Nurse Education in Practice 10 (2010) 144–152

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Nurse Education in Practice

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Student nurses’ experiences of community-based practice placement learning:A qualitative exploration

M.R. Baglin *, Sue RuggFaculty of Health and Social Work, University of Plymouth, Centre Court, Drake Circus, Plymouth, Devon, United Kingdom

a r t i c l e i n f o s u m m a r y

Article history:Accepted 26 May 2009

Keywords:Nursing educationClinical practice placementCommunity practice placementQualitative research

1471-5953/$ - see front matter Crown Copyright � 2doi:10.1016/j.nepr.2009.05.008

* Corresponding author. Tel.: +44 1752 586972; faxE-mail address: mirren.baglin@plymouth.ac.uk (M

United Kingdom (UK) health policy has adopted an increasing community and primary care focus overrecent years (Department of Health, 1997; Department of Health, 1999. Making a Difference: Strength-ening the Nursing, Midwifery and Health Visitor Contribution to Health and Health Care. Departmentof Health, London; Department of Health, 2004. The NHS Knowledge and Skills Framework (NHS KSF).Department of Health, London). Nursing practice, education and workforce planning are called upon toadapt accordingly (Department of Health, 2004. The NHS Knowledge and Skills Framework (NHS KSF).Department of Health, London; Kenyon, V., Smith, E., Hefty, L., Bell, M., Martaus, T., 1990. Clinical compe-tencies for community health nursing. Public Health Nursing 7(1), 33–39; United Kingdom Central Coun-cil for Nursing, Midwifery and Health Visiting, 1986. Project 2000: A New Preparation for Practice. UKCC,London). Such changes have major implications for pre-registration nursing education, including its prac-tice placement element. From an educational perspective, the need for increased community nursingcapacity must be balanced with adequate support for student nurses’ learning needs during commu-nity-based placements. This qualitative study explored six second year student nurses’ experiences of12 week community-based practice placements and the extent to which these placements were seento meet their perceived learning needs. The data came from contemporaneous reflective diaries, com-pleted by participants to reflect their ‘lived experience’ during their practice placements (Landeen, J.,Byrne, Brown, B., 1995. Exploring the lived experiences of psychiatric nursing students through self-reflective journals. Journal of Advanced Nursing 21(5), 878–885; Kok, J., Chabeli, M.M., 2002. Reflectivejournal writing: how it promotes reflective thinking in clinical nursing education: a students’ perspective.Curationis 25(3), 35–42; Löfmark, A., Wikblad, K., 2001. Facilitating and obstructing factors for develop-ment of learning in clinical practice: a student perspective. Issues and innovations in Nursing Education.Journal of Advanced Nursing 34(1), 43–50; Priest, H., 2004. Phenomenology. Nurse Researcher 11(4), 4–6;Stockhausen, L., 2005. Learning to become a nurse: student nurses’ reflections on their clinical experi-ences. Australian Journal of Nursing 22(3), 8–14). The data were analysed using content analysis tech-niques, exploring their contextual meaning through the development of emergent themes (Neuendorf,K.A., 2002. The Content Analysis Guidebook. Sage Publications, London). The identified themes relatedto elements of students’ basic skill acquisition, the development of their working relationships withmentors, patients and others, the learning opportunities offered by community practice placementsand the effects that such placements had on their confidence to practice. These themes are discussed withregard to the published literature, to arrive at conclusions and implications for future nursing education,practice and research.

Crown Copyright � 2009 Published by Elsevier Ltd. All rights reserved.

Introduction

United Kingdom (UK) health policy has adopted an increasingcommunity and primary care focus over recent years (Departmentof Health, 1997, 1999, 2004). Nursing practice, education andworkforce planning are called upon to adapt accordingly, as hashappened elsewhere (Department of Health, 2004; Kenyon et al.,

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: +44 1752 586748..R. Baglin).

1990; United Kingdom Central Council for Nursing, Midwiferyand Health Visiting (UKCC), 1986).

Pre-registration nursing education’s ability to meet futurehealthcare delivery needs remains unclear, particularly with re-gard to its practice-based elements (Cheek and Jones, 2003). Inthe UK, practice-based learning constitutes 50% of the time spentin pre-registration nursing education. Student nurses must achievecompetence in a mandatory range of areas in order to qualify(European Directive 77/453/EEC; Nursing and Midwifery Council(NMC), 2004). Practice placements must ensure the quality of their

rights reserved.

Table 2Participants’ demographic details.

Name Age Type of practice placement

1 Anna 27 District Nursing Team2 Barbara 43 GP Surgery/Community Nursing Team3 Claire 30 District Nursing Team4 Denise 39 Community Clinic/District Nursing Team5 Elaine 22 Outpatient Department/Gynaecological Outreach Team6 Frances 23 Outpatient Department/Chest Clinic Outreach Team

M.R. Baglin, S. Rugg / Nurse Education in Practice 10 (2010) 144–152 145

learning environments in order to facilitate students’ learning(Department of Health, 2000; Quality Assurance Agency for HigherEducation, 2004/05).

To date, most UK nursing practice placement experiences havebeen hospital-based; reflecting the latter as a major UK nursingemployment sector (Baillie, 1993). More community-focused nurs-ing employment has led to the development of community-basedpractice education placements, however, both in the UK andabroad (Baillie, 1993; Dixon, 1996; Hallett et al., 1996; Dana andGwele, 1998; Carr, 2001; Stevens, 2003; Iipinge and Venter,2003). Past innovations in such placements have included tele-phone-based and interdisciplinary placements (Wheeler andPlowfield, 2004; Reeves, 2000), as well as those focused on assess-ing vulnerable community groups’ needs (Smith and Flint, 2005).The community placements undertaken in the current study wereeither delivered in patients’ homes, or in hospital-based serviceswith community outreach provision (Table 2).

The quality and nature of students’ placement experiences candirectly affect their ability to perform effectively. Reflective diariescompleted by 47 final year Swedish degree student nurses whilston placement (Löfmark and Wikblad, 2001) identified a numberof factors influencing this outcome, including variations in the per-ceived clinical opportunities to which students were exposed, thefeedback that they received from mentors and other practice staff,and the perceived culture of the practice workplace. Such findingsrelate well to the current study; given the same data collectionmethod, students’ stage of education and the general comparabil-ity of the Swedish and UK nursing education systems.

To succeed, modern pre-registration nursing education mustbalance the requirement to increase community nursing capacitywith the provision of adequate support for student nurses’ learningneeds during community placements. Understanding learners’experiences of such placements is crucial to providing such sup-port, but this issue remains relatively unexplored. This study seeksto add incrementally to the body of knowledge in this area, in re-sponse to the following questions:

� How do student nurses experience community-based practiceplacements?

� In what learning activities do such nurses engage during suchplacements?

� How do student nurses see the value of such placements aslearning experiences?

Literature review

Computer-based searches of the Cumulative Index to NursingAllied Health Literature and Medline databases were undertakenfor the years 1998–2004, as well as hand-searches of nursing jour-nals focused on clinical education and education research for the

Table 1Data analysis process used.

Activities undertaken

1 Each participant diary was read with care. The first author’s initial thoughts on the2 The first author re-read the participants’ diaries and her own notes systematically, f

were then divided into separate meaning units: phrases or sentences relating to speclarify any ambiguous meanings, in a process of ‘member checking’ (Driessen et al.,

3 Similar data were assigned to specific codes. These codes were used to define/re-defias ‘extra’. Similar codes were collapsed into fewer, broader themes. Emerging them

4 The final list of study themes was shared with a research literate colleague to ensurefour anonymised scripts, and was asked to code these independently as a cross chec

5 Verbatim extracts were taken from the text to illustrate the content of each final st

Adapted from Burnard (1991), cited by Clayton and Thorne (2000).

years 1994–2006. Search terms used related to student nurses’experiences of practice placement learning, community-basedpractice placements, community nursing and reflective diaries.

The value of practice placement learning

Practice-based learning is a vital part of pre-registration nursingeducation, enabling students to translate theory into practice byproviding ‘real-life’ experiences to underpin the academic pro-gramme content (European Directive 77/453/EEC, NMC, 2004). Inrecognition of the importance of this ‘theory–practice’ link, prac-tice-based learning accrues academic credit in UK nursing educa-tion, alongside classroom-based studies. Koh (2002) accountedstudent nurses’ ability to link theory and practice vital, noting thatthose unable to do so could be left ‘floundering, lacking in confi-dence and disenchanted, with some being forced to leave nursing’(p. 41) Holland (2002) echoed Koh’s view, promoting greater col-laboration between academic and practice-based nurses, to ensurestudents’ effective preparation for ‘the day-to-day drama that ispractice’ (p. 147).

Practice placement experiences can also enhance studenthealthcare workers’ motivation and develop their professionalidentities. For example, a grounded theory study by Dornan andBundy (2004) explored such placement’s perceived role in medicaleducation. In small group discussions with 64 participants, includ-ing students and curriculum leaders, medical students describedtheir placements as motivating and good for developing their pro-fessional identities. Such findings echo those of Hallett et al. (1996)in student nurses.

A further function of the practice placement environment is theprovision of opportunities to master basic nursing procedures andtechniques. As Nolan (1998) notes ‘learning by doing is the crux ofclinical placement, as problems are placed within context and criti-cal thinking can be developed’ (p. 626); a view shared by Hallett etal. (1996) and Stockhausen (2005). Acquiring competence in con-crete tasks is seen as important within nursing. For example, Boxerand Kluge (2000) asked 206 Australian nurses, in their first year ofpractice, to rate 97 clinical skills by the frequency of their perfor-mance and the extent to which they considered them essential totheir daily work. The results reinforced the primacy of clinical skillperformance as an attribute valued above all else by newly-qualified

content of the text were recorded in note formacilitating comparisons and recognising emergent similarities/differences. The datacific topics (Polit and Hungler, 1991) (Appendix 1). Participants were telephoned to2005)

ne the data into themes, using a colour coding system. Unassigned data were codedes were scrutinised for similarities/differences until a final theme list emerged

that bias had not been introduced during the coding process. This coder was givenk on the first authors’ coding. General agreement in the coding process was found

udy theme

146 M.R. Baglin, S. Rugg / Nurse Education in Practice 10 (2010) 144–152

nurses. Although Boxer and Kluges’ work was completed in an acutehospital, rather than the community, it provides insight into stu-dents’ views on the perceived importance of gaining practicalcompetence.

In similar fashion, the 33 Australian nurses interviewed by Hen-derson (2002) recalled how, as students, they had been ‘mainlyconcerned with becoming competent in doing tasks’ (p. 246). Thisfinding was seen to reflect the reality of the practice environment,rather than ideals about holistic care espoused in academic nursingeducation: the ‘theory–practice’ gap. This study also suggested theextent to which student nurses were influenced, for better orworse, by their senior nursing colleagues during their practiceplacements. This debate goes beyond practitioners to policy mak-ers, with the importance of student nurses’ acquisition of practicalskills for effective practice amongst newly-qualified UK nursesengendering much discussion in recent years (UKCC, 1999).

Student nurses’ focus on acquiring practical skills competencemay be linked to their levels of confidence. Kelly (1993) found thatstudents completing ward-based practice placements readily suc-cumbed to the pressures of compromise, due to poor self-confi-dence and the desire to complete their practice placementssuccessfully. Such findings have implications both for the qualityof students’ learning experiences and for patient care, especiallyin practice environments under pressure from service deliverychanges (UKCC, 1999).

Nursing depends on more than practical skills, however. Theincreasingly complex healthcare environment requires a corre-sponding development in the full breadth of nurses’ knowledge,skills and attitudes. Practice placement is the place to practiceand prioritise the varied elements of the modern nursing role.The complexity of this role was suggested in interviews with 38Australian nurses by Cheek and Jones (2003). These nurses, someof whom were community-based, identified a range of complexskills as key to contemporary nursing, including assessment, com-munication, management, leadership and conflict resolution.Although this study was conducted in Australia, the UK and Austra-lian healthcare cultures are similar, potentially enhancing thesefindings’ transferability. All of the above study participants werequalified nurses, however, unlike those in the current study. Givensuch complexity, student nurses’ need for high quality practiceplacement learning is clear (Adams, 2002).

The practice learning environment

Student nurses’ reactions to their practice placement learningenvironment vary, with some researchers identifying significantamounts of stress in such settings. For example, the 110 Irish thirdyear Diploma nursing students, surveyed by Timmins and Kaliszer(2002), characterised their placement learning experiences as ‘oneof the main stressors for nursing students’ (p. 206). A major com-ponent of this stress related to participants’ relationships withpractice placement staff. Gidman (2001) also identified stressamongst student nurses, this time amongst those returning frompractice placements. Particular stress stemmed from students’ per-ceptions of the poor mentorship support received, with fears ofmaking mistakes and of working in unfriendly atmospheres alsoarising.

Community-based placements may lead to stresses not encoun-tered in hospital-based settings, given that they are frequentlyspecialised and may involve lone working amongst trained staff.In addition, in the community, physical mentorship support maybe limited, with support and/or supervision being delivered at adistance, by telephone. The absence of colleagues can be stressful.,with the student nurses taking part in Lindhop’s (1999) compara-tive study of placement learning in different English HealthAuthorities seeing their failure to be included as part of a team

as stressful. The quality of nurses’ colleagues is also important. Ina longitudinal interview-based study conducted with 39 Englishnurses, all were able to give examples of nurses with whom theyhad earlier worked bullying junior colleagues (Randle, 2003). Suchexperiences during placement learning had greatly influencedthese nurses’ paths from student to qualified nurses, and thus theircareer development.

If some researchers have found practice placements stressful,others have found the opposite. For example, 93% of the 315 pre-registration nursing students surveyed by Kinsella et al. (1999)saw clinical placement as ‘relevant and useful’, characterising itas the ‘most popular (and) most influential aspect’ of studentnurses’ education (pp. 323/30). Clinical placement learning hasalso been seen as more meaningful than classroom experiences(Government of Ireland, 2000; Quinn, 2000). Stockhausen (2005)identified a number of positive accounts of clinical placementlearning in the reflective journals completed by her 18 Australianstudent nurse participants. These journals contained numerousreferences to qualified nurses who had made participants feel ‘wel-come through a friendly and approachable manner, enhancingtheir practice placement learning experiences’ (p. 11). It shouldbe noted that Stockhausen’s participants were a self-selectinggroup, however, with positive experiences that they were fully pre-pared to share.

Mentors’ role in practice placement learning

Practice placement mentors are fundamental to studentnurses’ smooth entry into the practice environment, influencingboth the nature and quality of placement experiences, be theyward- or community-based (Baillie, 1993; Field, 2004; Lambertand Glacken, 2005). The student/mentor relationship is a complexone; the multi-dimensional mentorship role both being seen dif-ferently by students and mentors, and varying over time (Wilkes,2006).

From student perspectives, good mentors are supportive rolemodels who act as guides, teachers and assessors, ‘coaching excel-lence’ and showing how theory translates into practice. Such indi-viduals are seen to be genuinely concerned about their students,with their best interests at heart (Andrews and Roberts, 2003;Field, 2004). Quality mentorship has been linked to mentors’ pro-fessional competence, personality characteristics, inter-personalskills and teaching ability, with mentors’ attitudes towards stu-dents being seen as particularly crucial to their perceived effective-ness. The latter findings, from a questionnaire-based study of 214Taiwanese student nurses by Tang et al. (2005), did not differbetween nursing programmes, suggesting a degree of generalis-ability. Students report that some practice placement mentorsact to increase the likelihood they will have a positive placementexperience (Wilkes, 2006). Community-based health visitors, forexample, are known to actively select the families that studentsencounter on placement (Dixon, 1996). This small qualitative studyof health visitors mentoring nursing students, found some mentorsadapting their interview approach to accommodate students’ pres-ence. This finding suggests that students’ learning experiences aremodified by considerations other than solely meeting their corelearning needs.

For mentor’s part, Gray and Smith (2000) noted that, whilstmost mentors were genuinely concerned for their student charges,and sought to be supportive, difficulty arose from a lack of recog-nition for the mentorship role and protected time for performingit, as well as from competing demands and expectations from stu-dents, patients, colleagues and others. Other researchers haveagreed (O’Malley et al., 1999; Hancock, 2003). Such difficultiesmay help to explain some senior nurses’ reluctance to serve as rolemodels for student nurses (Mabuda et al., 2008) and students’

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resulting feelings of abandonment (Shin, 2000; Chun-Heung &French, 1997). Single-handed community-based mentors can feelparticularly over-stretched (Baillie, 1993).

Community-based nursing practice placements

An early researcher in this area, Baillie (1993) investigated thefactors affecting student nurses’ ability to learn in community-based settings, collecting data from interviews with a conveniencesample of eight student nurses undertaking a total of eight weeksin four different community placements. The placements con-cerned included working with healthcare workers such as healthvisitors, community midwives and osteopaths, as well as place-ments in schools, nursing homes, fitness centres, occupationalhealth departments and day centres. Baillie’s participants saw theirlearning influenced by their own approach to, and role within,these placements, their mentors’ knowledge, skills and attitudes,and the perceived relevance of the placements to their nursingstudies. These themes are broadly similar to those identified inthe current study. The range of community placements experi-enced by Baillie’s participants differed from those used in the cur-rent study, however, as participants experienced only two weeks ineach practice setting, unlike the 12 weeks experienced by currentstudy participants (Table 2). The selection of placements used byBaillie meant that participants’ time in each placement settingwas short, with many working on a one-to-one basis with theirmentors rather than as part of a larger team. Such differencespotentially influence the transferability of Baillie’s findings to thecurrent study.

Three years later, Hallett et al. (1996) interviewed 15 commu-nity nurses who had supervised second year UK student nursesfor 9 week placements, and 12 of the student nurses concerned,as part of the introduction of Project 2000 (UKCC, 1986). Studentparticipants spoke of developing their ‘learning career’ on place-ment; encountering ‘real’ (as opposed to academic) nursing,mastering basic nursing procedures, gaining confidence, increas-ing understanding and being independent. Many positive place-ment experiences were reported, although students found timespent practicing without understanding or supervision challeng-ing. Supervisors spoke largely of the steps taken to facilitatestudents’ learning, noting that this was made more difficult bya general lack of recognition for the complexity and time-con-suming nature of this task. The range of inter-personal interac-tions noted by Hallett and colleagues is generally echoed in thecurrent study.

Carr’s (2001) study was also related to assessing the outcomeof the introduction of Project 2000 (UKCC, 1986). This studyaimed to compare and contrast the perceived opportunities of-fered by hospital- and community-based practice placements.Data came from sequential mixed focus groups, non-participantobservation, recorded practice narratives and discussion basedon these narratives. Community health nurse mentors, and thestudent nurses placed with them, participated in the study.Whilst the number in each group remained unspecified, fourfocus groups were held with a total of 45 participants and sevenmentor-student pairs provided practice narratives. Only the com-munity nurse participants discussed the latter. The differencesnoted related to the complexity and ‘untidiness’ of the commu-nity practice environment. In the community, Carr noted, muchof the power rested with patients, physical environments andlifestyles varied, and patients’ problems failed to fit into neatcategories. Such issues made it difficult for community nurses,and students placed with them, to set firm boundaries to theirroles. As Carr noted, ‘part of the community nurses’ skill appearedto be being able to function within these apparently blurredboundaries and redefine the role as situations arose’ (p. 334).

Community patients’ needs are not defined by medical diagnosesand nurses’ roles are correspondingly broad. Some studentsreported difficulty identifying patients’ care needs, and theirown related learning needs, as a result. Participants saw commu-nity practice as less standardised, less predetermined, more nego-tiable and more open than hospital-based care, opening the doorto more individualised care. Carr concluded that community-based practitioners are ‘exposed to a great deal of informationusually filtered out in the hospital environment’ (p. 336). Pre-reg-istration student nurses placed in this setting need to identify andnegotiate varied roles, manage different types of nurse-patientrelationships, undertake new types of assessments and participatein unfamiliar decision-making processes; all high-level skills fornovice practitioners.

In summary, the literature suggests the need for further re-search into community-based nursing practice learning, includingthe factors that influence students’ integration into, and experienceof, such learning. Identified problems relate to such issues as com-petence, skills literacy, mentorship and the pace of change. Increas-ing understanding about the nature of student nurses’ practicelearning enables closer collaboration between nursing academicsand practitioners, adding educational value to both settings. Devel-oping such understanding in the community allows this setting tobe enhanced to the benefit of all. The methods used in the currentstudy will now be described.

Method

Rationale for the methods used

Many possible philosophical approaches underpin qualitativeresearch (Dowling, 2004). Gadamer’s (1989) positions of prejudge-ment and universality underpinned the position taken in the cur-rent study; positions based on individuals’ ability to understandeach other and the links of common human consciousness (Gad-amer, 1989). This approach fits well within the field of phenome-nology. Phenomenological data collection aims to generate richdescriptions of participants’ experiences in order to understandtheir ‘lived experience’ of a chosen phenomenon (Creswell, 1998;Cheek and Jones, 2003). The current study sought to construct a ro-bust, insightful, representation of student participants’ commu-nity-based practice placement experiences, and the meaningsthat they ascribed to these experiences.

The study data were collected from semi-structured, contempo-raneous, reflective diaries completed by the six participants. Thisdata collection method was chosen as participants were familiarwith it, having used it in the academic part of their nursing pro-gramme. It has also previously been used internationally, with suc-cess, to research a variety of nursing fields (Landeen and Byrne,1995; Neary, 2000; Lloyd Jones et al., 2001; Kok and Chabeli,2002; Löfmark and Wikblad, 2001; Priest, 2004; Stockhausen,2005). Clayton and Thorne (2000) linked such diary use to a ‘veryhigh response rate and level of motivation’ in their participants(p. 1515); an important consideration in a relatively small study.With regard to the latter, Morse (1994) notes that data from sixindividuals is usually sufficient to discern the essence of an expe-rience for research purposes; a view echoed in a reflective jour-nal-based study by Kok and Chabeli (2002).

With regard to data analysis, the potential for researcher biaswas reduced by the systematic approach taken. This processrelied on content analysis, with stable codes being assigned tosimilarities within the data and corresponding categories(themes) being devised to describe coherent groups of thesecodes (Graneheim and Lundman, 2004). Priest et al. (2002) seethis approach as particularly reliable. The ease with which coded

148 M.R. Baglin, S. Rugg / Nurse Education in Practice 10 (2010) 144–152

data can be revisited and checked potentially increases the trust-worthiness of the coding process and, thus, of the study findings.Trustworthiness was further enhanced by ‘member checking’ inthe current study, ensuring that appropriate meanings wereascribed to the study data during the analysis process (Driessenet al., 2005).

Data collection methods

Study participantsThis study was conducted with a small convenience sample

of six female second year nursing students enrolled on thepre-registration nursing programme of one higher educationinstitution. All had previously been allocated a 12 week commu-nity-based placement to work with multidisciplinary teamsassessing and planning for the needs of adults requiring health-care. Participants ranged from 22 to 48 years old. All participantswere volunteers.

Reflective diaryParticipants were each given a personal diary in which to record

their reflections. These contained a number of prompts to aid thesereflections at specified points in participants’ placement experi-ences. General instructions on methods for the diaries’ completionwere also included. Data were collected at three points in time.Participants were initially asked to record their expectations fortheir practice placements before starting them. They recorded asecond set of data at the end of their first week of placement, not-ing their perceptions of this experience by completing the follow-ing statements:

� During the past week I have been able to practise some of thecompetencies that match my learning outcomes for this place-ment. This was demonstrated by. . .

� During the past week I have/have not been able to fully meet myrequired learning outcomes despite/because of barriers thathave occurred, namely. . .

The final set of data was recorded at the end of participants’placements. At this time, the above statements were completedonce again, as well as the following statement:

� This community-based placement has/has not been a worth-while practice learning experience because. . .

Each of the above statements was designed to be neutral,suggesting neither the content nor the nature of the material thatparticipants should record. The statements were also based onstudents’ recent learning experiences, as the first author feltthis would reduce any potential bias due to selective or faultymemory.

Data coding and analysis

Qualitative data are seen to convey both manifest and latentcontent (Graneheim and Lundman, 2004). The former refers tothe actual text, as written, whilst the latter relates to the subjectof the text, whether overt or allusive. In this way, data may havemultiple meanings, making an element of interpretation necessary.The current study data appeared to have both such meanings.

Having retrieved the participants’ diaries, the first author con-sidered their content in depth. Burnard’s (1991), 14 stage dataanalysis process (cited by Clayton and Thorne (2000)) was con-densed (where the categories overlapped) by the author into fewerstages (Table 1) (Appendix 1). The resulting process, summarised

as one of ‘condensation’, ‘abstraction’ and ‘content area identifica-tion’ by Graneheim and Lundman (2004, p. 106), was then applied.

Ethical considerations

Permission for this study was obtained from the Ethics Commit-tee of the University of Plymouth, Faculty of Health and SocialWork. In the study recruitment material, all participants were ad-vised that the study results would remain confidential, and thatthey would not be identified in any final written material. In addi-tion, participants were advised that they were able to withdrawfrom the study at any time and that if they did so, any informationthat they had provided would be destroyed. In compliance with theData Protection Act (1998), all data were kept in a secure environ-ment and handled exclusively by the first author, apart from theanonymised scripts which were also seen by the independent co-der. When no longer required all data will be destroyed using aconfidential waste management system.

The first author’s role within the university is not primarily aca-demic. As such, she is not involved in assessing participants at anypoint in either the academic, or the placement-related, elements oftheir studies. Potential recruits to the study were made fully awarethat participating in the study would have no direct impact ontheir progression through their programme of study. To ensurethis, participants’ data were recorded, stored and communicatedanonymously. In the spirit of this agreement, and for the purposesof this article, participants are referred to using gender-appropriatepseudonyms (Table 2).

Findings and discussion

Study themes

The following four themes emerged from the study data.

Theme 1: Nature of community placementsInformation coded under this theme included the type of

clinical environment experienced by participants, acquiring anunderstanding of local policies, procedures and resource issues,the mechanisms used to practice and the healthcare require-ments of the patient/patient population encountered. Whilstcommonalities exist with regard to core practice placementlearning activities, individual community placement settings dif-fer in the opportunities and experiences that they provide. Cur-rent study participants expected their community placementsto enable them to experience the ‘reality’ of community nursing,accurately reflecting the nature of UK community nurses’ roles.This may be difficult for students to judge if, as Dixon (1996)reported, community-based nurses alter their practice to accom-modate students’ learning needs. The extent to which thispractice may affect students’ learning requires further investiga-tion. Students’ learning experience may also be affected by thecommunity practice placement setting in which they findthemselves, for example Elaine, who was based in a hospital out-patient department with access to a community outreach team,commented:

‘Although I am based with the gynaecological outpatients clinic, Iexpect that most of the placement will be spent with the gynae out-reach team’. (Elaine)

In the event, this participant reported that she spent only threedays of six weeks with the community outreach team. Despite this,this participant found this a positive experience.

M.R. Baglin, S. Rugg / Nurse Education in Practice 10 (2010) 144–152 149

Students, perceptions about the nature of community settingsalso coloured their expectations as expressed in the followingcomment:

‘I feel that my community placement, that I am about to com-mence, may not fulfil my expectations, and may limit furtherknowledge, compared with my previous placements’. (which hadbeen hospital-based) (Claire)

Another participant had more positive expectations, however,noting:

‘I hope to find out more about how patients are allocated to DistrictNurses, and what the procedure is for discharging them when nofurther treatment is required’. (Anna)

All participants expressed both expectations and anxietiesabout their allocated placements, which might be mitigated bothby better preparing students prior to placement, and by improvingthe support structures available to them whilst they are in thepractice placement setting (Timmins and Kaliszer, 2002).

Theme 2: Relationships/teamworkData coded into this theme included work with mentors, pa-

tients and the wider professional team. Implicit in the concept ofplacement learning is the ability to access appropriate opportuni-ties to practice skills, to be provided with good role models andto enjoy the chance to develop relationships that result in feelingpart of a team. The first author’s experience leads her to believethat community practice placement learning offers good opportu-nities for multi-professional team working, with the potential toenrich student nurses’ experience and promote a sense of purpose,beyond the achievement of successful assessment results. To oper-ate effectively in practice, however, student nurses must learn toestablish sound relationships with both staff and patients quickly.Participants perceived relationships to be of considerable impor-tance in the current study. This area of learning about people skillsand teamwork was often expressed in terms of ‘legal and ethicalpractice’, relating to gaining consent from patients before givingcare. Cheek and Jones (2003) also found effective communicationand conflict resolution skills to be key skills in contemporary nurs-ing practice. The current study data give a clear picture of partici-pants’ interactions with staff and patients.

All current study participants identified aspects of their com-munity placement experiences that related to working with men-tors and other placement team members. Some reported positivementor relationships noting, for example:

‘It has already been established, with the team I am working with,what my learning outcomes for this placement are, and how thesecan be achieved’. (Barbara)

‘I spoke to the sister [and] voiced my concerns. She agreed with myobservations and the issue was addressed at the multi-professionalmeeting’. (Denise)

These extracts convey the positive relationship that thesestudents had with their practice placement mentors. They felt sup-ported, and confident in voicing their concerns. Their expectationsthat their needs and concerns would be addressed were borne outin practice. Such relationships, which enabled students to experi-ence learning as part of a team, increased their confidence.

Whilst research is lacking into the precise role that patients playas ‘experience brokers in clinical teaching and learning’ (Stockhau-sen, 2005, p. 13), current study participants saw their interactionswith their patients as important:

‘My mentor allowed me to visit a patient, who I have cared for overthe last five weeks under observation, on my own this week. It felt

really good that a patient and the team trusted me enough to carryout the planned care independently’. (Denise)

Some participants reported less positive relationships, citingexamples of poor support and mixed success in their interactionswith both staff and patients, as reported elsewhere (Mabuda etal., 2008). As Frances noted:

‘I feel there was too many of us for the staff nurse to teach, as wellas carry out her duties’. (Frances)

Other community-based nursing students have also foundthat their comfort with their role, in particular the need toobserve, rather than to ‘do’, affected their ability to learn (Baillie,1993). Such experiences may stem from mentors’ need tobalance students’ needs with patient and other service demands(Gray and Smith, 2000). At least none of the participants inthe current study reported having been bullied, as has beennoted elsewhere (Randle, 2003). Frances went on to say thather inability to relate well to her mentor affected her learning,as follows:

‘I feel that there were times this week that I was in the way, maybebecause of the size of the clinic and the number of staff, includingtwo students’. (Frances)

This participant seemed aware that competing priorities for hermentor’s attention caused difficulty for both parties, reducing theeffectiveness of the resulting relationship. This situation was seenas partly due to the constraints of the working environment. It mayalso reflect the fact that the skills needed to develop sound thera-peutic relationships are not formally taught in traditional nursingeducation, on the apparent assumption that they will developwithout such input.

As expected, all of the participants commented about theirmentors, as these people are critical to the students being able toprogress through their courses. They also saw building relation-ships with their patients as rewarding and directly relevant to theirlearning outcomes. These findings accord with the study recom-mendation of Dornan and Bundy (2004) on the value of placingmedical students into the practice area early in their professionaleducation.

Theme 3: Learning opportunities in practiceInformation coded under this theme principally related to the

acquisition of clinical skills, undertaking patient assessments andsupporting patients by providing health promotion information.Acquiring basic clinical skills was often participants’ primaryplacement learning goal, as follows:

‘My main expectation of this placement is related to improving mypractical nursing skills. By practical skills, I mean:

� Observations: I want to be able to use a manual BP cuff� Dressings: I want to be able to be more hands-on learning

about dressings

In my last placement, I had little or no opportunity to practicethese skills, which I see as a vital grounding in nursing . . .

(and I would like to) . . . confidently and efficiently use a manualBP cuff, and monitor visually rather than using a machine’.(Barbara)

‘From the first day, I have been encouraged to do as much ‘hands-on’ work as possible with my mentor doing mostly the tasks I can’tdo, such as venepuncture, compression bandaging and male cathe-terisation’. (Anna)

‘I was able to see a variety of things and do dressings in the. . .clinic’. (Claire)

150 M.R. Baglin, S. Rugg / Nurse Education in Practice 10 (2010) 144–152

Participants spent much of their reflective diariesidentifying potential learning opportunities, both before and dur-ing their placements. This material largely focused on theneed to master a range of practical clinical skills. Participants ex-pressed their strongest feelings on the topics of skillsacquisition and competence in practice, as noted elsewhere(Boxer and Kluge, 2000; Henderson, 2002). Such pre-occupationis likely to reflect students’ anxiety about assessment and theneed to meet set learning competencies on each practiceplacement.

Contrary to findings by Cheek and Jones (2003), thoseparticipating in the current study did not identify assessment,management or leadership as key skills that they needed. Thismay have been because the participants in the current studywere only just moving into year two of their nursing educationprogramme, whereas the participants in the Cheek and Jonesstudy were qualified nurses. The findings of the current studysuggest that, in spite of the increasingly academic nature ofnursing education, the acquisition of skills now frequentlyperformed by healthcare assistants is important to studentnurses. Such assistants’ role as permanent staff may mean thatregistered nurses have a vested interest in training them, in pref-erence to more transient student nurses (UKCC, 1999). The ex-tent to which this finding reflects poor preparation for thepractice-based elements of students’ education, or the perceivedreality of the healthcare workplace, is difficult to determine,although participants’ acquisition of practical nursing skillsclearly relates strongly to their confidence to practice as studentnurses.

Theme 4: Gaining confidence to practiceThe information coded under this theme included

participants’ prior level of confidence to practice, increasedconfidence from being listened to, and confidence built frompatient related activities. Student nurses’ confidence isfragile (Kelly, 1993) and needs careful nurturing if it is tosurvive in today’s fast moving, complex healthcare world(Stockhausen, 2005). One current study participant explicitly ex-pressed anxiety, and a resulting lack of confidence, in her abilityto cope with the potential challenges of practice placement, asfollows:

‘I’m feeling apprehensive about my placement. . ..due to the natureof this placement and the duties I will have to carry out regardingsputum which, unfortunately, is a weakness I find difficult to over-come’. (Frances)

Other participants reported more confidence, during andafter their placement, noting that this came from a range offactors. These included encouragement to engage in, andmaster, new skills as part of their practice placement, asfollows:

‘I am encourage[d] by the nursing team to take part in asmany activities as I can . . . (so that) . . .I am now more comfort-able setting up syringe drivers, also the importance of record-ing accurately and completely, and being a safe practitioner’.(Denise)

Working closely with their mentors also boosted participants’confidence, as the following extract from a student allocated to aDistrict Nursing team highlights:

‘We looked at factors such as underlying health conditions . . . thisreminded me of the importance of looking at the whole picture, andnot just the presenting problem . . . (which) . . . has given me moreconfidence about planning care’. (Anna)

The findings of this study suggest that not all student nursesnaturally increase in confidence as they progress through theirprogramme of study. The development of student nurses’ confi-dence may be embedded partly in their perception that they arecapable of performing clinical skills. Student nurses’ lack of practi-cal skill, and the confidence that results from its mastery, may leadto stress and poor relationships with their colleagues and patients(Timmins and Kaliszer, 2002). A combination of the nature of theplacement, the relationship with their mentor and the opportunityto practice clinical skills all influenced students’ assessment of thevalue of their community practice placement. Interestingly, despitewide variation in the practice experienced, all of the study partic-ipants saw their practice placement as a worthwhile learningopportunity.

Conclusion

The six female student nurses who participated in thisstudy experienced a variety of community-based practiceplacements, generating four study themes. These related to stu-dents’ basic skills acquisition and practice, the development oftheir working relationships with mentors, patients and others,the learning opportunities offered by practice placement andthe effect of such a placements on their confidence topractice.

The study data showed that participants’ expectations prior toplacement were coloured by their understanding of what acommunity placement is or should be. Their ability to findmeaning in their placement learning experiences appeared tobe determined by their expectations, the support available, thelearning outcomes set and the type of placements allocated.The data suggest that participants were genuinely willing, andable, to make the best of the situations in which they foundthemselves. This was particularly apparent in the diary entriesprovided by students allocated to hospital-based outpatientdepartments (with access to outreach teams) as their communityplacements.

The acquisition of practical nursing skills engaged much of par-ticipants’ expectations and energies in this study, despite the gen-eral absence of these tasks from contemporary qualified nurses’repertoire; being often undertaken by healthcare assistants. Mas-tery of such skills however, still strongly related to participants’confidence to practice as student nurses. This study has demon-strated some of the potential challenges of delivering commu-nity-based nursing practice placements. In the new and changinglandscape of healthcare service delivery, such placements mustbe developed and managed with care to best prepare tomorrow’sstudent nurses.

Recommendations for nursing education, practice and research

The above findings suggest the value of:

� Ensuring the quality and appropriateness of community-basedpre-registration nursing practice placements.

� Ensuring that all pre-registration student nurses receive com-munity-based practice placement experiences.

� Exploring potential influences on, and changes in, pre-registra-tion student nurses’ confidence to practice throughout theireducation.

� Exploring ways that nursing practice placement mentors adapttheir practice to present positive experiences to the studentnurses placed with them.

M.R. Baglin, S. Rugg / Nurse Education in Practice 10 (2010) 144–152 151

Appendix 1

Example of initial coding

Original text Meaning unit Code assigned Themes

‘This has been mainly to firstly meet patients, but also to ensure thatthey are comfortable with me before I am involved in their care’

This is to meet patients beforebeing involved in care

BR – Buildingrelationships withpatients

2

‘The care that the patient receives is discussed with the patient; itinvolves personal information which is only disclosed to otherhealth professionals if required’

Disclosing personal informationappropriately to the wider team

TM – Functioning aspart of a team

2

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