurses are often placed into teams with so few registered nurses that they cannot act as assessors. The RA role removes the need for these nurses to undertake the assessor role so they can concentrate on supervision and development and thereby also removes potential barriers to assessment. Nonetheless, the nurses still contribute to the process of assessment. Students and their supervisors can focus on the vital process of learning to ensure they reach the appropriate level of competence before entering the profession (Lovecchio et al, 2015; Tomietto, 2018; Immonen et al, 2019).

Work undertaken by universities and Health Education England via the clinical placement expansion programme (NHS England, 2020) has meant the focus on the expansion and generation of placements has increased. Although this work began before 2020, it has accelerated since the COVID-19 pandemic during which there were significant shortages of placements (Swift et al, 2020; Agu et al, 2021; Chan et al, 2021; Ulenaers et al, 2021).

Because of COVID-19, student nurses saw placements cancelled and changes that impacted their learning and development. This led to some students not performing at the expected level (Radu et al, 2020; Ramos-Morcillo et al, 2020). The NMC introduced emergency and recovery standards during the COVID-19 pandemic to address some of these problems, although these were reviewed in 2021-2022 (NMC, 2023b).

The RA role has evolved since its introduction to meet the needs of student nurses in practice, providing teaching where knowledge and skills required for qualification may be lacking. The role has also developed the five qualities associated with robust practice assessment in other practice assessors: dependability; solidarity; tenacity; audacity; and integrity (Hunt, 2019).

RAs have a significant opportunity to engage in placement generation and expansion because they are active in placement networks. As part of these networks, RAs work across universities, integrated care systems, organisations and the private/voluntary/independent sectors thereby improving collaborative working. They may work with link lecturers and academic assessors to prepare students for their recovery or retrieval placements through development and action planning. These activities often take time, and dedicated support for these activities may be helpful.

The position is also able to open or reopen placements where numbers of registered nurses are low or there have been quality issues previously because RAs have a role in the quality improvement and enhancement of placement experiences.

Limitations of the roaming assessor role

While there are many benefits of the RA role, there are also limitations, and these should be acknowledged.

Because RAs perform practice assessments on such a regular basis, there is a risk that these could be seen as routine, and RAs could become complacent. Complacency can occur when similar actions are repeated many times, and assessors could potentially miss concerns (McGregor, 1997; Gershenson, 2020; Pampati et al, 2020), risking a change to the level of standards.

They may also fail to recognise individual circumstances and, while this can be useful to prevent bias during assessment (West, 2007; Kondrasuk, 2012; Hull and Sevdalis, 2015), sometimes individual circumstances need to be recognised. The NMC's policy changes have reduced the role of mentor, and split responsibility for support and decisions between practice assessor, practice supervisor and academic assessor (Pearson and Wallymahmed, 2020). This separation may result in gaps, so ensuring experiences remain holistic is important (Royal-Fearn, 2019). However, this is a limitation of the SSSA rather than of the RA role.

There can occasionally be difficulties in communication between the RA and the practice supervisor, despite the NMC SSSA (NMC, 2023a) requiring those in the two roles to communicate regularly about students' performance, attainment and conduct. These communication difficulties originate from the RA and practice supervisor not being co-located. When the practice supervisor is not on the same site or available, the RA must rely on information provided by the student or only in writing from the practice supervisor. This could lead to inconsistencies in the assessment process or an inaccurate judgement of the student's abilities. A lack of communication between the academic assessor and the RA can also be a problem particularly in the case of failing students.

Students may dislike the process of being assessed by someone they do not know but this may decrease over time as awareness of the RA role increases throughout practice learning environments. Anecdotally, apprentices in general have reported feeling there is a conspiracy to fail them or that the assessment process is not independent enough.

The workloads of the two RAs are high because they support a whole trust across a large geographic area. There is a risk that an RA may be unable to assess a particular proficiency because of a lack of capacity or if it not within their scope of practice. As the service expands and the requirement for RAs becomes embedded as business as usual, the ability to provide a quality RA service may become more difficult if demand for the role continues to rise. This can be mitigated by recruiting additional RAs; however, implementing the two roles costs in the region of £85 000 a year. This is a significant investment and, although this project was funded by clinical placement expansion programme monies initially, this funding has now ceased, and the trust is funding these roles with placement tariff income. It may become difficult to fund these roles on an ongoing basis.

Looking forward

There future appears bright future for the RA role. This innovative way of working has potentially demonstrated positive impact on the availability of placements and the quality of experience students receive.

The flexibility of the role allows RAs to support students in a variety of clinical areas, modifying work times, resources and training to meet learner needs. RAs were trialled in the first instance, but this has project has been extended from its original term of 12 months to 24 months. The roles have been extended because the need for placement support and practice assessments is forecast to rise, given an increase in student numbers. This reflects the ongoing need to provide high-quality practice learning experiences for all students. The DHCFT RAs will continue to support teams struggling to provide the assessor function, whether that is a result of sickness or staffing issues. They will also continue to offer teams support with student assessment. RAs will continue to assess students offering them support for their learning and development needs.

RAs will continue to work with university partners on the development of high-quality placements, as well as providing enhanced development for reflective writing skills and knowledge. This is to assist with the application of both the theoretical and practical elements of learning and development. RAs are also working on innovative ways to increase placement capacity. They will also continue to develop practice assessors and supervisors to contribute to and assess students in an effective, open, and transparent manner.

Further work needs to be undertaken to evaluate the roles more formally including their impact on the accuracy, validity and reliability of practice assessment, their impact on placement quality, and their effects on clinical nursing teams' workloads and working experience. The impact of RAS on the student experience should also be assessed.

The outcome of this evaluation could inform future funding opportunities. Funding is vital if these roles are to continue, and such positions could be supported by trusts with placement tariff funding or by central bodies such as NHS England (e.g. through targeted activities such as the clinical placement expansion programme).

Conclusion

This article aimed to explore the use of practice learning facilitators as RAs for student nurses in the UK by examining the implementation of the role in DHCFT. It also aimed to examine the potential benefits and limitations of this approach and explore its implications for the future of nursing education.

The RA role can support students learning in practice and may improve standardisation and quality of assessment, based on the NMC (2023a) SSSA standards. RAs provide opportunities to develop placements and the process of practice assessment to ensure it is fairer and more equitable for all.

Future research should focus on assessing the impact of the RA role on student nurses more directly and considering the impact it has on practice environments. This role could, if demonstrated to have impact, be deployed across other professional roles where learning and assessment are required. Discussions are ongoing between RAs and DHCFT leaders on expanding this role into allied health professionals.

The implementation of RAs in DHCFT has shown potential benefits for student nurse learning and assessment. RAs may promote standardisation and quality of assessment based on the NMC (2023a) SSSA standards and could have a positive impact on student experience and placement quality.

Universities and practice learning partners should consider the potential of RAs as an innovative method of collaboration and improvement for the student nurse experience.

KEY POINTS

• Demand for student nurse supervision and assessment have increased because of rising clinical commitments, workforce shortages and greater student numbers, issues that were exacerbated by the COVID-19 pandemic
• The Nursing and Midwifery Council's standards for student supervision and assessment separated the roles of practice supervisor and assessor, opening up opportunities to assess in a more flexible way
• The roaming assessor, a new role, fulfils the role of practice assessor while providing additional support for student nurses
• This role is not unique to nursing and could be expanded across other professions
• Practice learning facilitators can be employed as roaming assessors and this has potential benefits and limitations
• Roaming assessors may increase the reliability and availability of assessments and reduce time demands on clinical staff

CPD reflective questions

• How do you provide assessment in practice? How could you assess students in different ways?
• How do you know assessments are valid and reliable in your practice area?
• How could educators you work with improve the assessment of students?
• What challenges do you experience when assessing students?