Supporting student nurses on placement in nursing homes: The challenges for the link-tutor role

Work-based learning 

Gallagher and Holland (2004) define work-based learning as the bringing together of self-knowledge, expertise in the work place, and formal knowledge. It is a concept which encourages reflection, values learning opportunities in practice, and promotes the development of professional knowledge. Work-based learning promotes learning through experience, and experiential learning is based on the premise that learning gained through experience is more meaningful to the learner (Kolb, 1984), and ensures a high degree of relevance. Guiding nursing students to reflect on, and use, their experiences to help them contextualise and conceptualise new information, is important in order for them to understand, learn and develop as effective practitioners (Dix and Hughes, 2004).

The importance of work-based experience, in the development of professional expertise, has refocused the role of the teacher from transmitter of knowledge to that of facilitator, drawing on the experiences of the learner (Benner, 1984, Schon, 1987, Duraghee, 1998, Scanlan et al., 2002). This is particularly important for the role of the link tutor in clinical learning.

In the UK, although the importance of work-based learning in the education and training of student nurses has been emphasised nationally (Department of Health, 1999, English National Board/DoH, 2001), providing appropriate work-based learning placements remains a challenge, as it does for nursing in many countries of the world. In the USA, the National Council of State Boards of Nursing (NCSBN) places a high priority on student nurses gaining clinical work-based experience across the lifespan (NCSBN, 2005), however, Li (2007) highlights that there is a lack of both mentors and clinical placement sites for student nurses in the USA, leading to the need to find new ways of providing clinical experiences for students.

The role of the link tutor 

Little significant literature is available on the specific role of the link tutor in nursing homes, however, literature related to the generic role of the link tutor can be applied. In the USA, the NCSBN (2005) suggest that prelicensure nursing students should be supervised, in clinical placements, by a suitably qualified faculty member, whose role is that of facilitation of learning and promoting reflection. In the UK, Gerrish (1992) identified key roles for lecturers in practice settings, which can serve as a guide for the LT role in nursing homes. Firstly, LTs should provide educational support for the clinical staff to enable them to support the students. Secondly, they should support the students and facilitate their work-based learning, particularly the integration of theory and clinical practice. Finally, the lecturer has a responsibility to ensure good practice through keeping themselves up-dated, being a resource for the practice area, and encouraging a critical approach to practice. However, in a study in Sweden, Fagerberg et al. (2000) found that clinical teachers in elderly care were seldom seen as people who inspired students to want to work in the speciality, and this will have a bearing on the way the role of the link tutor in nursing homes is conceptualised.

The role and value of nursing homes as clinical placements 

An increase in the number of student nurses at the end of the last decade (DoH, 1999) resulted in an increased need for high quality placements for them to gain practical skills (United Kingdom Central Council, 1999). At the same time, the shift in healthcare, away from long stay hospital care to a more acute, short stay model, led to the increased use of nursing homes to meet this demand. This scenario is not confined to the UK, and the literature indicates that the shortage of hospital-based placement areas is a global issue for nursing education, and is leading to an international increase in the use of nursing homes for clinical placements (Chilvers and Jones, 1997, Li, 2007).

Davies et al. (2002) highlight the importance for nurses, working in this kind of environment, to feel valued in creating positive learning environments for students, particularly as they are often perceived as only providing basic care, with no requirement to develop any specialist skills (Lumley et al., 2000, Richardson et al., 2001, Banning et al., 2006). Wade and Skinner (2001) suggest that the ability of the staff to recognise their work as skilled and expert will influence their ability to convey this to the students, which in turn will influence the students’ perceptions of the care delivered.

Philipose et al. (1991) undertook a review of the evolution of gerontological education in nursing, in Greece, and cites the value of nursing students undertaking placements in a variety of elderly care settings. A decade later, Kotzabassaki et al. (2006) examined the perceptions of student nurses in Greece, about caring for older people, and found that nursing education, including placements in elderly care facilities, was effective in preparing them to give better care. Similar findings were identified in a more recent Australian study (Abbey et al., 2006). This study also showed that if certain negative elements of a nursing home placement were addressed then the experience could lead to more positive perceptions of elderly care nursing as a career. In the USA, Williams et al. (2006) described the positive impact on students’ attitudes, and career choices, of integrating elderly care experience into the final year of placements.

The value of a nursing home placement for students’ is in the opportunity to participate in person-centred holistic care, where they can understand the transitions people make at different stages of their lives (Rogan and Wyllie, 2003). According to Wade and Skinner (2001) looking after different groups of people in different settings makes a whole nurse; nursing home placements enable students to move towards this by caring for older people, and meeting their needs in a different context of care.

LTs work with students on placement in nursing homes 

The work of the LT with students involves a range of activities to make Gallager and Holland’s (2004) definition of work-based learning a reality. Students have identified that the provision of learning and personal support, from both their LT and mentor, is key to the success of their placement (Lumley et al., 2000, Wade and Skinner, 2001). The need for emotional support has also been identified, as the students may be exposed, for the first time, to a patient whose condition is deteriorating, and who may be dying. Wade and Skinner (2001) suggest that students may also need the support of the LT to confidently challenge practice or raise issues of concern. Students report the fear of repercussions whilst still on placement as the main barrier to challenging practice (Wade and Skinner, 2001).

A second activity for the LT is to promote a positive attitude. Through the use of guided reflection, the LT can help students to process their nurse-led care experiences, and challenge any negative attitudes and preconceptions about older people and nursing home care (Duraghee, 1998). Burton (2000) suggests that if reflection is seen as a part of a developmental cycle, whereby new knowledge is integrated with old, then changes in practice are more likely to occur.

Finally, LTs can participate in teaching sessions on aspects of care related to older people in nursing homes. Clinical competence and credibility, as well as teaching skills, are identified as key requirements for staff in a clinical teaching role (Williamson and Webb, 2001, Ramage, 2004). Wade and Skinner, 2001, Rogan and Wyllie, 2003 suggest that the ability of students to recognise the skills and expertise required to provide expert care in a nursing home setting, is often dependant on having a knowledgeable LT, and specialist knowledge is needed in order to support the students in this type of placement. This can be facilitated most effectively if the LT allocated to a nursing home has some previous clinical experience and expertise in this field (Clifford, 1999, Griscti et al., 2005).

LTs work with nursing home staff 

One key activity for LTs is undertaking the educational audit of the nursing home environment prior to students taking up their placements. Such an educational audit is a collaborative activity between the LT and nursing home staff, and requires extensive preparation and considerable commitment from both.

Richardson et al. (2001) report that having students in their workplace makes nursing home staff question their own practice, and motivates them to develop their own professional knowledge and skills. This may be of particular importance in this setting as there is some evidence that the majority of nurses working in nursing homes are not engaged in any form of continuing professional education, and that it is not given the same priority as it receives within the NHS (Davies and Nutley, 2000, Davies et al., 2002). The reasons for this are varied and not always easily resolved; staff may have difficulty accessing development opportunities; the cost to their employer may be prohibitive; isolation from other colleagues prevents sharing of good practice, and terms and conditions of employment often do not consider this aspect of the nurse’s role. Storey and Adams (2002) also report that not all registered nurses enjoy the challenge that mentoring students provides, and although this may be linked to pressures of work, it may also be a by-product of their own feelings of inadequacy due to a lack of professional development opportunities. Providing learning resources for clinical staff enables the nursing home to have access to up-to-date resources for challenging (and changing) their own practice.

Supporting staff is a key responsibility of the LT in the nursing home setting (Gerrish, 1992), and Duffy et al. (2000) identify the need for this support to be provided in the clinical placement rather than a remote classroom. Although the nature of this support is unclear, other than acting as mentor to the mentors, it is clearly evaluated as an important factor in the learning experience of both the students and their mentors (Duffy et al., 2000, Wade and Skinner, 2001), and there seems to be a direct correlation between good mentor support from the LT, and good student support from their placement mentor. Williamson and Webb, 2001, Hutchings et al., 2005 also report the value that managers place on the supportive role of the LT, suggesting that it has a positive effect upon the way in which students are perceived by all staff.

Supporting the staff in meeting the requirements of the practice assessment may be a particular challenge for the LT in a nursing home setting, as staff in this environment may have little experience of pre-registration nursing assessment (Richardson et al., 2001). Quinn (2000) warns that training, preparation and support for staff in this important role are crucial, and Billet (2004) suggests that the more often staff mentor or assess students the more proficient they will become.

Inadequate preparation for this role is cited as a problem for both students and placement (Richardson et al., 2001, Wade and Skinner, 2001, Davies et al., 2002), but mentor updates, which include the dissemination of guidelines for mentors (NMC, 2004c), give clear standards to be achieved, and can be delivered in the clinical setting by the LT.

The LT as a bridge between the nursing home and the university 

The LT gives the nursing home a voice within the university, and provides a conduit for improved channels of communication. Williamson and Webb (2001) suggest that there is much for nursing home staff to value, in having close ties to a university, not least the opportunity for staff to engage in both continuing professional development and collaborative practice development. In-house learning experiences such as workshops, and work related conferences, can contribute to the support of nursing home staff, and mentor training and updates are ways in which the LT and University can provide the most up-to-date guidance available. A collaborative relationship also gives nursing home staff the opportunity to participate in university-based activities such as curriculum planning groups, journal clubs, research projects and assessment boards, which are beneficial to both parties.

In summary, Fig. 2 shows the model of the role of the LT in the nursing home setting.

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Figure 2. A model for the link-tutor role in nursing homes.