Introduction
Thirty years ago we were seen as ‘angels’. We were revered and supported. It’s not the same now.
(Nurse)
In this chapter you will look at some of the processes that you need to consider when working as a member of the clinical team whilst learning in your practice placements. A number of writers have remarked on the complexity of nursing and the demands made on nurses (Glouberman 2002, Revill 2005). Many recognize how the pressures of an increasingly technical age and government demands for greater efficiency – which is measured with through-puts rather than quality – makes compassionate caring more difficult to achieve (Shorr 2000). What is indisputable is the extent to which good nursing makes a difference to each patient’s experience of care. Many practitioners strive to implement their vision of high-quality care that is patient-centred, but are often frustrated by the pressures under which they are working. As a nursing student learning in and from practice you will inevitably be exposed to the same pressures. This chapter will help you to think about managing your time and yourself in relation to other staff and in relation to patients or other service users whilst learning and working in your practice placement. We shall be exploring the following:
• Presenting yourself in the practice environment.
• Setting priorities and managing your work and patient care.
• Communication skills and documentation.
• Confidentiality.
• Looking after yourself.
Each of these aspects will examine elements in your role as a developing practitioner, raising issues that you might experience throughout the process. We will also be reconsidering some of the safeguards to promote ethical practice and prevent the misuse of power in the caring professions.
In Chapter 10 you explored some of the issues that arise when working in health and social care teams. The main goals of these health care team members are to collaborate to deliver care to patients or users and the nature of interprofessional working (Williams & Laungani, 1999). Chapter 10 also identified the challenges and barriers to becoming an effective team, which include power and status differences, heavy workloads and belonging to multiple teams (see Box 10.2). As a nursing student you will experience this in different ways, depending on the team setting in which you work. The hierarchy and demands on you in an acute care setting will be very different from those in a long-term care setting (Cott 1998). Strategies to prioritize the demands on you and to manage the competing claims of your role as student and as practitioner will help you to succeed in the practice placement setting and to complete your studies successfully.
Why are placements so important?
Under statutory regulations, all nursing students in the UK have to complete 4600 hours of learning, of which half (2300 hours) must be carried out in a practice placement undertaking direct patient care before they can become a registered nurse. This requirement is one of the reasons for ensuring that you keep an accurate record of all your placements. It is also important to ensure that you keep your own records up-to-date. All nursing students in the UK have to meet these requirements and all universities and partner placement providers will have a strategy in place to help you achieve this requirement. It is highly probable that you will undertake a range of placements to meet the curriculum requirements of your foundation programme and then your specialist branch requirements. Managing these placements for such a wide range of students and very frequently across large geographical areas is a highly complex activity. Changes to the delivery of patient care and policies that increase the range and number of people who receive health care in their own homes rather than in hospitals means that your learning in practice also needs to take place in such settings. Inevitably this means that you will have to travel to a placement, and this may be personally expensive and time-consuming. You need to consider how you are going to manage your time, your personal responsibilities (e.g. child care arrangements) to ensure that you arrive in your placements at the agreed times. You also need to be thoughtful about your arrangements for travelling home at unsocial hours. You should be aware of how you can claim your travel expenses and ensure that you follow local procedures. This will help ensure that your travel claim can be dealt with as quickly as possible.
In terms of the location of your placements, all universities have carefully developed policies and agreements with their partner placement providers about the numbers of students they can accommodate and ways of allocating students to particular patterns of placement. The intention is to ensure you receive the best possible learning opportunities across a range of placements according to professional and statutory requirements that have been laid down by the European Union and the Nursing and Midwifery Council. Some placements may not necessarily be convenient for all students. Some universities may allow students to change their allocated placement in exceptional circumstances. A more strategic approach is to negotiate your placement before it is planned, which is often 12 weeks before the placement is due to commence. This reduces the amount of work and disruption that last-minute placement changes incur not only for allocations staff but also for practice placement staff and your peers. Take time to find out your own university procedures so that, should you feel a particular placement would be very difficult for you, you know who you can talk to about this. It is critical that you arrange to meet with the relevant person before the change list is published (often 6 weeks before). Changing placements after this time, if it can be done, is generally very difficult and is very expensive to undertake as well as delaying other allocations lists.
What is a placement and who will support me?
A useful definition of a placement is provided by the Royal College of Nursing (2002, p 2):
A practice placement is where learning opportunities are available for you to undertake practice under supervision.
In reality, this could be a wide range of different learning environments and will depend on the particular learning needs that you require at any specific time. You may spend time in different wards and departments in hospitals, community areas such as nursing homes, self-care homes, nurseries, working with specialist practitioners, visiting patients in their own homes or meeting them in clinics to name a few. Some programmes also provide opportunities for students to spend time in a range of non-health care work environments such as factories, offices or schools. These placements are designed to help you understand the dimensions of public health and ill-health and the factors that contribute to ill-health. They are also designed to introduce you to the core elements of nursing practice rather than to be an expert in all aspects of your chosen area of nursing practice.
In contemporary nursing education, a high percentage of nursing students are embarking on their second or third career and may be entering higher education for the first time. Many students now enter nursing with previous health care experience. It is therefore inevitable that you will be allocated to spend time in a practice setting that may be similar to an area that you have already experienced. In this situation, it is critical that you spend time before the placement reviewing your learning to date, reading your placement objectives carefully and deciding how you will use the experience to learn more. Try to use the opportunity to learn new skills and to develop knowledge that may previously either have not been relevant to your role or not available to you. Whatever practice placement you are allocated to, learning how to use your practical experience to increase your professional knowledge is a critical factor in your success. Chapter 6 provides some ideas about how to learn in and from practice.
Who will support me in practice?
Several different staff will be available to support you in your placement learning. Their job titles will vary slightly from placement to placement and across different settings and universities. However, the main person that will support you will normally be referred to as a mentor or supervisor or coach. Throughout this text we have used the term mentor. Your mentor is normally a member of the health care team and a registered nurse. Nurses providing mentorship receive special preparation for their role, but do not receive any remuneration either in the form of financial reward or relief from their normal caseload. Your mentor will facilitate and assess your learning, supporting you to achieve your required learning outcomes and competencies. In addition to the mentor role, many placements have a lecturer from the university who supports the practice placement staff and in some cases works with students in groups or as individuals. It is also common for partner placement providers to employ staff who work specifically to improve and develop the learning environment for students. These may be referred to as practice educators, practice education facilitators or clinical educational facilitators. In some cases, these staff will work exclusively to sup-port nursing students and are qualified nurses. It is becoming more common, however, to appoint staff with other professional backgrounds to sup-port all health care students. Find out in advance of the placement the names and contact points for the staff who will be available to support you.
What can I do before I commence a placement?
So that you can make the best use of learning from your placements, you can do quite a lot of preparation work prior to commencing. The Royal College of Nursing (RCN) has produced clear guidelines for students and mentors (Royal College of Nursing, 2002 and Royal College of Nursing, 2005). Key points from the guidelines have been extracted below with additional notes that others have found useful. Thus, before a placement, you have a responsibility for the following:
• Know your own programme. Read and understand your own programme/course handbooks. These handbooks contain a great deal of very useful material and have been devised to help you. Quite often students have problems because they failed to read their own programme course handbook or practice placement guidelines.
• Know the policies relating to the practice placement. Familiarize yourself with any policies and procedures concerned with your practice placement. These are likely to relate to your specific programme of study (these are correlated to practice placements).
• Know your assessment. Your programme course book will include information about your practice placement assessments and the pass/fail criteria. Quite often one practice placement may host students from several different programmes and from several different universities. So it is important that you accept responsibility for knowing the details of your own programme and your assessments, as it may mean that you are more aware of your specific needs than your mentor. All mentors will fully understand the importance of providing an effective learning environment for you.
• Why this placement? Understand the purpose of the placement experience and the learning outcomes you need to meet and ensure that your mentor is clear about these expectations. As you will read later in this chapter, it is important that you understand the priorities that mentors have to deal with in terms of supervising your learning and providing client care. Always ensure that you are working under the supervision of a registered nurse or midwife.
• Be proactive about your placement. Many placements have websites that you can visit or provide a welcome pack for students; these often contain useful information about the nature of care and relevant theoretical knowledge that you need in order to make the most of the placement. Use this information to ensure that you have some theoretical knowledge relating to the placement. No-one will expect you to be an expert in any particular area of care. You should, however, have learnt some of the key concepts. You can often find out about the type of client that uses the placement that you have been allocated to.
• Know your strengths and weaknesses. It is important that you prepare for your placement by identifying your own strengths and the areas of your practice that you want to improve. Arriving in your placement with this knowledge helps your mentor to understand your learning needs and to help you make a plan that will assist you.
• Brush up your technical skills. Before you start your practice placement it is a good idea to spend some time in the skills laboratory improving your technical skills. If, for instance, you are going to be working in the community, you may have the opportunity to give injections and deliver wound care, so it is a good idea to improve your techniques and confidence in these areas. If you are going to work in a mental health setting, you may want to think about how you present yourself and how you might respond to someone who is physically or verbally aggressive.
The RCN guidelines suggest that you contact the placement and mentor prior to starting a placement. Although this is generally useful advice, it may not always be the preferred approach for some placements. You may find that you will be invited to a special induction day designed to introduce you to the key staff, the relevant policies and procedures and to your placement. You will probably be told which is the preferred approach, but it is a good idea to find out in advance of the placement start date and it is essential that you attend.
When you first meet your mentor it is worth being as open and honest as you can, and discuss with them any specific or special support that you need. This is important, as they may need to discuss your needs with other members of the placement team and possibly with relevant university staff.
First days in your practice placement
First impressions
As an ambassador for your university and for the profession it is critical that you always act professionally with regard to punctuality, attitude and image, and dress according to uniform policy. Wearing your uniform with pride is important as it communicates a great deal to the public and can either instil confidence or distrust. Your uniform should always be clean and smartly worn without the use of make-up, jewellery or flashy accessories! With the complexity of society in the UK and the wide range of values and beliefs, modesty is an important attribute to cultivate in the way you dress: short skirts, low necklines and tight-fitting clothes do not communicate a professional approach. Such an attire can cause deep offence to many patients and could also put you at risk of sexual abuse due to misunderstanding by some patients.
Punctuality
Practice placement staff are very busy people and can not wait for students who are poor time-keepers. So it is essential that you do not underestimate the importance of attending at the agreed times. In most nursing areas the handover is an important learning opportunity. If staff have to repeat information because you are late, this will detract from the care that they should be providing and may mean that patients miss out on essential care. You will miss out on learning opportunities and you are unlikely to achieve the required professional competencies. Naturally anyone can be late on very rare occasions for a variety of reasons. If you suspect you are going to be late, it is important that you leave a clear message including your anticipated arrival time. The same principal applies if you are unwell and not able to attend. It is essential that you develop and maintain effective communication with patients, mentors and link personnel from both the placement and university. We shall explore this point further on in other parts of this chapter.
Confidentiality
It is critical that you maintain confidentiality with respect to the patients that are using the services in your placement environment in accordance with the ‘NMC Code of professional conduct’. Ensure that you respect the wishes of patients at all times and make sure that, at the first opportunity, your patients understand that you are a nursing student.
What is the role of the student in a practice placement setting?
Are you an extra pair of hands (i.e. supernumerary) or are you seen as part of the team with workload expectations? This is quite critical to the scope for individualizing your practice experience to your particular learning needs. Being supernumerary means that you are not part of the staffing and skills mix of the practice placement.
As a nursing student you will be supernumerary, participating in the delivery of care under the supervision of a qualified professional. Usually your supervisor’s background will be nursing, but not in all cases. It is important to clarify the team’s expectations of you at the beginning of the experience. For example, you need to clarify whether or not you will be able to have study time as part of your shifts. In this context, study time would be time to complete requirements for your programme such as reflective learning logs or journals. This may sound like a small point but it may be crucial to your work/life balance as a student.
How shall I present myself?
It can be difficult to present yourself as a nursing student in a situation where the patient is probably anxious about their condition or treatment and anticipating that an experienced practitioner will be caring for them. In some settings uniforms and badges immediately identify your status to others that are familiar with uniforms and badges. In other situations (e.g. some community settings such as in homes for people with learning disabilities or in mental health environments) it is difficult for patients to identify what role you might play, or your level of experience. Wearing your identification badge is essential for your protection as well as that of your patients. No matter where the practice setting is, you have to think about how to present yourself to people, not just those that you will be caring for but their carers and also to all members of the team. Box 11.1 provides some questions to follow up when you are next in a placement.
Box 11.1
Identifying staff in placements
Spend some time in your first placement identifying the wide range of staff that work in the environment.
• How do people dress?
• If staff wear a uniform is it obvious what experience people have?
• Can you tell from the clothes that they wear?
• If uniforms are not worn is the dress code smart or casual?
Talk to a visitor and a patient and find out how people who are using the services feel.
• Do you believe they can tell who is who?
• What are the implications of your learning for those that use the services?
• Is there a notice board with the photographs of staff and their names available for visitors to see?
In terms of presenting yourself, you can see that it is important that you introduce yourself and explain your part in the team when you first start working with a patient. It is important that you explain that you are a nursing student and you are learning the necessary skills. Mentors and other supervisors working with you should explain your role to people when they are working with you. At times, however, it will be entirely appropriate that you are delegated a task to perform with minimal supervision. Introducing yourself and your role at the first opportunity is not only a good example of courtesy but can really help people understand, such as why you are perhaps taking more time than others to perform the task or need to seek additional help.
Starting a placement is an exciting time. Now is when the theory you have studied moves into the practical world of nursing. You will be anxious about your performance and keen to be competent and successful in the placement. At this stage some students find themselves trying to take on too much as a result of their enthusiasm and desire to learn and also in order to impress those others more experienced in the team. This may be particularly the case if you have worked in health care before starting your programme. Others feel paralysed by the new environment and are reluctant to take on responsibilities. This initial stage sets the scene for your whole placement experience and careful setting up of what is expected from you helps optimize the learning potential. Box 11.2 will help you organize your thoughts about this process, and you should spend some time making sure that you can answer all the questions raised.
Box 11.2
Preparing for work in practice
The setting. What do I need to know about it?
Learning outcomes. I will be assessed during my time at the placement. Do I understand what I will be assessed on?
The team. Who will I be working with? Will there be other students from different health care professions there (i.e. will it be interprofessional)?
Presentation. Consider what is appropriate dress, language, behaviour, respect.
Recording. What will the requirements be?
Time-keeping. What are the expectations?
Confidentiality. Read the relevant code of practice.
Supervision. Think about the supervisory relationship. My mentor will be assessing my overall competence and performance.
Once you are clear about what you need to achieve during the placement, and about the constraints of the setting, you need to move on and plan how to achieve this and to work out where any pitfalls may be.
How can I manage my time?
In Chapter 2 you will have learned about personal time management to help you balance your studies, social activities and other responsibilities. This chapter focuses more on achieving effective time management in your practice placements. Some of the same principles apply; for example, knowing how you spend your time and learning to allocate time to important tasks. But a critical learning element for providing effective care is knowing how to prioritize your time in placements when several competing demands are evident. For instance, in a children’s setting, how would you deal with the situation described in Case history 11.1? On the surface this probably appears to be a simple example of conflicting demands. No doubt you can determine how you would prioritize these demands. You will encounter this scenario again later in this chapter. Other scenarios that you encounter will be more challenging.
Case history 11.1
Responding to requests
Sofia is on placement in a nursing home for young adolescents with severe physical disabilities. She is comforting a teenager who is very distressed, when a visitor tells her that another resident in the side-room wants to use the toilet. At the same time, a physiotherapist comes up to ask Sofia to ensure that another resident that has fluid-balance difficulties needs to be assisted to have a drink.
Effective time management is an important lifelong learning activity. As life changes then so do the priorities that have to be dealt with. A significant number of books and websites exist that deal with effective time management. You may have noticed that most of the current NHS targets in all four UK countries are time-related. An example is the 4-hour waiting time for accident and emergency departments, which is a high-profile target frequently cited in the press and other media (Johnston 2005). This means that staff have to work quickly and still provide high-quality care. Knowing how to set priorities by selecting the right things to do at the right time is vital to make sure that patients’ needs are met. Observing experienced staff working in placements can be stimulating, but as a person learning to undertake the same skills it can be a challenging prospect.
For a number of nursing students and qualified staff ineffective time management is a common reason for complaints to arise. When you are next in a placement listen out for any member of the team who says to a person that they will be with them in a minute, and then try to keep a watch out for how long this minute really is. Try to listen to yourself in placement settings. Do you ever say that you will be with someone in a short period of time and then forget to go back to them? Scheduling and managing time wisely is important. Omitting activities of care can lead to serious problems, resulting in distress, anxiety, frustration and guilt for carers and service users.
Case history 11.2 provides an illustration of what often happens:
• What might have happened to Mat, if he was at risk of self-harm? What should have been Jerome’s priorities? Should he have told a staff member what he was planning to do?
• What actions could Jerome have taken if he discovered Mat in the process of self-harming?
• How much time might have been saved if he had notified staff of his concerns and they had accompanied him to find Mat and prevent him from self-harming?
Case history 11.2
Consequences of delays
Jerome is working in a mental health ward where some patients have been admitted following an incident of self-harm. Jerome has been working alongside his mentor assisting her with her caseload. She has gone to discuss a matter with one of the doctors and, during her absence, Jerome notices that Mat is not in the day room or in the ward. Jerome wonders whether it is important and whether he should tell another staff member, or if he should go to find Mat.
Jerome decides that he will try to find Mat and, after searching around the ward, wonders if he has gone into the garden, which is where he finds him. Fortunately all is well with Mat.
The dilemma Jerome faced was not knowing what had happened to Mat and whether he was ‘making an unnecessary fuss’ by raising the alarm. However, if Mat had been intent on self-harming, by raising the alarm and getting help Jerome might have saved everybody a great deal of time as well as saving Mat from self-harming.
Knowing your role in your practice placement is an essential aspect of learning how to use your time appropriately. The dilemma for foundation course nursing students is that it is hard to anticipate questions or situations when everything is so unfamiliar.
Other situations can be easier to manage, such as having a series of tasks to complete or having a small caseload of patients that provide you with your planned learning opportunities.
Knowing how you currently use your time and how to set priorities can be an important first step in learning how to prioritize your activities in this area of care.
Managing your time
To begin managing your time you first need a clearer idea of how you currently use your time. To get a reasonably accurate estimate, you might like to keep track of how you spend your time in your everyday life. Analyse how you set priorities and think about the principles you use. Now try the same exercise during a typical period in a your practice placement setting. This will help highlight areas where you are time-efficient and possibly help you identify areas where you might be able to improve. To be worthwhile, this exercise re-quires you to be very honest. Do not forget that, as a learner, some of the tasks that you are allocated will take you longer than more experienced staff will take. Ensure that you take time to complete any task safely. If in doubt, ask a more experienced practitioner for advice.
Learning what must be done: handover and note-keeping
Critical to any nursing system is providing care in a way that ensures all people that require care are receiving the care they need in the most effective manner. For those working in hospital-orientated care environments, one of the most important points for learning about the care to be delivered is obtained during the ‘handover’. This is the time when staff share the care requirements at the start of the working period. You will note different approaches to achieving this handover. In some areas, staff will meet in an office or the nurses’ station. In community nursing, handover could be in the car or in a car park.
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