The UK Nursing and Midwifery Council (NMC) education framework contains standards for student supervision (NMC, 2018) that intend to change the way student nurses and midwives are supported and assessed in learning environments. The NMC places responsibility on the partnership between universities and placement providers for the quality of the learning. It also requires the clinical placement areas to be fully immersive clinical learning environments in which all staff become involved in supporting the education of future nurses and midwives. The existing mentorship model (NMC, 2008) therefore requires significant overhaul to meet the new standards that stress separate roles for supervision and assessment of students in placement areas.
Under the 2008 model, midwifery students are supported in clinical practice by a mentor to whom they have access for at least 40% of their placement (NMC, 2009). Mentors are trained to a standard set by the NMC (2008) and retain the qualification through annual updates and triennial reviews to ensure quality of placement education (Fisher et al, 2017). The mentor supervises the learning and conducts the assessment of practice in the placement area. The assessment is supported in many areas by a university academic midwife, resulting in a tripartite process between student, mentor and academic. Although the process of grading practice is controversial, Fisher et al (2017) conducted a survey of midwifery educators and found that the supportive collaborative relationship between clinicians and academics was generally viewed as robust.
Student learning in placement is important to safe patient care. Criticism of nursing and midwifery practice by Francis (2013) and Kirkup (2015) drew attention to the quality of training environments in hospital settings and has encouraged closer collaboration between universities and placement learning environments to ensure that quality of care is at the heart of the learning process. The duty to report concerns is now made clear to students, and to nursing and midwifery staff who support learning in clinical placement areas. The Willis report (2015) on nursing education recommended that one-to-one models of mentorship should be reviewed, citing collaborative learning in practice (CLiP) as a possible way forward.
The CliP model (Lobo et al, 2014) is based on a real-life learning ward system used in Amsterdam. It has been evaluated (Hill et al, 2015) and has been shown to have a number of benefits, but is not without issues (Table 1). It requires training for coaches and preparation of both students and staff in the placement environment by dedicated practice education staff, which is the key to successful implementation. Huggins (2016) explained the process of coaching in terms of the ‘conversational questioning’ skills used to support student learning by enabling them to solve problems regarding the prioritisation and provision of patient care. In this way, coaches stand back from care-giving and allow students to develop nursing skills. Experienced mentors in midwifery already embrace a model where supervision becomes increasingly distant over time. In the University of East Anglia midwifery curriculum, students move from observer-participants in care to become supervised participants, supervised practitioners and then competent practitioners in the final year of the programme.
| Students and coaches/mentors positively evaluated students' preparedness for qualification |
| Coaching as a principle is accepted as a strength, but adequate preparation of all stakeholders is important |
| Balance of staff, patients and students (ie proportion of senior and junior students) on a shift could positively or negatively affect the working of the model |
| The relationship between the student and the mentor/coach was perceived to be complex and this may affect overall assessment of student performance by a more distant mentor |
| The perceived rigidity of the model made it appear more difficult to implement in some areas. Potential adaptability of the model was not always appreciated |
CLiP: collaborative learning in practice
Students' preparedness for their role as registered practitioners has been evaluated a number of times in the literature (Monaghan, 2015), and the way in which students are supported to develop independence is key. Coaching models such as CLiP appear to prepare students to take more responsibility for learning, thus preparing them better for their role as practitioners at the end of their programme (Hill et al, 2015).
Implementing the model
The CLiP model was introduced at the University of East Anglia (UEA) with the support of Health Education England. This change was due to the need to provide increasing numbers of students in line with the national drive to meet future staffing levels (NHS, 2014), and the need to create learning environments in clinical areas that could support student midwives through collective responsibility and collaboration. The work before the implementation of the coaching model included discussions between the UEA and James Paget University NHS Foundation Trust that included the head of midwifery, lead midwife for education, the link lecturer from the university, midwives, and clinical educators from both nursing and midwifery. Although many universities and placement areas will already have collaborative relationships, the role of the clinical educator has been perceived to be key to the successful delivery of the model (Hill et al, 2015). In this case, the clinical educator (JY) was instrumental in initiating and sustaining the coaching model.
Implementation required the placement areas and university to work in partnership to ensure that timing and preparation were co-ordinated. Introducing such a model in practice involves both behavioural and organisational change. Plans for implementation were discussed with all relevant parties and stakeholders Effective, educationally sound, practice-based learning was the focus, with the aim of producing forward-thinking, responsible, resilient health professionals able to provide safe, effective care. Those involved in the planning used various dimensions of leadership behaviours (NHS Leadership Academy, 2013) to ‘engage the team’ and ‘share the vision’ of the coaching model, while ‘evaluating information’ from pilot of the model in nursing. The implementation happened over a sustained period of time and still continues to evolve as the model further embeds itself in practice (Figure 1).
Training and preparation
The coaching model emphasises a student-focused approach to learning, encouraging students to identify their own needs and objectives and work with their coaches and peers to accomplish them. The care of women and babies is provided by students, who are being supported by coaches. Hope et al (2011) suggest that students learn best through active engagement and reflecting on experiences in the practice environment, which is similar to the model adopted in collaborative coaching.
Identification of wards or areas in which to introduce coaching is very important, and certain criteria need to be considered. Possibly the most important criteria are the department team leaders' enthusiasm and commitment to a new concept of student learning in practice, and an effective and positive relationship between department leads, clinical educators and the link lecturer. Once areas were identified, workshops were set up to train staff. The main aim of training was to ensure that staff were aware of the similarities and differences between mentoring and coaching (Table 2), and could identify the skills needed to be an effective coach, including an ability to ‘stand back’ and allow the students to deliver the care while providing a supportive and understanding learning environment.
| Coaching | Mentoring |
|---|---|
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As with mentoring, coaches are seen as role models, providing advice and constructive criticism to enable the students to realise their potential. Barriers to effective coaching were also considered during training, such as how best to deal with feelings of being the ‘expert’, and how to avoid dominating or regulating situations, which could hinder meaningful learning for the students. Coaching also involves identifying a student's level of ability, and supporting them to set appropriate learning objectives through effective conversational questioning and listening. Developing trust between coaches and students is paramount to the success of the model, and careful consideration should be paid to the importance of developing working relationships, as well as reflecting on how coaches can enable students to develop solution-focused responses to difficult situations (Huggins, 2016).
Coaches were also trained on the importance of completing daily learning logs. These are an essential tool in this method of learning in practice and are completed daily by both the student and the coaches. These reflective learning logs form an ongoing record of achievement for each student, as required by the NMC standards (NMC, 2008). They also encourage students to develop reflective learning skills, which are an essential part of the triennial revalidation process once qualified (NMC, 2015). Reflective learning logs also help coaches, enabling them to support students to set and meet goals, and identify learning opportunities linked to their assessment of practice requirements. Students then share this learning by producing presentations of key topics learned during the placement to peers and staff members, which enhances students' confidence, develops public speaking skills, and promotes value and satisfaction. This feedback loop enables coaches and other staff to see the effectiveness of the clinical learning environment, while the shared learning contributes to the overall quality of care.
A typical day
The coaching model is underpinned by a philosophy that students take on a greater responsibility for their own learning. A typical day on the maternity ward starts at handover, with the midwifery students being actively involved and identifying a woman or small number of women for whom they will provide care. The midwifery students are expected to set a learning objective specifically related to the care of these women, ensuring that this meets with predetermined learning outcomes in the practice assessment documents.
At James Paget University Hospital (JPUH), students are allocated a ‘learning hour’ in each shift as part of the coaching model, which is pivotal to enhancing the students' knowledge and bridging any potential theory-practice gap. During this hour, students can access learning materials online or through the library, enabling them to make sense of the learning outcome in relation to the practical care being provided. The coach or clinical educator discusses the learning outcome and the evidence that the midwifery student produces within the hour, which is then collated and can be presented as part of the student's personal portfolio. This learning hour reinforces the philosophy of the clinical area as a learning environment and ensures that the supernumerary status of students remains a feature of their education.
In addition to the learning objectives, students take the lead in the care of the woman or women selected, depending on the student's stage of development. They work alongside their peers, who would collectively be supported by a coach, who is usually a registered midwife, but could be a midwifery support worker or nursery nurse. The literature shows that students can benefit from gaining experience with a range of different people as opposed to a one-to-one mentoring model (Hill et al, 2015). Coaches are allocated to the care of the women with whom the students are working to enable appropriate supervision of students, who can then take on increased responsibilities and enhance their practice experience. This forms coaches' clinical responsibility for the shift and ensures safe care and clear lines of student supervision and reporting. Coaches are responsible for providing written and verbal feedback on student performance in relation to the particular learning outcome for the day, and reporting any issues to the supervising mentor. The evidence from coaches is collated by the student so that a range of practice contributes to the mentor's assessment process. Students have access to their mentor for a minimum of 40% of their time on placement, and have an opportunity to discuss their learning outcomes and progress at a midpoint review meeting at with the mentor and the link lecturer.
Midwifery students are key members of the team caring for a woman and other members of the multiprofessional team are encouraged to liaise with the student, who will in turn feed back to the coach. It is therefore important to prepare the whole team for the change in coaching model to support students.
The coaching model encourages students to work closely with their peers, which has enabled them to develop coaching skills between themselves. Coaching is increasingly being recognised as integral to the role of any practitioner working with students in practice areas (Narayanasamy and Penney, 2014) and being able to develop these skills during their pre-registration training is an additional benefit of this model.
Student and coach evaluations
The evidence suggests that both students and staff have found coaching to be a positive experience. Students have reported feeling more confident in their knowledge and skills, and where collaborative coaching has been used in nursing, there has been a marked reduction in anxiety related to the transition from student to qualified practitioner (Willis, 2015; Huggins, 2016).
The first cohort of students who have experienced the coaching model in their training at JPUH have provided written feedback during module evaluations. Students were encouraged by the midwifery clinical educator to formally share an aspect of their learning that has been enhanced by coaching, generally in the form of a presentation, in a session that takes place once during each module. Clinical managers, link lecturers and student peers are invited and there is always shared learning. This is an opportunity that has been effective in questioning practice, generating interprofessional discussion, empowering students and creating a sense of confidence in their contribution to the team.
The feedback from students and clinical staff was positive, and the advantages of the working closely together and learning from each other were identified.
‘I felt I had gained confidence in my abilities much quicker by being able to complete the care package [for] the woman myself, but felt well supported by my coach and the other students, knowing that if I was unsure about anything I had someone right there to ask.’
‘My advice to those of you who are considering a coaching model as a learning platform, is it works, it makes us more confident in our abilities to complete our role whilst still students. Once qualified I am confident we will feel ready to step over the threshold from student midwife with confidence and competence.’
‘I feel that using [the coaching model] during my training is developed my confidence from being an observer-participant on the way to becoming a competent practitioner. Through [the coaching model] I am learning it is essential to be organised, have good time management, be a good communicator and work as part of a team … and also gives us the independence to identify our learning needs and build upon our clinical skills whilst having the support of a coach and our fellow students … already I feel my knowledge base is benefitting from this style of learning.’
‘[The coaching model] gave me protected time to research and develop knowledge that related directly to women in my care. Also, the coaching model provided me with the opportunity to develop time/workload management skills, which have provided me with the confidence that I will be able to prioritise my workload and deliver excellent holistic care to women once I start my new role as a qualified midwife.’
‘I have found that [the coaching model] has allowed students to develop their clinical and communication skills by working alongside their peers and overall found the students have become more confident in their practice. The model encourages the students to share their knowledge to support others' learning in planning and providing individualised care.’
Discussion
A modified version of the coaching model used in the CLiP pilot project in nursing (Hill et al, 2015) has been embedded on the antenatal and postnatal ward, with further plans to expand the model throughout all placement areas. The ward did not accommodate large numbers of students and most students were in the same year group. The existing practice assessment processes, which included mentoring and tripartite assessment between students, placement mentors and university link lecturers was maintained; therefore this evaluation essentially explored the coaching method. Mentors were able to review written evidence of learning, which contained comments from the coaches who had supervised the students on each shift. This enables greater objectivity for mentors in assessing performance against learning outcomes, and this increased assessment validity was welcomed. The findings in relation to student preparedness for qualified role mirrored the nursing evaluation (Hill et al, 2015).
Questioning by coaches encourages students to critically examine practice and enables them to reflect on and in action, while presenting in a multiprofessional forum enhances learning and bridges the theory-practice gap. In questioning practice, students are able to consider macro-management and influence change. The opportunity to share their learning contributes to service innovation and multiprofessional awareness.
Conclusion
The model is being rolled out across other partner clinical environments, with a new placement circuit that enables students from different year groups to be placed together routinely in learning environments. This peer support and coaching should help students to develop confidence in sharing learning and supporting others. It is anticipated that the model, which allows for separate roles of supervisors and assessors and involves an academic in the assessment process, will meet the NMC requirements, with some modification to separate supervision and assessment. Key to the success of any new model are management support for change, support from the multiprofessional team in each learning environment, consistency of approach and support from a practice educator in the early stages to enable clinical teams to adapt to the new way of working.