Characteristics of participants
We placed 31 student nurses into six GP practices in three Primary Care Networks (PCNs); this being 15 students in Winter 2021 and 16 students in Summer 2022. Previously (pre-CLIP) one or two of those practices might have had one or two students in total. The student nurses were all female expect for one male. All the GP placement staff were registered nurses with experience in student support as well as in GPN. All staff were female. We conducted two FGs with student nurses, one in January 2022 and another in July 2022. Of 31 students invited, seven attended in Jan 2022 and another five different students attended in July 2022. With regards to staff data collection, we conducted two FGs with placement staff, one in January 2022 and another in July 2022. Of 42 GPNs invited, five attended in Jan 22 and a further six attended in July (one staff member attended both groups).
Qualitative findings
Table 1 summarises the final themes and subthemes from the qualitative data analysis. Indicative quotes are included in the following analysis. These are coded so that anonymity is maintained, referring to the status of the respondent and which FG they took part in, so for example the suffix ‘Staff FG 1 Participant 2’ indicates that the quote comes from the second staff member speaking who was taking part in the first FG.
Table 1: themes and subthemes from the qualitative data analysis.
Theme
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Subthemes
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Peer Support
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Psychological support
Helped with learning
Leadership for third years
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Interprofessional Learning
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Breadth of experiences
Multi-disciplinary team case management
Sense of belonging
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Importance of ‘own clinics’
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Enhanced Responsibility
Validity as a job destination (students)
Coaching (staff)
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Theme 1: Peer Support
This theme was central to the discourse in staff and student focus groups in both time periods. It is clear from our findings that these students had spent a majority of their previous placement experiences working in environments where they were the only student or if there were other students, they did not formally engage with them. Students felt inhibited in their professional relationships with RNs and other staff, and valued the opportunity that this GPN CLIP placement offered them to interact with other students, share their experiences and work collaboratively, whilst knowing that there was appropriate supervision available close by. The subthemes that emerged in this theme were Psychological support; Helped with learning and Leadership for third years. Regarding Psychological support, the following quotes are indicative of how students and staff perceived the benefits of CLIP with its increased capacity:
It's nice when you're working alongside other students, and you know that you've got that Friday where you're all together in the same place and you just kind of offload to each other about the week. And it's like a way of having a massive, deep group brief as a group, isn't it? Yeah. Because we're all in the same position. (Student FG 2 Participant 2)
This was echoed by staff:
They also encourage them to support each other a lot more, so they formed that sort of close relationships. So, if there was a problem on a shift or even outside of a shift… they really did communicate well between themselves. (Staff FG 1 Participant 1)
It was clear that students also valued being able to learn from each other and that being together facilitated that, in line with a second subtheme of ‘Helped with learning’ shared by staff and students across both FGs:
I felt learning from other students was brilliant. I think it boosted my confidence massively. (Student FG 1 Participant 2)
And this was reflected in the staff data:
I think that the way they do CLIP now and the way they collaborate together [is much better]. I see them learning much more than I used to…having them to bounce off each other. I think it teaches them a little bit more, to be fair. (Staff FG 2 Participant 1)
One further subtheme that emerged from the data concerned the leadership roles that third year students were able to perform with more junior students:
It was good for me as well as a third year… when I first started on the GP surgery, I didn’t really know what I was doing. And then having [junior students] coming to us and asking us questions about what we thought, that boosted my confidence, “no, actually, I do know what I'm talking about, and I'm ready to maybe be a [registered] nurse”. (Student FG 1 Participant 4)
And this was echoed in the staff data:
If a second year is struggling with something that the third will give them encouragement, you know, that's quite a benefit…it depends on their background but they all will support each other. (Staff FG 2 Participant 2)
Theme 2: Interprofessional Learning
Within the IPL theme, the first sub theme concerned the Breadth of Experiences that were on offer in the GP practice when students were able to link up and work with a wide range of professionals, and in different ways than might be possible in an in-hospital placement or another community setting. For example, students listed themselves as spending time with and learning from: GPs, Advanced Nurse Practitioners, Dieticians, Community Midwives, District Nurses, Physiotherapist, Podiatrists, Specialist Elder Care Nurses, Pharmacists, Well-being Coach, as well as un-registered healthcare staff. Students planned these liaisons themselves, and these were seen as good learning experiences by staff:
[Students’] having access to the clinics and PCN staff... they can plan their own week without us having that responsibility of making sure they've actually got something allocated every day. If they haven't got a CLIP clinic on, they have taken responsibility for their own allocation, their own learning objectives. (Staff FG 1 Participant 2)
And students noted how different their participation in learning was in the GP setting compared to hospital placements:
As soon as you go into hospital [placement], you can't really do anything. So, you're just sort of watching it. (Student FG 2 Participant 5)
In all cases this IPL was facilitated by students’ exposure to ‘Multi-Disciplinary Case Management’. The staff were clearer how this operated and what nursing involvement could be:
We have an 11:00 o'clock meeting, which, anybody [any healthcare professional] can come to … we can talk about patients or talk about the home visit that somebody might doing… it's good for all sorts of things, but it's good to hold the team together and it does help with the students. They [students] just bring another dimension to it and other you know, it's another voice. (Staff FG 1 Participant 4)
Students detailed how they were involved in IPL as they were given project work to do, and this student shows how students collaborated and learned from the experience of investigating patient journeys, eventually meeting one particular patient:
The first week or second week we were given a couple of case studies to look at and then we actually met one of them [patients]… We could ask questions and different things in relation to how he felt he was supported by the surgery and other community people [healthcare professionals]. We also had another patient…and we had to sort of determine how he was diagnosed, it was over three or four years. And it's amazing that he's still alive today to be honest. But yeah, I met him in the GP surgery. I think the week before I left. (Student FG 1 Participant 1)
The third subtheme relating to IPL and the students’ experience of working in GPN CLIP placements was how they felt a greater ‘Sense of belonging’ in the teams in which they worked.
This student makes it clear how she felt more valued in her GP placement, and this type of dialogue was echoed by almost every student in this study:
The staff treat you a lot differently in primary care than in acute. We like the staff, but that the GP surgery and [name] are amazing. They've all been so lovely, including the doctors as well. And I think that makes a massive impact to your experience. (Student FG 2 Participant 1)
This quote from a staff member illustrates how the students were valued and how staff worked to make them feel welcome and that they belonged:
[The GPs] love it to be fair, one of our partner GPs, he can't wait to call in a student [nurse] and teach them about ECGs... The GP and the other clinicians, they like sharing what you know and encouraging them. Yeah, they really enjoy it. And the reception team do as well. They like having young people around because most of us are ‘getting on a bit’ now. (Staff FG 2 Participant 3)
Theme 3: Importance of ‘own clinics’
Throughout the dialogue from staff and students, the issue of ‘how’ students worked in the GPN placements was mentioned. This was in their ‘own clinics’ (called ‘CLIP clinics’) and from that concept flows several other factors and benefits that accrued to staff and patients and impacted on the way in which staff worked with students. This had implications for students’ confidence as independent practitioners, as well as having an impact on their relationship to GPN nursing as a potential job destination, and for improving patients’ access to certain services which students were able to deliver. In this overarching theme, staff and students’ in their respective FGs discussed ‘Enhanced responsibility’, but there was a distinct dichotomy between staff and students related to other subthemes, such that it is justified to report staff and student data separately for the only instance in this paper. Staff discussed how students working in their ‘Own clinics’ meant they were using supervision at a distance in a coaching approach, but staff did not discuss any impact that the placement may have had on students’ job choices on qualification. Students discussed how this GPN placement has fostered a desire to work in GPN, but they did not discuss coaching as a placement learning strategy.
The first subtheme ‘Enhanced responsibilities’ relates to how students and staff perceived that GPN placements for these students had offered them enhanced opportunities to take responsibility for patient care that often were not available from in-hospital placements, largely because they were seeing patients in their ‘own clinics’, as well as because they were undertaking a range of activities with patients that are elements of the GPN role, many of which are listed below:
We found that [having our own clinics] an amazing experience…we did lots of things. And as the weeks went on, we added different stuff to our clinics, so it started out with… basic blood pressure, hypertension reviews, diabetic reviews and in the end we were doing maybe more complex dressings assessments, ECGs, flu vaccines. We were doing a lot. We found it really good and nice to learn in our own space. (Student FG 1 Participant 2)
This was echoed in the staff perceptions:
I think for all the practice nurses as well, we were quite concerned that [students] would be running a clinic, seeing their own patients. We wouldn't be in the room; it’s just something about having control, isn't it? Now we find it brilliant, because we spend the first couple of weeks training them up and working with them so that we are familiar a bit more with their capabilities. (Staff FG 1 Participant 4)
It was clear from staff data that they were using a ‘coaching’ approach in which students were facilitated to be at the centre of care delivery within their competencies, and that the students being independent in their ‘own clinics’ was central to that, as this exchange shows:
If you've got multiple students in general practice, it has to be a coaching approach because you don't have the capacity to be able to mentor, you can't just have one person on a 1 to one because we don't have the capacity for that. (Staff FG 2 Participant 2)
I agree with that. Yeah. You it is. It's naturally a coaching thing. Our students sit in with us for the first couple of weeks before they have their own clinics. (Staff FG 2 Participant 3)
Students discussed how this placement and exposure to GPN had helped them to identify its ‘Validity as a job destination’, which was their second subtheme. This dialogue took place in focus group 1:
You know, I never considered general practice nursing. Yeah, after the after [this] placement it is an option that I would consider now, definitely. A lot of students they don't consider that when they graduate. (Student FG 1 Participant 6)
Patient access audit data results
Regarding Aim 3: in one PCN that included two practices in one South West County, between November and December 2021, student nurses in this CLIP placement ran an additional 200 clinic appointments, so the total number of clinic appointments rose from 1060 to 1260, an increase of 20%. Students in these clinics saw patients for blood tests, long-term condition monitoring reviews, observations including hypertension reviews, simple dressings, ECGs. (Students did not review medications in their clinics). Also, 65 additional COVID vaccinations took place when student nurses were available. Anecdotal evidence from the PCN data manager indicates that having student nurses in CLIP meant that some patients were able to access same day appointments for blood tests when otherwise there could be a two week wait. This was supported in the FG data analysis.
Patient access and skill mix
Although not well developed enough to stand as a coherent theme or subtheme of the qualitative data, staff and students did allude to issues of patient access and skill mix in the focus group discussions, in ways that support our analysis of the increased clinical appointment opportunities detailed above. As this study took place at the end of COVID-19 pandemic in the UK, when physical access to GP services had been restricted for many months (even though it was available in ways other than direct contact), this was an issue being discussed in the media in the UK. Staff discussed how students could see patients in person and spend much more time with them, and outlined how student nurses taking their ‘own clinics’ could free up other professionals to do other things. Students did not go into detail about this but were clearly able to take on activities such as venepuncture for the patients attending ‘their’ clinics that might otherwise have been the preserve of HCAs or phlebotomists. The extent to which student nurses had an impact on the skill mix in the practices in which they were placed is unclear. However, it was clear from the audit data that there was an increase in capacity or clinic appointments available, and anecdotally that patient waiting times reduced dramatically, with one practice manager indicating that the waiting time for blood tests had gone from weeks to same day because student nurses were undertaking venepuncture in their practices.