Glass of Sangria, Sir?

It is four years since NUS last produced its charter for nursing and midwifery students in conjunction with the RCN, Unison and the RCM. Its aim was to outline, for students and their education providers, basic steps toward responsible learning and teaching for the professions.

With a decade of the HEI as the base for training, NUS believes that much has changed to ensure that students are able to enjoy the best mix of academic and professional in their qualifications. Yet students continue to face challenges as they attempt to integrate academic life within higher education to their professional and clinical responsibilities on placement.

Drop out continues to concern the sector, the DOH and students themselves. In the Pay and Workforce Research’s 98 report into Student Attrition, it is noted that

“The number of students who do not complete NHS-funded courses of study remains a problem according to the National Audit Office. Around 1 in 6 students do not complete their course, which has led to renewed interest in student wastage and ‘value for money’ on centrally funded academic courses.

The English National Board has estimated that the level of attrition – or student discontinuations as they refer to it – for the 1999-2000 cohort of pre- and post-registration courses was in the region of 14%. This amounts to a 2% reduction compared with the 1998-9 cohort.”

Yet I also believe that there is a huge human cost involved. It is unlikely that any student leaving a course does so without a heavy heart and considerable guilt, often set against pressure from family and friends to complete. Add to this the huge financial costs to students, even in terms of years “wasted”, and we have a problem that still desperately needs solving.

 

The vexing question of “why” students leave is complex and has been subject to a number of studies, many of which are referred to in the in the Pay and Workforce Research’s 98 report into Student Attrition. It is heartening and pleasing to see so much effort going in to solve the problem, even if there is a tendency in some reports to stress a students’ ability to handle difficulties as the key issue at selection (the student-at-fault approach) against the wider questions of support from the HEI/Placement (the institution-at-fault approach)

I remain convinced that the focus of some HEI’s on “rooting out” those unable to cope with or handle the demands of nursing and midwifery education is problematic. Whilst in all areas of HEI recruitment, talent and ability are important, the approach can dangerously assumes a personality type approach to student recruitment and seek to find only students who are prepared to cope with poor facilities, unsupported learning, placement problems and the almost laughable notion of “supernumerary” status on placement. We ought to focus on recruitment policies that test a students’ ability and potential to be a nurse or midwife; not their potential to overcome institutional bad practice and underfunding.

That said, a number of studies and strategies highlight areas where improvement has begun and is continuing; these include student and learning support, placement suitability and support, student funding and marketing.

Clinical placements themselves contribute heavily to attrition. The figures in the the Pay and Workforce Research report suggest between 15% and 20% of attrition is directly related to placements, and it is likely that placement experience is a significant wider influence on other factors.

Our charter sets out a series of specific expectations and rights we believe can contribute to supportive and effective placement experiences, and there is still some evidence to suggest that both HEI’s and service providers have a long way to go on support, mentoring, work ethos and stress.

Many institutions have begun to tackle these issues, and to some extent any strategies will only be successful in a wider context of NHS funding and staffing levels inside placement settings. However, there is also strong evidence that most of the studies and work focus on educational issues and support, rather than more basic human issues.

When I was an Education Sabbatical Officer at the University of the West of England, we persuaded the Faculty of Health and Social Care to attempt to adopt a more student-experience focus to work on the issue in an attempt to understand the life and context of students as students, rather than simply students as learners.

In its report “A Strategy for Improving Student Retention” a clear rationale is set out, that outlines the ways in which students focus on basic needs of food, shelter and successful relationships before worrying about their educational development. Based heavily on Maslow’s hierarchy of needs, it puts sharply into focus the issues around uprooting, “starting again” and isolation that accompany clinical placement.

My own experience is anecdotal but vivid. On several occasions I was called to assist with casework around placements and often visited students “in setting”. I witnessed lonely, geographically isolated individuals, often in poor and inadequate accommodation, citing basic problems with basic solutions; lack of friends, having “no-one to turn to” and feelings of insecurity in accommodation. I witnessed on several occasions rooms with no desks, dark foreboding streets in student-unfriendly towns and students unwilling to risk social integration in intimidating, stressful environments.

On one happier occasion I had the pleasure of assisting two first-time placement students with their temporary move to accommodation in Swindon, to a B&B on the outskirts of town with no sign of running water. Quite apart from the quality of accommodation, I was surprised to find that induction to the placement focussed on the hospital, and not the other students in the area, other students on overlapping placements, and social facilities and networking opportunities within the area. For these students, the mere ability to “call” on support was inadequate (and often not taken up based on the assumption of overworked individuals back at the HEI and within the hospital, not least for fear of “becoming a problem” within the setting and “getting a reputation” which would affect their placement assessment.)

In broader studies of student dropout, many suggest that first-year dropout is often a decision taken within the first 2-3 weeks, with the remaining time an opportunity to create and build other reasons (financial, course) to justify an essentially emotional response to setting. Orientation, particularly social orientation, is seen as important. The crucial issue for clinical placement is constant reoritentation to less supportive, more stressful environments.

Which got me thinking about holidays. Package holiday companies have identified Maslow’s hierarchy and initial experience as crucial to the tourist experience, and have identified a series of activities and competencies inside individuals to assist with providing “at first safe, then welcoming, the pleasant, then unforgettable experience”.

The crucial element to this is the holiday representative. Most are expected to possess

  • Social Skills
  • Local Expertise
  • Negotiation and Advocacy Skills
  • Listening and Empathy
  • Social Catalysts
  • Peer Group Leadership
  • Information and Referral

Their duties include ensuring tourists are initially accommodated properly, welcoming tourists, encouraging social networking and being troubleshooters for the holiday experience.

A number of studies have examined the role of posts designed to support learning in practice for pre-reg nurses and midwives. Some focus on individual pastoral and student support. Some focus on links between the HEI and the placement. Some focus around accommodation and setting assessment. Yet none that I can find properly support or consider the role of social networking, direct student advocacy, and all encompassing “one stop” support that is student focussed.

A common critique of the new connexions service for young people is its focus on connections between government departments and with the individual, rather than connections between young people themselves. It is my contention that this itself is a crucial factor in the sense of isolation felt by placement students, and when coupled with the usual “troubleshootables” and the difficulties of accessing appropriate support and we see a clear opportunity for a role that can cover the bases.

Students’ Unions have a long history of providing many of the functions outlined:

  • Social Networking
  • Acting as student centred providers of support
  • Advocacy
  • “One stop shop” support
  • Representation

Yet students’ unions remain in many ways wedded to geographical bases with large, physical facilities and a “traditional undergraduate” approach to involvement. I would propose that many of the functions outlined above can actually be carried out by individuals employed by a students’ union in or around placement settings.

Each placement area/town would have employed one or a team of students’ union co-ordinators whose role would be:

  • To effectively welcome and orient students to the area and accommodation
  • To support orientation to placement and provide materials and checklists for student and provider responsibilities
  • To identify areas for improvement inside placements set against NUS Nursing Charter standards and report those to the students’ union for liaison with the HEI
  • To provide basic levels of advice
  • To liase with relevant personnel in the HEI and provider
  • To create social networking opportunities for students temporarily in the area
  • To act as a bank of relevant information, both anecdotal and official
  • To act as a referral point for University, Provider and SU services and individuals
  • To act as informal researcher for placement and accommodation suitability
  • To act as troubleshooter for placement setting and accommodation problems
  • To be available at times that can be flexible to student need
  • To encourage and co-ordinate social activity between isolated students in placement towns
  • To encourage and co-ordinate representation within the professional associations and the students’ union/NUS
  • To generally promote and defend the rights of placement students in line with guidelines from NUS, RCN, UNISON and RCM
  • To be independent from both the HEI and the placement provider and as such engage in appropriate advocacy
  • Like holiday reps, they would possess
  • Social Skills
  • Local Expertise
  • Negotiation and Advocacy Skills
  • Listening and Empathy
  • Social Catalysts
  • Peer Group Leadership
  • Information and Referral

Both an office and transport would be provided within each town, and flexible working hours would be expected to meet diverse needs.

It would be desirable for people fulfilling the role to be familiar with nursing and midwifery education which may create challenges for effective recruitment. There would also need to be a clear commitment to effective support of geographically isolated employees themselves and the effective management and support of them from the students’ union.

 

I would estimate that the employment costs (including on-costs) to be around £16-20k per worker, and thus (notwithstanding the easy ability to pilot the scheme) careful consideration would need to be given to impacts and CBA of such posts.

It is arguable that students’ unions themselves have a responsibility to directly fund this group of largely underrepresented students; however, realities may mean that joint, match or full funding would need to be given by the institutions or departments involved.

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