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Enhancing practice teachers' knowledge and skills using collaborative action learning sets.


The professional group of specialist community public health nurses (SCPHN) comprises nurses on the third part of the Nursing and Midwifery Council (NMC) register and includes health visitors, occupational health nurses and school nurses. The NMC (2008) standards to support learning and assessment in practice set out the requirement that all students undertaking a programme leading to registration as a SCPHN must have a named practice teacher (PT) responsible for the design, delivery and assessment of programmes of learning in practice settings. More recently, the Health Visiting Implementation Plan (Department of Health (DH), 2011a; 2011b) set out a new challenging agenda requiring innovative flexible approaches to health visitor training and development (DH, 2011c).

Within the fields of school nursing and occupational health nursing there are also challenges with regard to numbers of qualified practitioners able to undertake the role of PT. The quality of practice learning opportunities, student assessment and the overall student experience are specific concerns to both the DH and the NMC (DH, 2006, NMC, 2008). According to Haydock et al (2011) there is a complex relationship between role satisfaction, organisational support, emotional exhaustion and professional burnout. This has major implications for students, employers and PTs as it is recognised that additional support is required to ensure retention of PTs and enhancement of the student experience. Current approaches to practice teaching have presented challenges such as confusion over the numbers of students assigned to practice teachers and concerns about how standards are being applied (Harries, 2011).

Increasing demands on SCPHNs, combined with relentless government reforms, make the dual role of PTs (clinical and educational) increasingly complex, causing challenges in the facilitation and assessment of students in practice (Gillespie and McFetridge, 2006; Carr and Gidman, 2012). As the SCPHN programme is 50% theory and 50% practice (NMC, 2004) it is vital that practice placements remain of the highest quality and that new and innovative strategies are developed to enhance PTs' knowledge and skills.

In recognition of the complex dual responsibilities of PTs and the lack of research in this area, this paper explores the PT role and how action learning sets (ALS) could enable trainee PTs to implement national policy and guidance in SCPHN education (DH, 2011a; 2011b). ALS are seen as a way to balance risk and uncertainty, facilitating learning or change for the benefit of the stakeholders of the organisation (Pedler, 2012).

Literature review

The SCPHN PT role is a complex and multifaceted responsibility with existing PTs facing unmanageable workloads and lack of support in practice as there are reducing numbers of experienced PTs to support novices (Lindley et al, 2011). SCPHN students require considerable support from PTs to develop leadership and cognitive skills (Carr and Gidman, 2012; Haydock et al, 2011). This is against a backdrop of reduced staffing levels and finite resources.

Anecdotal evidence suggests PTs are dissatisfied with the long-arm mentorship approach as they are increasingly asked to supervise numerous students and trainee PTs with no reduction in clinical responsibility (Harries, 2011). Additionally, novice PTs have difficulties accessing support when they are experiencing role difficulties (Sayer, 2011). This has implications for the student journey, the trainee PT and service requirements. Demographic profiles suggest that many experienced SCPHNs will retire in the near future, resulting in more newly qualified practitioners in the workforce than experienced practitioners, making effective practice education pivotal to the preparation of future practitioners (NMC, 2011; Centre for Workforce Intelligence, 2012).

Many areas of specialist practice have severe PT shortages, increasing the demands felt by those practising (Kin, 2010). This has implications for work-life balance as PTs report not being able to complete all of their duties within work time (Lindley et al, 2011). As the number of health visitor students increases, so will the pressure on PTs who will be required to develop models of education which are innovative and flexible (DH, 2012a). Such strategies will be necessary not only to meet the increased demand for student placements but also to take into account the changing demographic of SCPHN students who are entering the profession with limited experience (DH, 2012a). Despite this variance in prior experience the student is still required to develop specialist public health skills and advanced levels of critical reflection and problem-solving skills (DH, 2012a), further impacting on the role of the PT.

As the nature of community practice education has become increasingly complex, it is imperative that strategies are adopted to negate the problems encountered by PTs. ALS are seen as a way to promote the development of problem-solving ability and leadership skills within a supportive framework (McCormack et al, 2008; Richardson et al, 2008; Ceely et al, 2008; Plack et al, 2008). ALS are structured small groups typically consisting of six to eight members. At each meeting, set members present an issue from practice, the group helps the presenter to work on the problem through supportive but challenging questioning, encouraging deeper understanding of the issues involved and new perspectives. This facilitates shared learning and reflection on practice (Lamont et al, 2010).

Adult learning theories emphasise that knowledge development is an active process that encompasses personal motivation and previous experience (Knowles, 1990). ALS are built upon this bedrock of experience and the principle that students learn best from self-reflection within a mutually supportive group (Botham, 1998; Pedler and Abbott, 2008; McGill and Brockbank, 2004; Horsley, 2010). As PTs are both specialist practitioners and educationalists in practice, it is suggested that the added value that ALS bring to PT education will impact on student support through role modelling (Charters, 2000; Perry, 2009). Students who are placed with trainee PTS will be exposed in practice to the skills and values developed within the ALS, which could enhance their critical reflection and problem solving skills (Robinson, 2001), thus impacting directly upon the trainee PT, service delivery and employability of associated SCPHN students.

The ALS research highlights the importance of developing questioning skills (Harrison, 2006; Thorne and Corley, 2005; Plack et al, 2008) The facilitator role is seen as pivotal to this process, acting as a coach and guiding set members to deeper levels of reflection and insight (Sanderson et al, 2006; Robinson, 2001). For the facilitator to be effective they need to be well versed and proficient in the use of ALS.

The literature suggests that ALS do have the potential to contribute to the development of trainee SCPHN PTs as they promote contextualisation of practice within a relaxed atmosphere, thus encouraging expression of related issues and concerns (May, 1993). Consideration does need to be given to the use of ALS as an educational strategy and the voluntary nature of set membership is considered in much of the research (Dunphy et al, 2010; McCormack et al, 2008). Therefore, when ALS are incorporated into education modules consideration needs to be given to androgogical approaches. ALS should be separate to any assessment strategy and participants should be free to opt in or out of the ALS with no impact on any assessment process.

The primary education facilitator's (PEF) role is to ensure the student experience both pre and post registration is of the highest quality, primarily through the support of mentors and PTs. PEFs contribute to the learning environment by providing support and development activities (Carlisle et al, 2009).

Research design


This research explored the impact of collaborative ALS on SCPHN practice for key stakeholders, trainee PTs, their SCPHN students and associated PEFs. The research inquiry concerned is interpretivist in nature. Interpretivism aims to bring into consciousness the hidden social forces and structures where knowledge and meaningful reality are constructed (Scotland, 2012). Hermeneutic or interpretive phenomenology is centred on the way in which individuals make sense of their subjective reality and subsequently attach meaning to it.

Research questions

* Do collaborative ALS improve the quality of SCPHN practice placements?

* Do ALS enhance critical thinking and problem-solving skills of trainee PTs?

* Do ALS promote role modelling in PTs to increase employability of health visitor students?

Data collection

The total population sample consisted of eight trainee PTs, six SCPHN students and two PEFs, employed by four NHS trusts in north-west England. All PTs were mentoring a SCPHN student on a one-to-one basis and undertaking a postgraduate module, teaching and assessing for PTs.

Participants were approached for inclusion in the study when attending the module and agreed to take part. All participants were given the option to decline and reassured it would not impact on their module assessment should they do so. The four principles of ethical research: beneficence; non-maleficence; respect for autonomy and justice; and fairness in the distribution of benefits and risks, were applied (World Medical Association (WMA), 2004). The university research ethics committee granted approval and participation in the research was voluntary.

Two methods of data collection were used in the study--a pre- and post-ALS intervention questionnaire for the PTs and focus groups. Simple descriptive statistics were used to summarise questionnaire findings. Three focus groups for the trainee PTs, PEFs and allocated SCPHN students were held. Content analysis of the transcripts enabled the material to be explored systematically to identify relevant themes and categories within the data, helping to clarify descriptions of the major issues identified.

Qualitative findings

Pre- and post-intervention questionnaire quantitative findings

Data from the pre- and post-course questionnaire provide evidence of an increased awareness of the knowledge and skills required of the PT (Figure 1). Before the course, 37% of the PTs were unsure if formal preceptorship during the ALS would enhance their knowledge and skills (Figure 2). Following the course 100% agreed or strongly agreed that formal preceptorship had enhanced the development of their knowledge and skills (Figure 3).

Before the course 25% of trainee PTs were unsure if the ALS would improve their teaching. After the course 100% of the PTs strongly agreed that the ALS had improved their teaching.

Analysis of the focus group data elicited three broad themes:

* Knowledge, skills and role modelling in practice

* Dedicated PT development

* ALS in practice.

Knowledge, skills and role modelling

The PEFs valued the PT's knowledge and skills, which were used with a range of staff members including newly qualified practitioners and skill mix members. Skills highlighted were: higher levels of judgment making; advanced levels of communication; skills of enquiry and analysis; and the ability to deconstruct practice and tailor individual student journeys.

'It's challenging working in the community ... it's about having those difficult conversations, safeguarding issues and having the confidence to follow your gut instinct, you have to do that as a newly qualified HV.' (PEF2)

The PTs also made reference to how their knowledge and skills had developed over the course.

'I think my practice changed over the year and the team leader said you were more reflective and it was an unconscious thing that ... and I thought, yeah, you're right, it was because of the course and the ALS'. (PT1)

The students made many positive comments about their PT's level of knowledge and skill. The students alluded to the notion of a developmental journey, facilitated and guided by the PT. References were made to trust, and being valued and protected by their PT.

'Building on it layer by layer, if you like. It was like they [PT] had a very clear-cut idea of what they expected at certain times'. (S1)

'My PT did the learning styles with me at the beginning and, well, she didn't know me from Adam. She planned how I was going to learn certain skills around that, she had this knowledge about what to do before I did'. (S3)

'I felt very valued, which I have never done when I was pre-reg. She really took time at the beginning to get to know me, which nobody has really bothered to do in the past. I'm not blaming anybody from the past because I know they are busy and life on a ward is different but saying that, she has a busy caseload'. (S2)

The students commented on the importance of having time to reflect. The PTs would use questioning to guide the reflective process and this was also seen as a way to develop the students risk assessment and leadership skills.

'It's the reflection time that you get. They let you tell them what you think, I was quite shocked at first. I don't know this role so how can I judge the situation, but that's how she nurtured my independent thinking, because you are at the higher level and I think that very early on it made me realise that you really do need to step up your game'. (S2)

The students valued the PT's knowledge of specialist practice and the academic programme. This was discussed in terms of making sense of the NMC specialist competencies in relation to their practice portfolio.

'She was ahead of the course and me, making sure I achieved my outcomes. Before leadership was launched she discussed trust opportunities. She had my portfolio in her head from the word go.' (S3)

'She's constantly reminding me, all these things that I would just do in day-to-day practice, she'll go, "That's your portfolio, put it in there". So she's prompting that building but also acknowledging what I'm doing and what it relates to'. (S1)

The students commented on how they observed expert skills, such as advanced communication skills being modelled to them.

'My PT is a fantastic communicator in the way she deals with things and the way she deals with social care, very calmly. I learnt that from day one, sitting and watching'. (S5)

One student commented on their PT role modelling the use of ALS questioning, which she used with a range of clients. She discussed how the PT built upon her questions, encouraging the client to develop new perspectives and personal problem-solving ability.

'I have observed my PT doing that in practice with families. You've seen the master doing a really good job, what they're really good at, which is fantastic. When it's working, when it's done, it's a really good tool.' (S2)

For this same student the knowledge and skills role modelled by her PT had a profound effect.

'I take her as a role model and I quite often think "Well, what would she do? What would she say?" Yeah, it has been good and I do feel that if it wasn't for her I would have left the course. (S2)

Dedicated PT development

The PEFs and PTs raised the importance of academic PT preparation. The PEFs felt they had noticed a difference in the recently qualified PTs since they had been undertaking the newly validated PT module, which incorporated ALS. Differences in mentorship and practice teaching preparation were discussed with greater value being placed upon dedicated PT education.

'It's focused on practice teaching rather than mentorship, there's a distinct difference. Leadership is a very significant part of the role, hierarchy expect it, PTs are producing Band 6s, PT is grounded in leadership and public health.' (PEF1)

'I think the course made me realise how important we are ... when we have sign-off status we are responsible, not burdened but I was aware that ... it's like a gift, you've gotta pass it on to your student to make sure she's going to be good.' (PT3)

Reference was also made to the importance of managing the learning environment including failing students. The PTs felt that practice teaching required advanced levels of assessment skills and knowledge.

'It's a different skill, because we're not actually assessing them as just good enough, it goes deeper than that. We've got this higher level of knowledge and cognitive thinking that's important in sign-off because we're not just ticking a box' (PT1)

Practical application of ALS

ALS were discussed as aiding and developing critical thinking and problem-solving ability. The PEFs felt the newly trained PTs were more flexible in their approach to the student journey having been exposed to the PT course and ALS. As a consequence, both PEFs wanted all of the PTs in their organisation's to facilitate ALS with students.

'They (ALS) make you think differently, it's better than clinical supervision. We need a culture shift to move towards more productive and healthy ways to go about problems so that you're not constantly fire fighting.' (PEF2)

Four of six students had been exposed to ALS and found them to be beneficial. The sets were seen as a way of consolidating learning and sharing experiential knowledge of practice.

'ALS would be something really useful for the future, I thought that is a really useful tool, my mind was going all the time.' (S2)

'I think you could use it with clients. I could use it with young people, you know, the drop-ins, etc.' (S6)

All of the students said that the questioning approach challenged and developed their cognitive ability and they recognised that their PTs used ALS questioning processes with them.

'My PT does that a lot with me, draws ideas out like that.' (S5)

'By people asking you different questions you think, "Oh is that really what I want to do, perhaps I should think about it a different way?" Critical thinking is something that I would take from that, yeah.' (S2)

Facilitation was seen as key to the ALS

Four of the PTs had run ALS and others had used the acquired skills of questioning on a one-to-one basis. All felt the ALS had the potential to enhance the student experience and develop questioning and problem-solving ability. Facilitation was seen as key to the ALS.

'We wouldn't have known what to do if you [lecturer] hadn't modelled it for us. It's one of those things. It's hard to talk about it, it's much easier to do it but you need somebody who knows the game.' (PT4)

'With the students it's showing again and again you're not trying to fix people, you know. That's gone now, it's a skill, asking questions all the time. It's not easy, it's hard not coming up with solutions. It's for people to come up with their own solutions.' (PT4)


Quantitative findings demonstrate that all PTs felt that they had improved their knowledge of specialist practice education and acquired skills to become effective PTs. All of the PTs agreed that formal facilitation of the ALS enhanced the development of knowledge and skills in relation to practice education.

The PT's ability to develop individual programmes of education and act as guide and assessor was discussed by PEFs and PTs. The findings demonstrate the significance of the lone assessor role, with PTs expressing the felt responsibility of sign-off status. This is consistent with the literature documenting the accountability felt by PTs (Haydock et al, 2011; Carr and Gidman, 2012).

The increased responsibility of the PT role is pertinent as previous studies have highlighted that trainee PTs often have difficulties accessing support (Sayer, 2011). The PTs also stated that the sessions that incorporated the ALS benefited them the most as they were able to discuss and explore issues of SCPHN practice education gaining new perspectives, which were developed through group questioning. This highlights the importance placed upon working with other trainee PTs to reflect and develop critical thinking and problem-solving skills (Botham, 1998; Pedler and Abbott, 2008; McGill and Brockbank, 2004; Horsley, 2010).

The development of critical insight and problem-solving skills was seen as an integral aspect of the PT role. The students felt that this was developed through the use of questioning, reflection and ALS. This questioning process was described as collaborative in nature with the PT acting as guide, role model and expert practitioner. These key skills are cited in the ALS research highlighting the importance of developing questioning skills (Harrison, 2006; Plack et al, 2008). In particular, the process of questioning and reflection was said to aid the development of deeper levels of reflective enquiry and critical thought processes. This is seen as a fundamental skill of SCPHN (DH, 2012b). The PTs stated that the skills they had acquired as part of the ALS were used to good effect with students, colleagues and clients both as part of a group process and on an individual basis. These skills were then role modelled to students to guide both their reflective journey and clinical work enhancing the SCPHN practice placements. All participants stated their intention to incorporate ALS into their continued professional development.


* ALS should be integrated into PT preparation programmes to aid the development of questioning, reflective enquiry and problem-solving skills.

* All qualified PTs should be introduced to ALS as part of their PT updates to aid their educational development and role model ALS skills to students. These should be facilitated by lecturers and existing PTs well versed in ALS processes.

* Employing organisations and higher education institutions must ensure a culture that fosters critical reflection and questioning, as endorsed in the philosophy of ALS.

* Further research should be undertaken into the use of ALS with experienced PTs.

* Wider research is needed into how the differing SCPHN groups use ALS with their students.


A limitation that needs to be considered is that the findings from this research relate to a small sample taken from one university in the north west of England and may not be transferable to other organisations. However, it is anticipated that the rich data obtained will enable this university to continue to develop strategies to support and enable the PT role.


The pre- and post-intervention questionnaire data analysis demonstrated that all PTs agreed that they had improved their knowledge of specialist practice issues. All reported they had acquired skills to become effective PTs and that the ALS had enhanced the development of their knowledge

and skills. Importance was placed upon working with other trainee PTs to reflect and develop critical thinking and problem-solving skills through the use of ALS. This study highlights the value of integrating ALS as part of trainee PT development.

The process of questioning aided the development of deeper levels of reflective enquiry and participants stated their intention to incorporate ALS into continued professional development. These skills were role modelled to students to guide both their reflective journey and clinical work, enhancing the quality of SCPHN practice placements. A limitation of this research is the small sample size; however, the data obtained have been used to develop strategies locally. This will improve support for trainee PTs via the PT module and experienced PTs via SCPHN PT and specialist practice community mentor updates held bi-annually. Such strategies will support the development of PTs in enabling deeper levels of reflective enquiry and problem-solving ability.

Key points

* Data analysis demonstrated that the practice teachers (PTs) valued the dedicated module and action learning sets (ALS) enhanced their knowledge and skills

* The process of questioning in the ALS aided development of deeper levels of reflective enquiry

* ALS questioning skills were role modelled to students to guide reflection and knowledge acquisition

* All participants intended to develop ALS as part of continued professional development

This project was awarded a HEA Teaching Development Grant--individual strand in May 2012.


The authors wish to thank Barbara Holliday and Charlotte Eost-Telling for their valuable contribution to data analysis.


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Deborah Haydock MEd BSc(Hons) SCPHN (HV) RGN RM NP FHEA

Senior Lecturer, Department of Community Health and Wellbeing, Faculty of Health and Social Care, University of Chester

Jean Evers MEd BSc(Hons) SCPHN (HV) RGN FHEA

Head of Department, Community Health and Wellbeing, Faculty of Health and Social Care, University of Chester


Figure 2. I feel that formal preceptorship
during the action learning sets will enhance
the development of my learning and skills

Neutral          37%
Agree            25%
Strongly agree   38%

Note: Table made from pie graph.

Figure 3. I feel that formal preceptorship
during the action learning sets has enhanced
the development of my learning and skills

Agree      25%
Strongly   75%

Note: Table made from pie graph.
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Author:Haydock, Deborah; Evers, Jean
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Jun 1, 2014
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