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Ensuring that placement capacity was sufficient to meet demand was a high priority for HEI and trust staff. Participants’ responses (15) indicated a range of initiatives in place to enhance capacity of existing placements (6.6.1) and avoid placements being removed from the circuit if at all possible (6.6.2). Some participants (12) advocated adopting different approached to the provision of practical experience (6.6.3).

6.6.1 Enhancing capacity of existing placements

Initiatives to enhance the capacity of existing placements included encouraging and enabling staff to become mentors. Pursuing some of the points made in the previous section, particular reference was made to encouraging nursing home staff to undertake the mentorship course and one of the link lecturers for this sector spoke of the need to have marketing and public relation skills to encourage nursing homes to be involved in mentorship. A primary care trust link lecturer thought that many community staff nurses would be good mentors but needed to upgrade their academic skills to be able to get on the course; helping them to do so would enhance mentorship capacity in the community. Regular meetings with trust colleagues (Chapter 4, Section 4.5) provided a forum for discussing which areas should be encouraged to put forward more of their staff for the

mentorship course.

Good working relationships between HEI and trust partners were cited as facilitating getting staff onto a mentorship course very quickly in the event of a sudden deficit of mentors. This entailed the trust being able to access a spare place on a course at short notice and the HEI putting on a new course so that recently appointed staff could acquire the mentorship qualification quickly and make good the deficit of mentors. Another approach to enhancing capacity was encouraging specialist areas that had previously only been used for third year students to take students from other years, a task made easier by the NMC recommendation that all placements should be available to all

students.

6.6.2 Preserving existing placements

Placements were regularly audited to ensure that the quality of the learning environment met the required standards and could be removed from the placement circuit if these standards were not in evidence; a process discussed further in Chapter 8, Section 8.6.2. Of relevance here, is the effort HEI

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and trust staff expended in avoiding the removal of a placement from the circuit in view of the reduction in placement capacity that this entailed.

In the accounts given, participants spoke about ‘desperately trying to keep placements in’ and that removing one ‘would be a last resort’. The approach adopted was described by an HEI senior educationalist:

“We send the PEFs and the LLs down there, we meet with the sister, the chief nurses or the lead nurse for education might be involved. So we might go in a little bit top heavy but it is often because of poor performing ward managers or clinical managers.” (HSE5)

The importance of not adopting a punitive attitude was stressed by a programme director when referring to an area that had requested having a break from mentoring following a complaint from a student who had also requested a move. The approach taken was to grant the student’s request for a move but then the programme director met with the staff and discussed the complaint as an opportunity for learning; the staff subsequently chose to keep students. Another programme director discussed the challenge that concerns over placement capacity could present in achieving a balance between quality of the learning environment and having enough mentors to match student numbers:

“If I was giving you management speak I would say yes, we closely monitor the placements, but while we do monitor we are bit more, laisse faire about it, because we can’t afford to lose the placement. It’s that sort of paradox of trying to maintain the standards but if you stick rigidly to the standards you lose the placement and then we end up with loads of students without any placement.” (HPD3)

But quality was paramount as this participant went on to say:

“Because of lack of capacity we would try desperately hard to work with the placement area and keep close monitoring on it to make sure it is coming back up. If it’s just not getting there we would take our students off.” (HPD3)

It was also in the interests of clinical areas not to have their status as a suitable learning environment removed; a point made by one PEF in relation to annual updates.

“Placements can be removed if mentors are not up to date. And I said I would remove the students, and in a week everybody was up to date. Nobody wants to have a negative image.”(TPEF2)

6.6.3 New models and approaches to placement provision

Changes in the organisation of health service delivery had led some participants to consider different approaches to the provision of practical experience for students, some of which were in the process of being implemented with others under consideration.

One approach when the existing definition of requisite practical experience restricted the settings available to the point when capacity did not match demand, had been to change the focus and name of a placement to enable a wider spread of settings and people to be involved. Examples included a

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primary care trust with insufficient numbers of district nurse and health visitor mentors changing ‘community experience’ to ‘care closer to home experience’ and a hospital trust changing ‘critical care experience’ to ‘acute care experience’. Another approach under consideration was whether placement allocation should be centralised; either across all the health and social care schools in an HEI and/or nursing placements centrally allocated across a strategic health authority. The latter suggestion arose in response to a central allocation system that had recently been adopted for some of the allied health professionals to address difficulties finding placements for these groups.

As we saw in Chapter 5, Section 5.4, when participants were asked whether all nurses should be mentors some felt that a different approach to the current one was required. There were variants on the models proposed but in essence entailed all nurses supporting student learning and a smaller cadre of experienced mentors being developed to support nurses but also to assume responsibility for monitoring and assessing student progress. A similar situation arose over how placement provision should be developed with several participants offering different models to the current one and which to some extent were related to new models of developing nurses as mentors.

Some of the mental health settings had adopted a ‘client attachment’ model in which the student was allocated to a client and then gained the practical experience available at each stage of the client’s care journey with mentoring provided by staff at each of these stages. Observations by participants working with other branches thought that some students might need a more directed approach than client attachment and that the degree of supervision that the model entailed would be difficult to achieve with the numbers of students in the adult branch cohorts.

The other model was known as ‘hub and spoke’ in which a student was based in one setting with a mentor but during the placement period spent time in other related settings. Advocated by the NMC, partly in response to a perceived decrease in capacity for practice settings to host students for the full period of the placement, HEIs and trusts were at different stages of implementing the model at the time of project fieldwork (November and December 2011). A lecturer linking with a primary care trust said that they were using the model; the hub varied but might for example be a health centre in which students gained experience but also spent time in spokes such as a period of time with a district nurse and a period based in a smaller community clinic. However, the student always returned to the hub for periods within the placement although not necessarily always to the same mentor since the mentor might have moved.

In one of the mental health trusts, the PEF said that the hub and spoke model was in operation in some parts of the trust but not others. The link lecturer for the trust described some of the

difficulties encountered in trying to get staff to use the model. Using the example of a 12 week ward placement (the hub) with time also spent with community teams (the spokes); she said:

“Despite, every, every attempt it still hasn’t…I don’t think people feel brave enough to do it. I think they’re waiting for somebody to do it and see if it works and then they’ll take it on board. But they’re certainly not there yet.” (HPL 3)

A PEF and a link lecturer in one of the hospital trusts had both given consideration to the ‘hub and spoke’ model. The PEF described how various practice settings could be linked as hub and spokes but the link lecturer was concerned as to how it would work in practice:

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“And what they’re getting at there is that they foresee in the future it’s not going to be possible for a student to just sit in a practice area for x number of weeks, that it’s going to be far more hub and spoke and the whole thing is a Practice Learning Experience. Now how a mentor follows that through and assesses, I haven’t got a clue.” (HPL2)

Another PEF described how a ‘hub and spoke’ model might be linked to ‘long arm’ mentoring. Discussions had been held with clinical nurse specialists (CNS) to act as ‘long arm’ mentors – the scheme was based on the CNS mentoring a student for the whole of a year or the whole of the programme, the student gained requisite experience in a range of areas and the mentor to whom they were attached in each of these fed back information on the students’ progress to the ‘long arm’ mentor. The CNSs had seemed keen on the scheme but discussions were at a very exploratory stage over how it would be organised and how much time they would have to devote to their role as ‘long arm’ mentors.

6.6.4 Key points on sustaining and enhancing placement capacity

HEI and trust staff expended considerable effort in sustaining and enhancing placement capacity to ensure that there are sufficient on the circuit to meet the demand for places. Initiatives included: encouraging staff to become mentors, arranging more course places at short notice, and working with trust staff to retain placements that were seen to be failing in some way.

Such initiatives were facilitated by good working relationships between trust and HEI colleagues.

Several new models of placement provision were detailed (client attachment, hub and spoke, central allocation) and the importance highlighted of being able to engage staff in accepting new approaches.