Advanced Training Practices
Advanced Training Practices
Practice nursing has become a key role in primary care and general practice in particular, with nurses taking on ever increasing responsibility for the care of both individual patients and identified patient groups. With this in mind, general practice will in the future require more nurses to choose this area of nursing. Also on the horizon with GP commissioning and providing becoming core to the NHS, many hospital services may move to primary care settings, thus taking nurses out of secondary care.
The Advanced Training Practices has the aim of addressing these concerns by providing placements for undergraduate nursing students in general practice. It is hoped that this experience will encourage the consideration of practice nursing careers. The students are trained by mentorship trained practice nurses enabling them to gain valuable experience in this area of nursing. This forms part of their evaluated training and development. As it is being provided by training practices that place a strong emphasis on medical education and development this enriches the learning environment of the practice by including a further discipline into the professional learning sphere. The pilot is also looking at the development of other placement types, physiotherapy, paramedics etc. and in particular the Inter Professional Education opportunities.
We run the ATP using a hub and spoke model. The Hub, based in the Freshney Green PCC, manages and coordinates the scheme. The three practices within the our centre all place UG Student Nurses, HYMS Year 3, 4 and 5 Students, FY2 Junior Doctors and GP Registrars. Also, 16 of the further 18 Practices within North and North East Lincolnshire (Spokes) also have mentor trained nurses with whom the UG Student Nurses are placed with.
Most practices have independent contractor status. Although they have a contract with the NHS to deliver core services and are performance managed to ensure quality is sustained, they are still independent businesses. Practices can therefore choose what additional and extra services and projects they take part in. Asking practices to take student nurses and manage the process individually with an already crowded schedule and many financial pressures would risk the success of the project. When introducing the project to practices, the responses were to question the amount of extra work it would involve and how much of their nurse time would be directed away from patients in order to manage the students. Without the ability to manage the scheme and the workload generated in the administration of it, practices would not have signed up.
The hub has provided the following functions for the scheme, most of which would not have taken place without this model.
- Meeting potential practices to discuss and ‘sell’ the benefits
- Induction training session for student nurses
- Development of nurse mentor workshops
- Liaison with key stakeholders including University of Hull placement Learning Educators and Link Lecturers
- Development of website for all practices involved in the pilot
- Support for all nurse mentors
- Coordination of practice audit visits
- Support with completion of documentation to assess student placements
- Management of budget
- Audit visits to students at the end of placements
- Delivering reflection sessions with students during their placements
- Day to day trouble shooting
- Coordination of Inter Professional Education Workshops
- Attending meetings and forums to feedback progress and lessons learned by those taking part.
The staffing of the hub:-
- GP Lead to champion the scheme across all practices
- Nurse Educator to lead training and forum sessions
- ATP Lead – to take a strategic lead of the project and manage the hub and its focus
- ATP Manager – to manage the day to day running of the project
Members of the hub work part time and are equivalent to one half time post.
The spokes - Diversity in the Business of General Practice
The practices involved in the pilot are diverse. They range from small practices with one nurse to large practices with a team of nurses at different grades including Nurse Practitioners, Practice Nurses, HCA’s and Phlebotomists. They are geographically remote from each other and although they have been working more closely in recent years due to Practice Based Commissioning, they still retain their own individual ways of working and outlook on general practice and views of how to deliver their services. Being able to coordinate across the practices has allowed an economy of scale and the ability for the smaller practices to benefit from the team working approach the larger practices exercise. It would be doubtful that some of the practices would have had the resource available within the practice to take on the administration as well as the student placement.
Barriers to Implementation
The main difficulty the pilot has experienced has been encouraging practices to take part. Although initially very keen, when pressed could find many reasons why they may not want to get involved. The Hub has spent a great deal of time fostering good relationships with the practices and encouraging them to commit to the scheme. This has meant reassuring the practices that they would not lose too much of their practice nurse time and of all the benefits to the individuals and team as a whole. Whilst it has been a slow process, the participation of practices is constantly, but slowly evolving.
Another barrier has been the many stakeholders involved in the pilot with differing levels of understanding of how general practice operates. The expectation of some stakeholders is that practices ‘should’ just take students and that it ‘should’ happen very quickly. In fact the process has been long and carefully planned out of necessity. Without buy in and trust from the practices, success is jeopardised.
Advantages of Funding a Hub
Using the hub and spoke model allows an economy of scale when being rolled out across a number of practices. If the funding exclusively followed the nurses and was paid only to individual practices, much of the added value and success of the pilot would be lost. Although there are staff costs within the hub, these are relatively static and would not significantly increase with a greater number of practices taking part.
Coordination of Events
Having a hub and spoke model approach to the scheme has allowed the development of cross-practice working, mentor peer to peer support and the inception of a regular forum/workshop for nurse mentors. The students have had induction and reflection training as a group and the opportunity to share experiences.
Inter Professional Education
The scheme has also introduced Inter Professional Education Workshops (IPE) across the practices. The IPE sessions have been devised together with the GP trainer and provide opportunities for mentoring, training and cross boundary working for the nurse students. With nurses playing an ever increasing role in the management of patient groups, their close working with GPs and opportunity to share skills and learn with and from each other gives benefits all round. The ATP has also introduced more disciplines into the sessions and also to give the nurse mentors opportunities to have IPE sessions with the GP Registrars. There are also plans for the outcomes of the sessions to be evaluated and written up so that the good practice can be shared. The IPE Workshops have been taking place on a monthly basis, though it has been difficult encouraging the nursing teams to engage. There is a structured timetable, identifying workshop content in advance, in order to roll out to the Nursing Teams. To date, feedback has reflected that attendees have found these sessions extremely beneficial and the ATP team will be working closely with the VTS to develop this further for the future.
Forming, Storming, Norming and Performing
(Bruce Tuckman's 'Forming Storming' Team Development Stages Model – 1965)
The lessons learned from the scheme thus far have been that the initial difficulties getting the buy in from practices required careful management and the hub support has been crucial. Once on board, practices have needed constant and consistent support in order to make this part of their ‘normal’ working practices. We are now finding interested practices/mentors are enthused to take students and that the benefits of being part of the learning environment are being realised. The hub is managing the evaluation of the experiences of both the student nurses and mentors which can then be fed back into the planning and preparation processes. The feedback from the UG Nursing Students has been incredibly positive. The feedback from the nurse mentors is shared with the university and will hopefully shape the development of the nurse training programme of the future.
Key Benefits of Hub and Spoke Model
- The hub was the key success factor in signing up practices to take part
- The hub has ensured the practices taking part continue to take future students by offering consistent support and training opportunities
- The hub allows cross-practice working to take place
- Practices do not want to take on further administrative duties
- The hub has managed the step change required to make the scheme successful
- A hub was necessary to manage stakeholder expectation and involvement
- The hub has developed a basis for continued development of inter professional learning
- The hub allows the sharing of good practice across all practices involved
- The hub allows an economy of scale that would not be achieved otherwise
Summary of Workload to Date
The ATP currently takes 4 student nurses each semester (12 pa) and an additional Emergency Care Practitioner and 2 Paramedic Students. We also facilitate a number of Foundation Students. It is expected that the numbers will increase as more Practice Nurses undertake their Mentor Training and eventually become sign off Mentors. We anticipate that the Hub will take some18 students and the current spokes will take 35, but as more spokes sign up to the scheme, this number will increase. Clearly, the figures are very much dependent on the availability of students from the University of Hull, with which Freshney Green has an excellent working relationship.
For the future of the Hub and Spoke approach, it is intended that Students are placed throughout the practices involved, subject to funding availability.
Twenty practices have signed up over the past 6 years, they are:
Ancora Medical Centre – Scunthorpe Littlefield, Grimsby
Beacon Medical Centre – Cleethorpes North Thoresby Medical Centre, Lincs
Birches - Scunthorpe Open Door - Grimsby
Birkwood Medical Centre – Grimsby Pelham Medical Centre, Grimsby
Central Surgery – Barton on Humber Quayside Open Access - Grimsby
Chantry Health Group – Grimsby Raj Medical Centre – Grimsby
Clee Medical Centre – Cleethorpes Riverside Surgery – Brigg
Dr Dijoux & Partner – Cleethorpes Roxton Medical Centre, Immingham
Dr Mathews, Stirling St Medical Centre – Grimsby Scartho Medical Practice, Grimsby
Field House Medical Group – Grimsby Woodford Medical Centre - Grimsby
Current interested Spokes are:
Core Care Family Practice, Grimsby
Dr Sinha, Grimsby
West Common Lane, Scunthorpe
Manlake Surgery, Winterton.
New initiatives have also seen the introduction of HCA Apprenticeships, studying a comprehensive programme over an 18 month period. Fourteen have been recruited across the hub and spokes to date with a third cohort under consideration.
There is also a GPN Ready Practice Nurse programme, which includes a Preceptorship at the University of Sheffield, again over an 18 month period the newly qualified nurses will gain autonomy in many skills required to carry out their role – to date 6 have been recruited across the hub and spokes and both programmes have been very successful, helping to grow our HCA and Practice Nurse population locally.