Students' experiences of their final placements may contribute to their ability to transition into registered practice and may help to prevent ‘reality shock’ and burnout, first described by Kramer (1974), which is still evident in recent years (Broad et al, 2011; Walsh, 2015).
The undergraduate nursing curriculum has been revised regularly over the past 50 years, and particularly since the introduction of university-based training in the form of Project 2000 (Bradshaw, 2001a). We are in the process of reinvigorating pre-registration training once again following the publication of the new Nursing and Midwifery Council (NMC) standards (NMC, 2018a; 2018b; 2018c; 2018d). The current mentor system will be replaced by supervisor and assessor roles, where all registered nurses will be expected to undertake a supervisor role supporting students in their day-to-day practice. Students can, however, be supervised by any registered health professional. The formal assessment role will be undertaken by two assessors, a practice assessor and an academic assessor, who will provide formal assessment of practice and academic achievements. Each year of the programme will require a different academic assessor just as each practice period will have a different practice assessor.
Aim
This research was designed to improve understanding of the student's experiences and expectations of the final placements of nurse training with the aim of helping to better support the transition to registered practice. It aimed to examine how students experienced the current placement style and how it impacted on their perceptions/experiences of transition.
Objectives
Method and process
A Husserlian (descriptive) phenomenological approach was taken with this study to permit retrospective exploration of newly qualified nurses' experiences of their final placements (Parahoo, 2014). The sample was purposive, targeting newly qualified nurses within a specific practice partner. Six participants were recruited; their details can be found in Table 1. Ethical approval was obtained from the ethics panel at the higher education institution (HEI) and from the trust's research and development department. The study involved one-to-one interviews using targeted, semi-structured questions to produce a narrative on the experiences of the subjects. Interviews were recorded.
| Number | Age range | Male | Female | Qualified |
|---|---|---|---|---|
| 6 | 21–37 | 1 | 5 | August/September 2014 |
Data analysis was undertaken using Colaizzi's tool (Shosha, 2012) and trustworthiness was established by implementing member-checking, where the transcripts are sent to the participants for review and confirmation of the content prior to analysis of the themes at the final stage, in line with Lincoln and Guba's (1985) recommendations (Moule et al, 2016).
Findings
Following data collection and coding, Colaizzi's method (Shosha, 2012) was used in which data are analysed by looking for key words or concepts and these concepts are then grouped together to create themes. In this research, these themes were sorted into clusters and finally grouped again into three emergent categories. These categories were:
The theme collation process, using Colaizzi's method, can be seen in Figure 1. These categories and their underpinning clusters are explored in detail below, incorporating key quotes from the participants that supported the coding decisions. Names used within this article have been changed to protect the identities of the participants.
Placements
This category is based on clusters created from the coding process that relate to the placements the students undertook during their training. These include their experiences of their final placement, the learning opportunities they were exposed to and the feelings they experienced during the placement.
Experiences
All students had experienced a variety of placements, including in district general hospitals (DGHs), district nursing (DN), outpatients, intensive care units (ICUs) and specialist hospitals. This range of areas introduced them to a variety of patients and learning experiences, which were generally viewed positively. One participant (Robert), who spent time in a nursing home stated:
‘We did do quite a lot of assessments [of] residents coming in … that was a good experience.’
Another (Danielle) valued her DGH experience as she saw:
‘Chronic conditions that I've never seen before which was different … seeing stuff rather than just knowing about [them]…’
However, all participants mentioned staffing issues in at least one of their placements and one (Sarah) highlighted:
‘One of the wards I went on was so busy that it sometimes felt that it didn't have enough time for students … they were very short staffed.’
Danielle found that the staffing issues led to a feeling of being unwanted, stating:
‘They just didn't want us there … and weren't interested.’
On the other hand, participants generally spoke highly of the teams they worked in as students, with two stating that the team made the difference to the placement area. One (Kate) highlighted that a team that worked together and included students improved her learning by ‘being able to interact with other members of the team’. This was mirrored by Danielle, who said that when working with staff who ‘want to teach’ she felt much more part of the team.
Learning
All participants highlighted that areas that provided greater learning opportunities helped them grow in confidence as students. However, one participant (Alison) found there was a disparity in the skills and experiences students were allowed to participate in, even within the same organisation. She went on to say:
‘I don't think it was just me … a lot of people struggled with what can we do and what can't we do.’
When it came to their final placements, they reported that there seemed to be a greater emphasis on acquiring and improving non-technical skills. For example, Sarah learned about making prioritisation lists from a mentor, which she said helps her ensure her patients are safe and cared for effectively.
It was evident that the participants gained self-awareness throughout their training and this was reflected in their thoughts on the nature of learning. Alison said:
‘It's just sort of gathering all the different skills from all those different placements and just making sure you're taking that as a learning curve.’
This pragmatic approach to recognising the nature of learning as ongoing, and sometimes a steep learning curve, seems to have supported these participants to manage the transition into registered practice with limited difficulty. However, they expressed some conflicting feelings about their final placements and transition.
Feelings
Most participants felt that they were ‘thrown in at the deep end’ in their final placement when they were left with their own group of patients. However, this was met with a general sense of independence and seen as a chance to prove themselves, as Danielle noted:
‘I think when they just left me to it … they seemed to just say “Right they're your six patients, see you later, we'll see you for meds …” I think that was a really good way of doing it because then I had to think for myself.’
However, Kate found the opposite and that being ‘thrown in at the deep end’ could have been handled better. This approach harks back to the nursing apprenticeships of the late 19th and 20th centuries, and it was reduced through the introduction of supernumerary status and university-led learning (Bradshaw, 2001a; 2001b). It could be argued that students need to be included in the ward workforce to be prepared for their future practice.
It is clear that as with patient care, student support needs to be individualised to allow for more effective learning and a positive experience. This should be an important part of the new supervisor and assessor roles. The support students experience will shape not only how they approach registered practice but also how they will support their peers and juniors in the future as they progress in their careers.
Support
This category considered the different ways in which the students were supported during their placements, including teaching from mentors, support from other staff, and other forms of support, as well as considering what could change in this area to ensure students feel more supported.
Mentoring
Both Sarah and Danielle praised the system of having band 5 and 6 nurses as co-mentors, whereby both nurses supported the student and undertook the practice assessments together and/or shared their feedback about the student with their co-mentor. Sarah said:
‘I had a band 6 and a band 5 as well, which was really good because you had … the band 5 explain everything … they could relate to what you were going through. The band 6s had a bit more experience and were kind of like … “Look, you might be panicking but it's okay”.’
The trend of having co-mentors was also a common thread and all but one of the participants felt that this was a positive way to learn. One (Lisa) noted that it meant she would:
‘Always have someone to make sure that you could ask or be with, or fall back on if you need to.’
She explained that having two mentors meant there were few shifts when she wasn't working with one or the other of them, meaning that she could develop a good working relationship with them.
The mentoring experiences were not without issues, however, including mentor sickness, paperwork completion and personality clashes. Kate also noted that having two mentors sometimes meant repeating tasks or times when the communication between the mentors was inefficient:
‘My actual mentor came back and said: “We need to see you do this …” and I said: “Well, she [the associate mentor] has seen me do that and if you don't trust her to know how to do those things with me then what's the point of having an associate mentor?’”
The introduction of the Enhanced Practice Support Framework (EPSF) (currently being piloted), which uses coaches to support the students day to day, has documentation that should prevent such repetition of tasks—but only if staff have time to complete it (Council of Deans of Health, 2019).
The new NMC standards (NMC, 2018b) for supporting students in practice will remove the term ‘mentor’ completely and will require all post-preceptorship registered nurses to take on the support of student nurses within the practice areas. It remains to be seen whether these changes will provide better support for students or cause further frustrations.
Other support systems
The participants highlighted several other support mechanisms that they accessed. The first of these was the third-year student forum, set up jointly by the HEI and the practice partner to help students in final placements prepare for practice. All six of the participants found the forum to be invaluable with Sarah describing it as ‘brilliant’, and Alison calling it a ‘little group hug’. Most of the participants found that it allowed them to voice concerns that they did not want to raise on the wards and it gave them a sense of reassurance that others were feeling or experiencing the same things. This forum also included students from other HEIs, which allowed all students to see that the experiences were very similar, regardless of where they were training. The forum also included an hour of teaching once a month. Sarah stated:
‘[This] really helped when you actually went on the ward and you [thought]: “Oh, I can see why they do this now.’”
Improvements
The study participants were asked if they felt that anything could be done by the HEI or the practice partner to improve preparation for practice. Generally they felt that the practices in place were suitable and that they had been well supported, but they did highlight a few minor improvements that they felt would make a difference to the student experience.
Alison felt that there needed to be better communication between the HEI and the practice partners on the skills the students could undertake in each year of training.
Kate mentioned the idea of being able to commence preceptorship competencies during final placements if the student had a job offer from that employer:
‘The [preceptorship] competencies … I was told that you couldn't really get them signed off until you had a PIN … it was always a bit of a grey area … but if you could have done that it would have been really useful.’
This experience of valuing the co-mentor system in general, bodes well for the introduction of the new NMC standards within the next few years. In addition, the close link between the HEIs and practice partners allows for effective student support. The forums continue to run with teaching incorporated and are still well evaluated and attended. This study was able to demonstrate the value students placed on the forums to the HEI. A list of skills for each year of training was produced by the HEI and circulated to all mentors and the practice partner began to undertake preceptorship competencies alongside final-year practice assessment where the student was to be employed at that organisation following successful completion of their course
Qualifying
This category grouped together clusters that related to the students' experiences and feelings about qualifying as a registered nurse. Participants discussed how they decided where to apply for a job, how they felt about qualifying, and about their first days as a registered nurse.
Participants shared the positive experiences they had when starting their jobs with the hospital where this research was undertaken.
Job decisions
Participants discussed their decision to join the organisation and the consensus was that the friendly atmosphere and the staff were dominating factors in their decisions to apply for a job there. Sarah stated that, having attended an open day, the atmosphere and people meant that she ‘felt in love with the place’.
Two participants already had job offers elsewhere but when they attended for their final placements they changed their minds, as Kate stated:
‘I started my final placement here and had the interview [at the organisation] and then decided to stay here … after I'd verbally accepted [the other job].’
Feelings
Prominent feelings around registration included recognition of the enormity of the change in accountability status. Alison described this as realising that she was now responsible for her actions ‘especially with medication’. She said:
‘I just thought: “No one's counter-signing me now … it's just me”.’
The description of the transition from student to registered nurse as a ‘leap’ or ‘jump’ was also prominent. Lisa said:
‘It's kind of making that leap … one minute you're in the student uniform and the next minute you're in a nurse's uniform.’
The theme of confidence was also prominent for all; the six participants said that starting their first job was like being ‘back to square one’ or ‘like a student again’. There was also evidence of a loss of confidence in their own knowledge and skills, especially when they had taken a pre-employment break. This needs highlighting so that new staff are offered support based on their needs. Clinical supervision within the mental health sector is good at providing this support but it is often absent from adult nursing, without reasonable justification.
Experiences
Participants valued being familiar with the organisation when starting as a new staff nurse. Four of the participants were working in the same practice area in which they had completed their final placement. For Sarah this placement had been deliberate in the hope that it would help with the transition. She commented:
‘I'd been there [in the area] 3 months as a student and then 9 months there as newly qualified, which I thought was really good [it made for a] much easier transition.’
An area of concern for some was delegating to junior staff who had a lot of clinical experience. Youth and lack of experience made participants doubt themselves if they were challenged by a healthcare support worker.
Participants emphasised the issues of completing the preceptorship competencies and having to prove again what they had been assessed to do on placement only weeks earlier.
The key finding here was that students were more likely to apply for jobs at organisations that they felt were welcoming, supportive and friendly and that having had placement experiences at that employer meant their transition was smoother than they expected.
Discussion
It was noted that all the participants described receiving support during their final placement and this, combined with evidence from the literature, support the achievement of the first objective. The participants said that the teams in which they worked, the mentors, the practice partner's education team, management forums and the university links all had a significant impact on their experience. This is a positive shift from the findings of Gerrish (2000) whose exploration of Project 2000 found it to be woefully inadequate in supporting preparation for practice. With the changing curriculum in pre-registration education, including the introduction of the graduate-only entry to nursing and the redevelopment of the pre-registration nursing education standards by the NMC (2018a; 2018b; 2018c; 2018d) it would appear that the changes made have taken on board Gerrish's findings and are beginning to show fruition in newly qualified practitioners.
The participants' reflections that a positive and supporting learning environment with a team who enjoy teaching and support each other mirrors the findings in the literature (Doley and Roberts, 2005; Hartigan-Rogers et al, 2007; Nash et al, 2009; Pearson, 2009). However, Kelly and Ahern's (2009) study found that difficult student placement experiences still have a role in preparing students for the realities of working within an unsupportive workforce. It is worth noting, however, that those participants who experienced unsupportive placement areas developed a sense of dread when approaching each day of the placement. Thrysoe et al (2011) highlighted the importance of influential awareness (the concept of the mentors being aware of the impact their behaviours, attitudes and practice have on their students), but this appears to have been negated by the impact of a busy ward with staffing shortages. In essence, the staff were unable to devote the time to their students or to their own self-reflection and so failed to notice the impact of their own attitudes and behaviours on their learners. However, some of the participants noted that some staff could manage to balance these factors, and considered these nurses to be role models for their future practice.
Mentors often took a step back during final placements and allowed students to undertake practice independently. This was viewed positively by the participants in the study and in the literature. Doley and Roberts (2005)Nash et al (2009), Pearson (2009) and Thrysoe et al (2011) highlighted the benefits of having a mentor who allowed students to work independently as they neared graduation.
This mix of supernumerary status with supported independence in placements advocated under the current curriculum (NMC, 2008; 2010) is a step on from the rostered practice highlighted by Gerrish (2000) and Holland (1998) but remains in contrast to Mooney's (2007) conclusions that supernumerary status fails to prepare a student for practice. The evidence from this study and the majority of the literature supports supernumerary student status with a ‘winding back’ of mentorship support over the 3 years (Baillie, 1999; NMC, 2018b). In retrospect, all the participants valued being given a freer reign in their final placements and this in turn helped instil confidence. The new standards recognise this and highlight that students' level of supervision can be tailed back as they grow in confidence.
Five of the six participants saw working with multiple mentors and teachers as a significant benefit, which mirrors the findings of Hartigan-Rogers et al (2007). However, the fact that not everyone felt this to be of benefit is supported by Wieland et al (2007) who recommend the use of a single mentor. The new standards (NMC, 2018b) focus on supporting students with supervisors who are there to ensure the student can and does learn without being tethered to a nurse. This supervision should be tailored to a student's needs, allowing for those with less confidence or a recognised learning need to have greater supervision than those who are competent and confident.
Another area that the participants valued was the student forum, which met monthly in a teaching room with a member of the HEI faculty and one of the trust's education team. The benefits of this are clear; all the participants either brought up the subject of the forum independently or highly praised it when asked about their thoughts. This concept of peer support was highlighted in the CLIP project (collaborative learning in practice) (Merrifield, 2016) and the EPSF (Council of Deans of Health, 2019), both of which recognise the value of the support and teaching that students and other staff offer student nurses, which is also valued within the new NMC standards (2018b).
Holland (1999) noted that, despite the disadvantages of the rostered practice period, many students found their feet as a nurse during their final placements. The participants in this study were able to recognise the cumulative effect of the 3 years of training and the process of consolidation within the final placement; this is reflected in the new supervision and assessment standards (NMC, 2018b).
However, the push for third-year students to manage their own group of patients and develop their independent practice, is in contrast with the findings of Baillie (1999), Hartigan-Rogers et al (2007), Gerrish (2000), Cooper et al (2005), O'Shea and Kelly (2007) and Johanson (2013), who found their students to be ill-prepared in management and leadership skills. Further research will need to be undertaken to establish whether the new NMC supervisor/assessor standard is effective in supporting students to enter practice. The clear identification of the differences in student needs within these standards will, hopefully, support its success.
Feeling part of the organisation during their final placements was another key area that the participants voiced and the practice of keeping placements to a small geographical area meant that the students undertook many of their placements within the same organisation. This sense of belonging and the positive effect of familiarity with the trust and the team are mirrored in the studies of Doley and Roberts (2005)Nash et al (2009) and Newton et al (2011), who found familiarity or consistency of the core base improved the feelings of belonging and transition into practice. Nash et al (2009), Hartigan-Rogers et al (2007), Pearson (2009) and Doley and Roberts (2005) all emphasised the positive impact of belonging to a team on successful transition and learning.
The final objective of the present study was to consider areas of practice that could be improved. One area of practice that the participants and both Baillie (1999) and Ross and Clifford (2002) highlighted was an inconsistency in the skills that students could practise in the learning environment.
It was also highlighted both by the participants and in the literature that the start of some form of preceptorship during the final placement was valuable in supporting preparation for practice. Wieland et al (2007), Pearson (2009), Doley and Roberts (2005) and Newton et al (2011) all noted the benefits of specific supportive mechanisms, including beginning preceptorship competencies in the final placement.
Limitations
This was a small study and was limited to only one practice partner and HEI, which reduces transferability of the findings.
Conclusions
This study has highlighted several areas of practice where changes could be considered or have already been implemented within the HEI's practice partner.
As part of student support mechanisms, the third-year student forums have been continued. The use of forums for teaching and support improves the student experience and helps students with the choice of where to apply for jobs.
Mentorship itself was viewed very positively but further work was considered necessary for improving the consistency of mentorship support. However, in light of the introduction of the new pre-registration nurse educations standards and the Future Nurse proficiencies (NMC, 2018a; 2018; 2018c; 2018d), ‘mentors’ will be replaced with ‘supervisors’ and ‘assessors’. However, these roles will continued to be performed by the same nurses, who should continue their good practices when it comes to student support.
The introduction of post-registration preceptorship competencies for those students who are on target has now been implemented. These competencies are those that do not require an NMC PIN or staff ID badge, but this leaves a large number of competencies that can be signed off alongside the student's own practice assessment documentation.
The practice of rearranging final placements so that they take place where employment has been secured is also worthy of consideration and is recommended by the author. By completing the final placement in students' employing clinical area, the evidence suggests that their transition will be considerably smoother.
As noted above, further research will be warranted in this area once the new standards have been fully implemented. It should be noted that many of the recommendations made are still in place and are also used within other practice partners and organisations within the region.