Clinical learning environments: an evaluation of an innovative role to support preregistration nursing placements

© 2003 Blackwell Publishing Ltd.

Learning in Health and Social Care

,

2

, 2, 105–115

Original article

Blackwell Publishing Ltd.

Clinical learning environments: an evaluation of an innovative role to support preregistration nursing placements

Charlotte L.

Clarke

PhD MSc PGCE BA RN

,

1

*

Catherine E.

Gibb

PhD PGC BSc

MRCSLT

2

&

Vince

Ramprogus

PhD MSc BA RGN RMN RNT

3

1

Professor of Nursing Practice Development Research, Nursing, Midwifery and Allied Health Professions Research and Development Unit, University of Northumbria at Newcastle, Benton, Newcastle upon Tyne NE7 7XA, UK

2

Research Fellow, University of Northumbria at Newcastle, Benton, Newcastle upon Tyne NE7 7XA, UK

3

Associate Dean, School of Health, Community and Education Studies, University of Northumbria at Newcastle, Benton, Newcastle upon Tyne NE7 7XA, UK

Abstract

Contemporary nurse education places a high value on learning in the clinical

environment. Combined with increasing numbers of students there are

unprecedented demands on clinical areas and staff. One response to this problem has

been the development of the practice placement facilitator (PPF) role. This study

aimed to evaluate, over 12 months, the impact of the PPF role on the provision of

practice placements, student support during placement and professional development

needs of staff as clinical supervisors/assessors. The evaluation focused on three areas:

capacity to accommodate students; quality of placements in relation to the role of the

PPF; and the evolution of the role of the PPF. Data-collection methods included

interviews, focus groups, questionnaires and secondary data analysis. The findings of

the study demonstrated that: many different groups of learners are present in clinical

environments; students need to have continuity of support; clinical staff derive benefits

from an enhanced understanding of the needs of learners through the work of the PPF;

and that if the role and function of the PPF post is unclear and/or poorly maintained

there will be detrimental effects.

Keywords

clinical placements,

facilitator, learning

environment, role

development, student

nurses

*Corresponding author. Tel. +44 0191 215 6044; fax +44 191 215 6083;e-mail: [email protected]

Introduction

The thorny problem of nurse education in a clinical

environment continues to bedevil the advancement

of nursing as a profession, which aspires to be both

an academic and a practice discipline. Historically

there have been policy swings in favour of or against

the clinical environment as a learning environment.

At present, in the UK, the move is towards a greater

emphasis on learning in the workplace and on the

development of practical skills [Department of

Health (DoH) 1999], which requires the workplace

to be a learning environment. In addition, the

requirement for an increasing number of nurses and

106 C.L. Clarke

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midwives to be educated (DoH 1999, 2000a) places

unprecedented demands on clinical areas at a time

when they are themselves confronted with problems

of recruiting and retaining staff (English National

Board 1999) and an increasing throughput of patients

(Rinomhota 1998).

The quality of clinical placements constitutes

the most significant influence on the learning process

(French 1992), with the roots of most student

satisfaction being found in practice (Cahill 1997).

The dominant role of clinical staff in supporting

the learning of students has been highlighted repe-

atedly and with little apparent variation internationally.

Chow & Suen (2001) describe the clinical mentor’s

roles in Hong Kong – of assisting, guiding and

befriending – as most necessary to students. Smith

& Gray (2001) similarly highlight the importance

of the mentor role in the UK, being role models for

learning to care and supporters for the emotional

labour of nursing practice. Jackson & Mannix (2001)

analysed the helpful and unhelpful behaviours of

clinical staff for students in Australia: understanding

and being friendly, showing interest and explaining

were judged as particularly helpful actions. In a

Swedish study, Löfmark & Wikblad (2001) propose

organizational, educational and attitudinal changes

in developing student experiences. Jones, Walters

& Akehurst (2001) suggest that lack of access to

their mentors may be detrimental to a student’s

development.

The importance of clinical placements within

nurse and midwife education is re-iterated in the

publication ‘Making a Difference’ (DoH 1999), which

highlights the need for ‘practitioners who are fit for

purpose, with excellent skills, and the knowledge and

ability to provide the best care possible in a modern

NHS’ (DoH 1999, p. 23). In addition, ‘Making a Dif-

ference’ emphasizes the importance for student nurses

and midwives to be taught by those with practical and

recent experience of nursing, which will be achieved

through ‘boosting teacher support for students on

placements and stepping up the pace of joint

appointments with universities’ (DoH 1999, p. 27).

Whilst improving the quality of student place-

ments is widely acknowledged to be a high priority,

there is also a need to increase the actual number of

student placements available. This requirement is

created by two forces within the nurse and midwife

education arena: the intent to increase the number

of students recruited to preregistration nurse educa-

tion (DoH 1999); and the refocusing of preregistra-

tion education on outcomes-based, competency

principles (United Kingdom Central Council 1999).

However, the healthcare environment is under

pressure, with a greater number of patients (many of

whom are acutely ill) being treated than ever before,

whilst fewer qualified staff are employed. One con-

sequence of this situation is that there is less time

available for practice staff to supervise and mentor

students (Chaffer 1998), there being little doubt that

inadequate human resources not only affect patient

care, but also compromise learning and teaching as

well as the supervision and support of students.

It is against this background that the need for a

practice placement facilitator (PPF) has been argued.

Chaffer (1999) reports the recommendation of

the Royal College of Nursing (RCN) Association of

Nursing Students for the ‘identification of a

placement-based coordinator who recognizes the

demands on the clinical area in terms of workload,

changing patterns (such as the merging or closure

of placements) and the conflicting needs of various

students doing different courses’. Indeed, such posts

have existed in Ireland since 1994 (Murray 1999).

The holders of these joint Trust and University posts

take responsibility for placements, supporting

students and mentors, and ensuring that placements

are properly audited (Waters 1999); but the exact

nature of the post varies from one area to another,

thus creating the potential for ambiguity and lack of

clarity of role function (Williamson & Webb 2001).

One persistent feature, however, has been the aim to

create a link between theory and practice and/or

between clinical and educational organizations.

With the advent of PPFs, there is greater scope for

imaginative student placements, with students being

placed in areas that have not traditionally taken

them, such as general practitioner (GP) surgeries,

voluntary, prison and social services, and the inde-

pendent sector (Waters 1999). Students themselves

welcome these new initiatives, with similar recom-

mendations coming from student bodies. For

example, the RCN Association of Nursing Students

has suggested that there should be more emphasis

Clinical learning environments: support of preregistration nursing placements 107



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on placements as potential areas for learning

opportunities, focusing on where care is delivered,

rather than a traditional bed-focused approach,

with greater use of day surgery, theatres and primary

healthcare clinics (Chaffer 1999).

The present article describes an evaluation of

three such posts that were developed in the North-

East of England. Each postholder worked with one

National Health Service (NHS) Trust, had previ-

ously worked in the Trust as a practitioner and was

seconded to the University for the duration of the

post. The PPFs were managed through the Univer-

sity but retained organizational links in their Trust.

One Trust offered acute general and midwifery care,

accommodating around 450 learners. The second

offered primary, secondary acute, midwifery and

mental health care, accommodating around 150

learners. The third Trust offered primary, secondary,

midwifery, mental health and learning disabilities

care, accommodating around 110 learners. In addi-

tion to the PPF role, students had a mentor (a

member of clinical staff ) allocated to them for each

placement, and each clinical area had a clinical liaison

teacher (CLT – a University lecturer) allocated to

support staff and students in that area. Students

were only placed in clinical areas that had been

assessed by the CLT as able to provide an adequate

educational experience to a defined number of

student nurses (the audited capacity of the area).

The main aim of the study was to evaluate, over

12 months, the impact of the role of the PPF on the

provision of practice placements, student support

during placement and the professional development

needs of clinical staff as mentors with student super-

vision and assessment responsibility.

Data sources and methods

The evaluation focused on three areas: capacity to

accommodate students; quality of placements in

relation to the role of the PPF; and evolution of the

role of the PPF.

Capacity of the Trust to accommodate students

For all three Trusts with a PPF, the total audited

practice placement capacity was calculated on a

monthly basis for an 18-month period commencing

6 months prior to the introduction of the posts.

In addition, the total number of preregistration

students present in the Trust each month was

calculated. This information was collected routinely

by the University. However, the monthly total of

students present in the Trust is not necessarily a

complete reflection of the actual usage of practice

placements in any one week. Therefore, for a sample

of clinical areas in each of the Trusts, the maximum

numbers of students present during any single week

was calculated.

In addition, two questionnaires were sent to all

clinical areas within the three Trusts, to establish the

profile of all learners within the clinical areas during

two single weeks with a 2-month interval. On

each occasion, 260 questionnaires were distributed

with a 57% (

n

= 149) and 63% (

n

= 163) response

rate, respectively, representing the full spectrum of

clinical areas.

Quality of placements in relation to the role of the PPF

To provide some depth to the focus of the evaluation,

one of the three Trusts (the third described above)

was selected for greater attention. Within this

Trust, 12 clinical areas were selected and repeated

questionnaires collected data from staff working

in these areas, or associated with them, about all

the students passing through those areas during

the study period. Postal questionnaires were

developed using the indicators located within the

job description of the PPF to frame the questions

for six different categories of staff, the sample

numbers being the total number of staff in each

category:

• practitioners working directly with the student

nurses as mentors (

n

= 81);

• ward managers (

n

= 13);

• assistant service managers responsible for each

clinical area (

n

= 7);

• clinical liaison teachers (

n

= 9);

• The University Placements Office (

n

= 1); and

• the PPFs (

n

= 3).

Table 1 indicates the points at which each staff

category received a questionnaire. Practitioner

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questionnaires coincided with the end of student

block placements. All recipients received at least

three questionnaires and response rates varied

between groups and between time-points (ranging

from 26 to 100%). The 12 areas included maternity,

learning difficulties, mental health, paediatrics,

general adult and community.

In addition, all the students from one Diploma in

Nursing Studies cohort, who had placements in the

Trust, were selected for greater attention (

n

= 20)

and invited to attend focus group interviews at the

end of each of their three placements. This allowed

data to be collected concerning all the placement

experiences of this one group of students during

the period of the evaluation. The first placement

was designated a ‘taster’ placement, with students

spending short periods of time in a range of clinical

areas; the second was a placement with older people

(frequently in independent nursing homes); and the

third was in the community.

These focus group interviews were attended by

14, 5 and 13 students, respectively, with some

students attending all three. Some students were

unable to attend all three as a result of timetabling

arrangements, and some chose not to attend at

all. Questions concerned the experience of practice

placements, relevance of learning experiences, issues

around support and supervision.

Evolution of the role of the PPF

The role of the PPF commenced at the start of

the evaluation and was expected to evolve over at

least the initial year. Information about change in

role function and the consequences was provided

through monthly focus groups with the three

PPFs. In total, 10 focus groups were held. Each of

these focus groups used the same protocol, which

was based around the initial job description for the

posts but also included the identification of pres-

sures, role development and barriers to working.

A further focus group was held 10 months after

the PPF role commenced, to which all 15 CLTs for

one of the Trusts were invited (three attended). The

purpose of this focus group was to explore the learn-

ing environment and support for students in clinical

practice, and the effect of the introduction of the

PPF role.

At the end of the evaluation an individual inter-

view was held with each of the three PPFs in post, to

obtain a profile of the unique way that each had

developed their role within their respective Trust.

Data analysis

The focus group and individual interviews were

recorded on audiotape and transcribed verbatim. A

Table 1 Quality of placement questionnaires (timing, number and response rate)

Month

1 2 3 4 5 6 7 8 9 10 11

Clinical liaison 4/9a 4/7 5/7

teachers 44.4% 57.1% 71.4%

Practitioners 35/81 28/80 19/72 21/72

43.2% 35.0% 26.4% 29.2%

Service managers 7/7 4/7 5/7

100% 57.1% 71.4%

Ward managers 8/13 6/13 10/13

61.5% 46.2% 76.9%

Placements office n = 1 n = 1 n = 1 n = 1

Practice placement

facilitators

n = 3 n = 3 n = 3 n = 3 n = 3 n = 3

aNumber of questionnaires returned/number of questionnaire distributed.




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detailed analysis of each data source was undertaken

using standard methods of open coding. Thus,

topics and themes within each data source were

identified. Questionnaire data were entered into a

database to allow the comparison of responses from

the initial questionnaire with those from subsequent

questionnaires. The qualitative aspects of the ques-

tionnaire data were analysed across data sources, to

allow topics and themes to be identified. Data from

the individual interviews with the PPFs were analysed

to allow identification of the different models of

working that the three PPFs had developed.

Findings

Capacity for placements

Preregistration students from the University accoun-

ted for, on average, 70% of the audited capacity when

calculated on a weekly (rather than monthly) basis.

Even when the Trusts were at maximum capacity

for preregistration student nurse placements, they

were using just 80% of their total audited capacity.

The ability to use audited capacity to its full

potential for preregistration nursing students was

compromised, in part, by the substantial portfolio

of other learners present in the clinical areas. Indeed,

during the two sample weeks, preregistration

students made up only around 60% of learners in the

clinical area, the main groups of other learners being

national vocational qualification (NVQ), medical

and enrolled nurse (EN) conversion course students

(Table 2). As a result, several clinical areas were

managing the learning needs of up to 120% of their

audited capacity of learners. Some students, for

example overseas students and school work experi-

ence pupils, placed greater demands on clinical staff

than others, but in general the clinical staff felt that

they also benefited from the presence of students.

The PPFs highlighted the complex pattern of

learners in clinical areas, only some of whom were

student nurses and midwives from the local Univer-

sity. Scrutiny of existing systems within their Trusts

had revealed a number of anomalies:

Establishing exactly who takes students and who doesn’t and even now there are still anomalies in the system … it’s these sorts of things that you’re trying to collate and trying to make sense of that was nonsense at first. (PPF; Focus Group 3)

The PPFs recognized that it was unlikely that

there would be a large number of new clinical

areas, such as wards or departments, which could

join the circuit for clinical placements. All such areas

had long since been recruited to provide

placements. More likely was the identification of

underutilization of existing areas. The PPFs dis-

cussed the need to increase capacity for placements

cautiously, there being a potential tension between

a quantitative increase in capacity and the quality

of placement.

Table 2 Learners in clinical areas

Pre-registration nursing

students from local university Other learners

Number

Total

learners (%) Number

Total

learners (%)

Sample week 1

149 clinical areas

(57% response rate)

174 59.4 119 40.6

Sample week 2

163 clinical areas

(63% response rate)

368 62.0 226 38.0

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However, the PPFs found that they were expected

to have a more hands-on role in placing students

into clinical areas than they had anticipated:

[Placements office] are phoning me up and saying ‘you’ve got to find places for these students’ and I’m thinking, ‘I didn’t think this was my job’. (PPF; Focus Group 8)

It was this creation of ‘firefighting’ work to ensure

that students were placed (and often at the 11th

hour) that resulted in the PPFs feeling that they were

being used as ‘lackeys’. This was to the detriment of

developing more strategic ways of understanding

placement capacity.

Student views on the quality of placements

The clinical educational experience

Whilst some of the students found that their

placement provided them with a wide variety of

experience, there were others who felt that they

had not learnt a great deal. The three key factors

in creating a positive placement experience for

students were:

•

the ward was prepared for them and had some

structure to support the learning of the students;

•

staff were interested in them and they felt valued

in their role; and

•

students were able to work with their mentor.

The role of the mentor and other clinical staff was

viewed by the students as essential to a positive

placement experience:

If you get on with the staff you’ve pretty much got a good placement. (Focus Group 3)

Most students completing the placement-

evaluation questionnaires felt that their learning

had been facilitated by the attention of their mentor

and other clinical staff. Students very much wanted

to be given the opportunity to learn and to work

with staff, and appreciated their role in the

process:

You get out of your placement what you put into it – if you just sit round, they’ll just let you sit round. (Focus Group 2)

However, students recognized the pressure that

their presence put on the clinical staff, both in

terms of the volume of students and the variety of

learning needs that they present with:

When I was on my children’s ward there was about six students and two qualified staff. Ridiculous, it was overrun by students. (Focus Group 2)

The students felt vulnerable during their place-

ments and negotiating an improvement in the learn-

ing environment was a major cause of anxiety. For

example, one student was unhappy with the level of

work expected of her and talked of the ‘bottle’ needed

to approach her mentor to ask for the opportunity

to ‘move up and learn a little bit more’. Although the

approach was successful, the process was traumatic:

I went home on that Thursday and broke my heart. I sat and cried through sheer anger … I thought ‘I’m packing up, I’m packing in, I don’t need this hassle, I don’t need this stress’. (Focus Group 4)

However, several students found mentors to be

receptive to a critical approach from students, with

some actively encouraging the students to identify

and discuss practices that they didn’t understand or

questioned:

All the staff nurses you met said ‘if there’s something you don’t like just tell us’. (Focus Group 3)

Support for the clinical learning experience

The students who participated in the focus groups

saw the PPF as a primary contact while they were on




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placement, describing them as their ‘first port of

call’. The students appreciated having someone

who made it their job to ensure that the learning

environment was satisfactory, that the clinical staff

were briefed about curricula issues such as assess-

ment documentation, who actively sought them

out to ensure that their learning needs were being

addressed and that it was a familiar person who they

felt they could approach with any problems:

We’ve gone from having nobody to having somebody that’s dead reliable. (Focus Group 2)

The PPF was proactive in working with clinical

staff to solve problems such as: quality of patient

care; too many students in the area; ineffective CLT

role; and students not appreciating the relevance of

their placement.

The students also explored the relationship between

the PPF’s role and that of the CLTs. First, the role

of each was distinct and necessary:

Well, there’s a need for both because you need your clinical liaison because they link you to your University lessons and you need the other one [PPF] because she links you to your placement. (Focus Group 3)

Second, the continuity of the PPF in the clinical

environment was recognized as important. This

stands in some contrast to the role of the CLTs, who

are sometimes unknown to the student:

On the whole, students have a different clinical liaison teacher for just about every placement whereas with [PPF] you can build up that relationship with her. She’s the one that’s always there perhaps. (Focus Group 3)

Evolution of the post

Enhancing the learning environment

One feature of the work of the PPFs in developing

the clinical learning environment was through their

direct work with mentors and with student nurses

and midwives. They worked with clinical staff to

ensure familiarity with curricula and awareness of

the needs of the student placed with them. However,

the PPFs recognized the enormous pressures on

clinical staff for whom the acute shortage of nursing

staff in the UK challenges their capacity to deliver

care as well as bearing the additional responsibility

of educating increasing numbers of students.

The PPFs also worked with the clinical liaison

system, and in particular CLTs, to ensure that the

clinical placement was an environment in which

students could learn. From the outset, the PPFs were

mindful of potential tensions between their role

and that of the CLT. Indeed, by working as CLTs

themselves in some areas, the PPFs wondered to what

extent they were supplementing existing systems

rather than developing new ways of working:

We’re plugging the hole. (PPF; Focus Group 4)

Naturally, this also created the opportunity for

multiple inputs into a clinical area and inevitably

some confusion of information, a situation that the

CLTs found equally frustrating:

I think there was some tension there in terms of academic advice being shown and I’d given this person some academic advice that was contradicted. (CLT; Focus Group)

The PPFs also recognized many other benefits

that their role could bring, for example in network-

ing areas together and promoting good practice.

Developing the role of the PPF

The early days of being a PPF were occupied with the

excitement of their roles, explaining the role to a

wide variety of people and making the distinction

between their role and that of CLTs and mentors:

They don’t know where to categorize you because you don’t fit into a box. (PPF; Focus Group 1)

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However, 4 months later, the PPF still felt

misaligned with both organizations:

We’re in-between the two but we don’t have anywhere to belong. (PPF; Focus Group 4)

The sense of marginalization persisted throughout

the year and had a profound impact on the ways

in which the PPFs were able to engage with their

roles. The work of the PPF was also influenced very

strongly by the temporary nature of their 1-year

pilot posts. There was a need to balance activities

that would meet longer-term goals with a shorter-

term focus on demonstrating achievement within

the timespan of the posts.

As individuals, the PPFs felt very vulnerable

during the middle and latter parts of the year and

unable to effect changes:

… We’re very much pawns in a political game here. (PPF; Focus Group 7)

In their support, the CLTs spoke of the PPFs:

… Being put in an invidious position … they’ll be shot at from every direction. (CLT; Focus Group)

However, by the 10th focus group interview, when

the roles were known to have a future, the PPFs

spoke of the events of the preceding year as more of

a developmental process that would allow them to

realize their aspirations for the work in subsequent

years.

The PPFs attributed the difficulties of imple-

menting their roles to a lack of clear location in the

two organizations and a lack of understanding of

their role. Within the Trusts this meant that they did

not have the authority or credibility to effect change.

As much as anything, the PPFs felt that their posts

had exposed issues about clinical learning that were

simply not known about beforehand or that had

been not tackled:

There appear to be more and more things coming out of the woodwork. (PPF; Focus Group 5)

A few of these included:

• the unwritten rules that work to the advantage of

clinical staff and students variously, such as length

of student day, proportion of night duty, purpose

of observational placement, purpose of formative

assessment;

• the marginalized role of nursing lecturers who

are viewed as ‘not academics’ by the rest of the uni-

versity and not practice credible by the Trusts;

• the undermining of education and educationalists

by practitioners:

Some people are just so dismissive and so rude it’s unbelievable. (PPF; Focus Group 9)

• the undermining of practice knowledge and

practitioners by university staff:

It was the arrogance and the elitism of the fact that they think that they are above the clinical staff. (PPF; Focus Group 5)

At the end of the first year in post, the PPFs

were recognizing the gains that had been made dur-

ing the year, however frustratingly small they felt

these to be, and in particular recognizing the advances

in working relationships that had been made.

Discussion

Capacity and clinical learning environments

Clinical areas host a very diverse range of learners

and this complex profile presents challenges to the

ability of any single clinical area to manage the wide

range of learning needs. Preregistration students

made up only around 60% of learners in the clinical

areas surveyed. At times, the clinical areas were

accommodating learners at up to 120% of their

nominal audited capacity with no more than 80% of




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this being attributable to preregistration student

nurses and midwives. Not surprisingly, the PPFs

described these times as ‘manic’ in the clinical

areas. This volume and diversity of multidisciplinary

learning need has received scant attention in the

literature.

Earlier pressures to maximize the number of areas

that take students suggest that the addition of any

totally new areas to the ‘training circuit’ is unlikely.

However, there are a range of staff (such as clinical

nurse specialists) who work across departments,

who could provide good quality learning experiences

and who are currently under-utilized for placements.

Similarly, Waters (1999) suggests that PPFs create

scope for the development of imaginative place-

ments, which is supported by the RCN Association

of Nursing Students (Chaffer 1999) who urge a

focus on where care is delivered rather than on the

organizational definitions of ‘bed’ location.

Students and clinical staff found the PPF role to

be beneficial, for example in improving familiarity

with the curricula. In particular, the PPF role has

helped the clinical staff to be proactive in manag-

ing student-related problems. The management of

problems, and provision of support to enhance

learning opportunities, by the PPFs was also recog-

nized by students. Interventions to enhance the

quality of placement experience of students have a

major impact on student satisfaction (Cahill 1997),

and their learning (French 1992), and in turn may

contribute to a reduction in the student attrition

rate (UKCC 1999).

The students appreciated the continuity that one

person in post can offer them as they move through

different placements. Whilst the students have con-

tinuity in the PPF, they lack continuity from clinical

staff and CLTs who, at the time of the study, differed

between each placement and sometimes even within

a single placement. Student nurses and midwives

described occasionally feeling vulnerable on place-

ment, for example being dependent on clinical staff

for their assessment. This affected their ability to

negotiate improvements in their learning and it was

hard for them to challenge practices about which

they felt uncertain or unhappy. Löfmark & Wikblad

(2001) emphasizes the importance of the student–

mentor relationship, and in this study students

identified this relationship as the single most impor-

tant factor influencing the quality of their placement.

In this respect, clinical staff recognized that the

PPF role provided them with an improvement in

communication between the Trust and the Univer-

sity and an improved understanding of their role

and responsibilities to the students’ needs, with a

consequent positive impact on the learning experi-

ence of students. Hewson & Wildman (1996) have

challenged the assumption that clinical staff could

provide all student support and integrate theory

and practice. Certainly, the participants in this study

reaped the benefits of having the PPF articulate their

role and contribution in a consistent manner. In this

way, the expectations and responsibilities of all

parties have been refined and shared, as called for

by Wilson-Barnett

et al

. (1995).

The PPF role: working in the academic/practice interface

The PPFs recognized that they developed ways of

working that were unique to each of them. They

varied, for example, in the extent of direct student

contact that they had and in the systems they were

developing to manage the requirements of the posts.

Throughout the study period, the PPFs felt

misaligned with both their Trust and the University.

This may be associated with the developmental

nature of such a new role (Clarke

et al

. 1998), or may

be because of their position in crossing both organ-

izations. If it is the latter, it is a more fundamental

feature of the model of PPF adopted. However,

Williamson & Webb (2001) also describe the personal

costs to clinical staff employed to support students

in practice by a University and the lack of role clarity.

The ambivalence around the organizational location

of the posts resulted in considerable tension for the

PPFs. It reduced the sense of ownership and belong-

ing that the PPFs experienced from both organiza-

tions, and placed them in a position from which

they felt that both their authority and credibility

were marginalized and, with this, their ability to

effect change. This was exacerbated by the short-

term contract of the PPFs and everyone lacked

clarity about whether the roles were time-limited

projects or sustained infrastructure development.

114 C.L. Clarke

et al.



,

2

, 2, 105–115

Despite the DoH promotion of joint appointments

(DoH 1999, 2000b), working in this interface has

always been problematic. The ENB (1999) concluded

that lecturer/practitioner posts had not achieved an

integration of theory and practice. One model that

does seem to move forward from this stalemate is that

of the clinical facilitator, described by Rowan & Barber

(2000), who works alongside the student in practice.

However, the role and function of the PPF cannot

be considered in isolation. During the year of this

study, the more strategic functioning of the PPF was

undermined by the requirement to augment the

operationalization of the placements and clinical

liaison systems. Crucially, there was potential over-

lap between the role of the PPF and that of the CLT.

Academic nursing staff were themselves experienc-

ing pressure to revise their role and function, with

the DoH (1999) proposing to increase support from

teachers for students in clinical placements.

Fundamentally, there is a need to reverse the

distancing of academic nursing staff from clinical

areas (Ramprogus 1995). The CLTs in the study

cautioned against introducing a model of student

support, such as the PPF role, which provides the

opportunity for CLTs and indeed clinical staff to

displace clinical learning from their responsibilities.

The role and function of the CLT must be clearly

articulated, not just so that there is a clear interface

between themselves and the PPFs, but so that the

purpose of their presence in the clinical area is one

in which they have a sense of ownership and pride.

Hindering such work, however, is the mutual lack of

respect for each other’s knowledge and organizations

that is unfortunately held by some staff in the NHS

and the university.

The future of clinical environments as places of

learning rests in the ability of all stakeholders to

develop effective partnerships and adopt a shared

responsibility towards preparing future members of

the nursing and midwifery professions (Rafferty,

Allcock & Lathlean 1996; Rinomhota 1998). The

impact on the quality of learning of, as the UKCC

(1999) described them ‘the blurred responsibilities’

for nurse education, is destructive and unnecessary.

Nowhere was this more apparent during this study

than in the personal and professional discomfort felt

by the PPFs themselves as they worked in that

vulnerable margin between Higher Education and

NHS Trusts.

Summary

The development of the PPF role, and its evaluation,

has provided an opportunity to learn a great deal

about the clinical learning environment. Just some

of these lessons include:

• illuminating the complex portfolio of learners

present in clinical environment;

• the need for students to have continuity of sup-

port as they progress through different placements;

• the benefits derived by clinical staff of enhanced

understanding of the needs of learners through the

work of the PPF; and

• the detrimental effects of an unclear and/or poorly

maintained role and function of the PPF post.

The evaluation also raises further issues, such as

the need to reconstruct clinical learning environ-

ments, so that learning is not coterminous with

organizational structures such as a single ward, and

to develop ways of working effectively in the perme-

able space between clinical and academic environ-

ments, knowledge and employment.

The vicious cycle created by under-recruitment

and staff losses and the need to increase the number

of nursing and midwifery students results in a dis-

proportionate number of clinical staff supporting

learners in the UK. So long as this situation remains,

the potential for nursing to develop its professional

role will be compromised, and alternative skill

mixes pursued with vigour by service providers who

are required to deliver care. The PPF role can act strate-

gically to break this cycle, as this evaluation has in

part indicated. Its potential must not be compro-

mised by the immediate short-term needs of the

NHS and Higher Education Institutions. It is the

responsibility of NHS Trusts and Universities to

provide the infrastructure, strategic lead and inter-

institutional partnership that will allow the PPF role

to realize its full potential to the benefit of all learners.

Acknowledgements

We are indebted to the three Practice Placement Facil-

itators for their commitment to both their posts and to




,

2

, 2, 105–115

the evaluation, and to the students and staff who

participated in the study, in particular Aileen Sullivan.

The evaluation was funded by the former Northern

England Education and Training Consortium.

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Documents

Clinical learning environments: an evaluation of an innovative role to support preregistration nursing placements