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A preceptorship model for health visiting.

WHY DO WE NEED TO SUPPORT NEW HEALTH VISITORS?

The profile of health visiting education has been raised considerably since the Health Visitor Implementation Plan 2011-15: A Call to Action (Department of Health, 2011), which presented a real opportunity to strengthen and grow the health visiting workforce. The result of this rapid expansion of the health visiting workforce is that there is a large percentage (46%) HSCIC (Sept 15) in some areas of new and recently qualified practitioners, each requiring robust preceptorship and support in their first two years of practice. Just as education in the first two years of practice is important, having access to continuing education throughout professional careers is vital (McInnes 2013). "A Health Visiting Career" (DH, 2012a) highlights that completion of the Specialist Community Public Health Nursing (SCPHN) health visiting qualification, is only the start of the journey for continuous learning, growth and for the profession. All health visitors must be enabled to access and demonstrate achievement of continuing professional development (CPD) to meet the revalidation requirements for future registration to practice (Nursing and Midwifery Council, 2011). Evidence also indicates that care and the retention of staff is compromised if staff are not provided with access to professional education and training (Francis, 2013; Whittaker et al 2013). Willis (2015) in the Shape of Caring review, identified that further focused reviews are needed on the purpose of preceptorship and whether, in addition to being provided during the transition period, it should also be offered as a formalised follow-on programme. In this way, newly qualified health visitors (NQHVs) would be encouraged by preceptors to consider their future career pathway and create an appropriate foundation for this in their personal development plan.

THE PRECEPTOR FRAMEWORK

The Preceptorship framework aims to provide the basis for local organisations to develop a custom-made preceptor programme appropriate for the local area profile and priorities. It is outcomes focused and intends to:

* Set out best practice in health visitor preceptorship and consolidation of learning in the first two years of qualifying.

* Promote an understanding of the need for protected time for new or returning health visitors, preceptor period and activities.

* Promote an understanding of the need for protected time for managers and other staff responsible for organising preceptorship.

* Ensure organisations provide an equitable structure for all employees.

A 3-STAGE MODEL FOR DEVELOPING A SUCCESSFUL LOCAL PRECEPTOR PROGRAMME

The framework follows a simple 3 stage approach with the focus on best practice.

1. Preparation 2. Embedding 3. Sustainability

Stage 1. Preparation of a Preceptor Programme Preparation is key to the success of a preceptorship programme. Forward planning by organisations to allocate preceptors to preceptees should occur in advance of the new practitioners starting in practice. Deciding which model of preceptorship to use depends on the local organisational structure, geographical spread and most importantly the number of new practitioners arriving.

Stage 2. Embedding the preceptor programme Embedding the preceptor programme involves regularly undertaking reflective practice and building resilience to ensure good health as well as access to supervision on a regular basis. Having an action plan defined by a learning contract will enable the preceptee to take ownership of their development.

Stage 3. Sustainability of the individual's accountability

The sustainability phase should enable the preceptee to prepare for revalidation of their NMC registration and to provide continued protection of the public.

PRECEPTORSHIP MODELS

The Nursing Midwifery Council (NMC 2009a) suggests a period of preceptorship when moving to a new and different role. During the induction period the new health visitor (preceptee) should be introduced to their preceptor and be ready to start a preceptorship programme. During this period the new health visitor should work through a self-directed programme with a named preceptor.

Models available for organisations to consider are:

* 4-6 weekly meetings 1:1 with a practice teacher (PT)/HV;

* 4-6 weekly facilitated by a HV/PT- group (recommended up to 8 NQHVs);

* Combination of both.

A pilot study was conducted in eight different organisations across England employing health visitors (Rural, urban, city and London) funded by Health Education England to look at the implementation, usability and value to not only the families with whom we work but to individual practitioners and their organisations. During the pilot, the eight test sites were evenly divided between the different models of preceptorship. Figure one demonstrates the favoured model over the six months. A combination of both 1:1 with a practice teacher/manager and group facilitated support was the preferred model. The reasons for this included: the importance of involving the manager and practice teacher in meetings; preceptees benefited from group facilitated meetings where they discussed specific topics relevant to practice with a preceptor present; building up peer support networks (see Figure one).

Preceptees comments on the models of preceptorship included several about how the arrangements work in practice: "Sometimes (it's) difficult for staff to meet up for group sessions because of the geography of the area and time taken to travel to meetings/fit in with caseload requirements, especially if working part time."(Newly Qualified Health Visitor) "The Preceptor is usually in the same base, so has daily contact with time set aside for completing the more formal parts of preceptorship" (Practice Teacher)

SAFEGUARDING CASELOADS

During the focus groups and interviews the anxieties around when and in what format taking on safeguarding cases was discussed. The participants all felt the preceptorship framework required to have a statement added to provide clarity around this area. We devised a statement which was then tested with all eight pilot sites. The final framework (2015) has this added:

"Co-working is recommended for families with known safeguarding issues (section 17 and 47) within the first 6 months. Naturally arising safeguarding issues should be taken back and discussed with the preceptor and line manager. ideally, NQHVs should experience safeguarding families in the first 6 months. However for best practice the ideal time should be discussed between the NQHVand their manager" HEE/ iHV (2015)

A preceptee commented:

"My main anxiety was taking on safeguarding clients. I co-worked families in the beginning, had help in writing reports and attending my first conference. Now I am doing this on my own. Having a 'buddy' has helped hugely"

The pilot process provided the opportunity to make any necessary amendments to the preceptorship framework. We listened to the feedback and added in 3 (validated) important statements:

1. 10 top tips for organisational leads on implementing and embedding the framework.

2. A statement to support the role of the new health visitor whilst waiting for the NMC PIN number for families with safeguarding concerns.

3. 10 top tips to developing resilience in practice.

EMERGING THEMES

During the six month pilot three themes emerged:

Communication

We asked: How effective is communication with your organisation and manager?

We heard: Tripartite meetings were very useful. The preceptor met with the preceptee and team manager 3 times during the preceptor programme. The meetings were for 2 hrs and all relevant staff involved felt this was a suitable length of time. This was found to be very valuable for the following reasons:

* Highlighted to the manager the importance of providing a 'buddy' to co-work safeguarding clients rather than just focusing on KPIs.

* Participants felt this 3 way meeting would have a positive impact on staff retention.

* Allowed the Practice Teacher to step in if the preceptee felt pressurised to take on too many safeguarding clients.

* Allowed a 3 way conversation to meet the service and the practitioner's needs at an early point.

"I understand the pressures on managers but I felt sometimes they were 'papering over the cracks'. Having the tripartite meeting allowed the manager to understand the longer term benefits of putting the right support in from the start" (Practice Teacher)

Support

We asked: What support do you have from your manager and teams?

We heard: Good support from the team is very important; new staff welcomed it. On reflection, interviewees wondered if the introduction of mobile working may adversely affect capacity for team support when welcoming new staff. "When you first arrive you feel quite vulnerable in a team where there is a lack of positive support. I moved base after 4 months and now feel more confident in my role and have a great 'buddy'" (Newly qualified health visitor)

"This year is much better with the 'buddy' arrangement. This is having a positive impact on experienced staff. We are beginning to see the benefits of 'call to action'"(Practice teacher)

Benefits

The benefits of preceptorship for children and families

We asked: Do you think preceptorship will benefit the children and families in our communities?

We heard: Every respondent felt Preceptorship would positively benefit children and families, relating the benefits to support within the teams.

"Supervision, daily support from a 'buddy' and planned meetings means I feel a confident practitioner" (Newly qualified health visitor) "If we provide a safe meeting place where they [preceptee] can share anxieties, they feel restored and allows them to do their job 100%" (Practice Teacher)

The benefits of preceptorship for staff retention

We asked: Do you think preceptorship will benefit staff retention?

We heard: Perceptions of the impact on staff retention from the practice teachers were positive, although it is too early to provide numerical data to support perceptions. They indicated that in relation to this time last year they were experiencing fewer anxieties from the new staff, and experienced staff were beginning to feel the benefits from additional staff.

"Last year, before we had a preceptor programme in place, staff were leaving due to heavy caseloads and stress. Newly qualified staff not being supported in the right way had a knock on effect on experienced staff, making them feel exhausted. I notice a positive difference already this year. Providing the right support, a 'buddy' to co-work safeguarding families in the beginning means at this 6 month point all staff are beginning to feel the benefits" (Practice Teacher)

"I asked at interviews if the organisation has a preceptor programme in place. I chose the organisation who had invested in this programme" (Newly qualified health visitor)

WHAT DOES A SUCCESSFUL PRECEPTORSHIP PROGRAMME LOOK LIKE?

There are key components to a successful programme for organisations to consider:

* Provide a buddy system is key to daily support.

* Provide a system of co-working for safeguarding clients from day one.

* Change the culture--to embrace and embed CPD into the business plan.

* Include staff in developing the service delivery plan.

* Provide workshops between local authorities and health visitor teams to brainstorm integrated working.

RECOMMENDATIONS

Research

Conduct further evaluation: From this short evaluation involving eight pilot sites further urgent research is now required to evaluate and compare the impact of local preceptorship programmes in those areas outside the pilot sites. Additional evaluation is recommended to measure the value of embedding CPD into organisations business planning. This evaluation identifies that preceptorship will be taken more seriously if it is included as part of the overall training model and better linked to more formal systems.

Sustainability

Best practice standards

Two key elements of preceptorship are: maintaining good communication between preceptors, preceptees and line managers and mutual support through group meetings for newly qualified staff. Senior managers should hold responsibility for creating the right conditions, as far as is practically possible, for best practice. We recommend that organisations and teams allocate a preceptor on Day 1 or before a new health visitor begins employment. Caseloads should be acquired gradually, starting with a small generic caseload from 2 weeks into new employment and building up to a full and more complex caseload after 6 months of employment. Newly qualified and return to practice health visitors' shadow or co-work safeguarding cases from day one, and only take on named person responsibility for safeguarding cases when they feel competent to do so and on discussion with their line manager and preceptor. Equal emphasis is given to encouraging health visitors new to a role or an area to use the frameworks, in order to challenge the assumption that the Frameworks are for newly qualified staff only.

Culture change

Develop Best Practice Toolkits: As we enter a period of significant change and a shift from health led to that of joint health and social care led, we must work swiftly with organisations to develop skills in leadership for all Band 6 health visitors in order for them to be able to lead the early year's teams across health and local authority staff groups. Enhance understanding of Outcome Measures: From this evaluation it is clear there is still work to be done in understanding the importance of the Public Health Outcomes Framework and how to use profiling effectively in the local communities.

CONCLUSION

Preceptorship should not be seen as a training course (i.e. is something that follows the education programme). Instead it should consist of at least 1 year including regular supervision both child protection (3 monthly) and clinical supervision (4-6 weekly). The end of the first year flows into the second with the preceptee organising peer supervision groups and support as required from a mentor. From day one of a career in health visiting, practitioners are encouraged to keep reflective journals both to support their practice and provide evidence for revalidation (iHV, 2014). It was clear through the stages of the pilot that we have very high quality health visiting being delivered in many areas around the country. However whilst the framework goes some way to highlighting the benefits of a preceptor programme we must do more. Urgent further research must be commissioned to evidence the effectiveness of providing a more formal preceptorship period of continuing practice development on the retention of high quality reflective health visitors.

Key points

* AH health visitors must be enabled to access and demonstrate achievement of continuing professional development to meet the revalidation requirements for future registration to practice (Nursing and Midwifery Council, 2011)

* Preceptorship should include a buddy system for daily support

* Preceptorship should include a system of co-working for safeguarding clients from day one

* Organisations should consider a change in the culture to embrace CPD into the business plan

* Research must be commissioned to evidence the effectiveness of providing a more formal preceptorship period of CPD on the retention of high quality reflective health visitors

ELAINE MCINNES FiHV, RN, RM, BA (Hons), MSc Lead Professional Development Officer, Institute of Health Visiting

CORRESPONDENCE elaine.mcinnes@@ihv.org.uk

References

Cowley S. et al,. (2013) Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. NNRU, King's College. London. bit.ly/1pK2stt

Department of Health. (2011) The Health Visiting Programme: A Call to Action. DH. England. bit.ly/1Bqc0MS Francis R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry--Executive summary London: Crown Copyright

Health Education England & Institute of Health Visiting (2015) National Preceptorship Framework for Health Visiting http:// bit.ly/1PPv2Ta

Health and Social Care Information Centre (HSCIC) http:// www.hscic.gov.uk/workforce

Mclnnes E. (2013) Views of Community Practice Teachers in Long Arming student Health Visitors Journal of Health Visiting: Dec (2013) Nursing & Midwifeiy Council. (2009a): Standard to support learning and assessment in practice, London, NMC

Whittaker K,. Grigulis A,. Hughes J,. et al,. (2013) Start and stay: The Recruitment and Retention of Health Visitors. National Nursing Research Unit, London.

Willis Lord. (2015) Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants. http://bit.ly/1FQKGsU
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Title Annotation:PROFESSIONAL AND RESEARCH
Author:McInnes, Elaine
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Oct 1, 2015
Words:2573
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