This article discusses the

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1 Welcome to JCN s learning zone. By reading the article in each issue, you can learn all about the key principles of subjects that are vital to your role as a community nurse. Once you have read the article, visit to evaluate your knowledge on this topic by answering the 10 questions in the e-learning unit; all answers can be found in the article. If you answer the questions correctly, you can download your certificate, which can be used in your continuing professional development (CPD) portfolio as evidence of your continued learning. Using a narrative framework in nursing students community placements Fern Todhunter This article discusses the applicability of a narrative framework to support student nurses learning when on placement with a team of community matrons. A narrative framework involves gathering, evaluating and discussing information and the rationale for using one here was that it helped the students think critically about what they had experienced while on placement and provided a specific language for them to make sense of their surroundings, which would in turn influence their subsequent decisions and actions. In primary care, the case management of high-intensity patients with long-term conditions and complex needs is predominantly nurseled. Community matrons are responsible for taking the lead and making informed decisions about the direction and nature of advanced care, using a case management approach. In undergraduate nurse education, the qualities of leadership and decision making are introduced to students as prerequisites for registration. The learning opportunities afforded by this experience offer insight into how patient care services are reviewed and coordinated by the community matron In contrast to the ward environment, community nurses contact with patients is not Community matrons are often presented with an incomplete history of the patient s health status but will be expected to make sense of these gaps. Witnessing this in practice exposes student nurses to skill sets such as assessing, prioritising and planning that are required when managing uncertainty and dealing with change. The narrative framework is a structure which allows students to join-up conversations about these skill sets. THE NARRATIVE FRAMEWORK Emerging in the 1980s, the narrative framework was a relatively new theory with a focus on narratives as stories that look at social change and political conditions (Bruner, 1986), while its application to psychotherapy showed how patients could drive the narrative framework (Tantam, 2002). Professional communications in health care are often a sequence of listening and observing, thinking and transforming, and responding, all of which help to form a programme of care. The narrative framework is a conversation about the thought processes that take place during this chain of linked events. Together, these conversations create a story, or narrative that follows each stage of clinical practice. During a student s placement with a community matron, there is a requirement for the practitioner and the student to discuss each level of practice; the aim is that the student learns what it is like to think as a practice lead. In this instance, the narrative framework structure presented excellent learning opportunities for undergraduates to explore the critical thinking skills and professional language used by community matrons, including professional, business and leadership language. BACKGROUND Fern Todhunter, division of nursing lead for interprofessional learning, The University of Nottingham What is the role of the community matron? Based on the Evercare model (NHS Institution for Innovation and Improvement, 2006), the role of the community matron emerged from policy that recommended intensive programmes of care in the patient s own setting (Department of Health [DH], 2004; 2005; 2006). In this context, the community matron s case management role can be summarised as a combination of (World Health Organization 62 JCN 2016, Vol 30, No 4

2 [WHO], 2002; DH, 2005): Holistic assessment Prioritising patients health needs Acting as a referral agent Making informed judgments using contemporary evidence. Case management is the structure used to integrate bespoke services for patients with long-term conditions, for example chronic obstructive pulmonary disease (COPD) (Ross et al, 2011), and the objective is to prevent deterioration while managing those patients at risk of unnecessary hospital admissions. Working with highintensity patients based in the community requires an expert level of nursing skill and knowledge (Drennan et al, 2011; Grange 2011; Hall et al, 2011). As mentioned above, this level of accountability and responsibility means that community nurses have to understand complex professional, business and leadership language, as well as being able to analyse clinical data to procure appropriate resources. Similarly, case work is also significantly influenced by reflective professional-patient conversations, aimed at accurately assessing Table 1: Application of a narrative framework to the community matron s case management approach Observe Sequence Vocalise Evidence for portfolio Duty of care Respect for the patient and their Prioritise health needs Assessment Reflective discussion and problem-solving significant others Current health status Medication management Changes in health status Verbal references to peer reviewed literature, procedural information, protocols, policies and research to inform practice Level of symptoms Social care needs Care plan Question and answer session Ability to manage symptoms Level of monitoring required Recommendations, e.g. referral, medication review Written record of anonymised contribution to multidisciplinary team meeting Surrounding scenery, e.g. professional support from GP, physiotherapist, community nursing team etc; social care by family, friends neighbours voluntary sector and self-help groups Clinical data, e.g. temperature, pulse, blood pressure, oxygen saturation etc the patient s experience of their symptoms and management; likewise, discussions with the multidisciplinary team can determine which clinician is best equipped to deal with a particular patient (Roland and Paddison, 2013; National Institute for Health and Care Excellence [NICE], 2013; Oliver, 2014). NURSE EDUCATION: PREPARING UNDERGRADUATE LEARNERS The responsibility of nurse education is to prepare student nurses for registration. This includes dealing with the challenges of contemporary practice and recent studies have supported the value of developing leadership traits in student nurses from the outset (Clarke et al, 2014; Gazarian et al, 2016). These studies also demonstrate how the voice of nurses is key to patientadvocacy and for prioritising needs and resources in a complex care environment. Statutory guidance for practice learning is set out in the Nursing and Midwifery Council s (NMC) standards framework for preregistration students (NMC, 2010). Standard four in the NMC framework Consult relevant procedure, protocols and policies Coordination of different services and required input advises that student nurses should be provided with the best possible opportunities in the practice setting with particular emphasis on their own and others safety. Nurses are required to develop the knowledge and skills to decipher visual imagery that involves more than simply observing the patient in front of them, for example the condition of the patient s home and the effect of treatment on their family s overall health. In partnership with the patient, student nurses are encouraged to identify and engage with the patient s support network of family and friends. The competence of the student nurse in dealing with the complex problems they will encounter will in part depend on the quality of the mentorship they receive (Kinnell and Hughes, 2010). Introducing student nurses to advanced practice in a community setting therefore requires careful consideration of the type of teaching and learning that would work for each individual. In the author s locality, the desire to provide students with a positive experience of practice placements sparked the idea to place relatively junior student nurses (at the Anonymised written reflective observations Written observations from insight visits with signed confirmation from relevant practitioner Work products anonymised charts and care plans JCN 2016, Vol 30, No 4 63

3 beginning of year two in a threeyear undergraduate degree) with a community matron. The aim was to provide student nurses with a taste of how the matrons used their expertise in action. The Royal College of Nursing (RCN, 2010) defined advanced practice nurses in primary care as having a wide range of skills, a broad knowledge and the ability to deliver specific aspects of care. The term advanced nurse practitioner has increasingly been used to distinguish where these emerging roles have a higher degree of autonomy and application of expertise. It was hoped that exposing student nurses to the experiences of community matrons would provide them with some insight into how applying advanced care leadership skills with high intensity primary care patients can work in practice (East et al, 2014). Using predetermined standards (NMC, 2011; Quality Assurance Agency 2014a,b,c), the priorities were set as: Safe professional practice Meaningful learning experiences The development of competence in professional thinking and the use of professional language. USING A NARRATIVE TEACHING FRAMEWORK TO SUPPORT UNDERGRADUATE LEARNING Facilitating advanced practice requires a supporting framework otherwise conversations become, at What is a narrative framework? best, superficial observations (Costin et al, 2013). Successful teaching and learning frameworks that use a narrative approach place the emphasis on the student describing details and then interpreting the circumstances of a particular scenario (DH, 2004). In a placement with a community matron, the student is asked to notice the kinds of support the patient receives from family and friends, as well as the interactions between them. Application of the narrative framework here helps students to analyse the patient s reactions to changing circumstances, i.e. from a stable condition to the emergence of an acute health event. In this way, the narrative provides a picture of the sequence of unfolding events. As with any other skill, identifying the narrative chain has to be practised to be learnt and the success of the learning experience is dependent on the student s willingness to explore the strength of their knowledge and skills, as well as identifying their limitations. As narratives are reproduced through conversations there is value in using this framework to step back from clinical scenarios. This is an opportunity for the community matron to use the patient s story to frame a particular issue with a student. The scenario of family support is an example of how a word in this case support can influence the student nurse s thinking and help them to determine The narrative framework is a conversation about the thought processes that take place during a chain of linked clinical events. what clinical steps to take; the preceding word family provides the context for that support. Paul (2008) proposes using the narrative to demonstrate good practice in any real-world situation; in the family support example used above, good practice means using the narrative to assess students understanding of the carers experience. Vandermause and Townsend (2010) distinguish between using narrative as a reflection on personal thoughts and for thoughtful practice. This important distinction explains how the clinician needs to be able to engage in, and master, the language of professional care, as mentioned above. In health care, this has never been more important. Community nurses increasingly work with a range of professional and voluntary groups to deliver health and social care and all of the evidence cited above helps to demonstrate the value of a using a narrative to understand clinical events. Using a narrative approach can help the student nurse to appraise a clinical situation and decide what action to take. INTRODUCING THE NARRATIVE STRUCTURE TO THE STUDENTS Under supervision, the students were invited to question, interpret, make decisions about and then reflect on theory in practice. In their mentor role, the community matrons helped the students to consider the interconnections between the patient s condition and the required care resources. For example, if the patient was in pain, the discussion centred around ordering analgesia or referral for pain assessment. Together these conversations create a story about the meaning of each stage of clinical practice. In this instance, the student and the community matron were required to discuss their practice to develop an understanding of what it is like to think as a practice lead. The structure of the narrative framework presented excellent learning opportunities for undergraduate student nurses to explore the critical thinking and professional language used by community matrons, including professional, business and leadership language. Students were then asked to think constructively about what clinical steps to take following the narrative framework; this was also an opportunity to use language to organise and lead on a programme of care. Taking a step back from hands-on clinical activity required a detailed discussion with the students. The focus was on how 64 JCN 2016, Vol 30, No 4

4 the role and responsibilities of the community matron differed from other nurses in the primary care team; this included the kinds of skill sets they required, such as being able to make leadership decisions for patients at risk of rehospitalisation as well as identifying the necessary interventions. From a competency perspective, it was important that the students understood advanced leadership. They were encouraged to talk about the links between interventions and consequences, as well as the role of the community matron in leading discussions between primary and secondary care providers. Using a professional-patient narrative in the patients own setting also helped students to recognise how patients cope with illness, as well as providing first-hand insight into genetic and environmental influences on health. Crucially, the students saw the benefit of entering into dialogue with other nurses, medical staff and allied health professionals. They were encouraged to make contributions at briefing meetings and in turn they were invited to respond to questions about their own experiences. Mentoring using a narrative framework raised a number of issues that needed to be tackled before the students began their placements, including: Time management, e.g. students were encouraged to help organise multidisciplinary team meetings Being patient with students as they considered and discussed practice Framing opportunities for reflection and discussion with a range of stakeholders, including patients and carers, GPs, district nurses and the specialist palliative care team. CREATING A PORTFOLIO OF EVIDENCE FOR COMPETENCY It was important to give clear guidance on how the students could maximise their learning opportunities using a narrative approach. Clark s (2010) work provides advice on how students can collate evidence into a learning portfolio and, using this structure, the students were asked to think about the kinds of evidence that would demonstrate how a narrative could act as a template for a care package, for example: Communicating with patients and other professionals Chronic illness knowledge and skills Polypharmacy Problem-solving Referrals. Table 1 demonstrates the narrative framework in practice. The structure explains care delivery using prompts for students to observe, sequence, and vocalise. The patient is central to the discussion. The observe column opens with reference to providing care with dignity and respect this presented an opportunity to remind students that while service provision is statutory, access to patients homes is not a given. The students recognised the importance of good social skills and being an invited guest in the patients homes. While on placement, students were encouraged to talk to patients. This meant that they experienced first-hand how the majority of patients had a good understanding of their condition and any resulting pathophysiological changes. This was an opportunity to draw on the patients own experiences to inform thinking, discussion and actions. At the end of each working day, the students wrote statements about what they had experienced, underpinned with research-based evidence. It was anticipated that these post-practice evaluations would help the students reflect on the benefits of advanced practice leadership, advocacy and discretionary decision making in the patient s best interest (an example of discretionary decision making is where the nurse critically reviews an intervention and its potential for unintended consequences). CONCLUSION This paper has reported on the WHAT S YOUR NEXT STEP? To use the knowledge that you have gained from this article to inform your continuing professional development (CPD), you should take the following steps before logging onto the website ( co.uk/learning-zone/) to take the learning zone test: Reflect Do you understand some of the issues with providing student nurses with leadership skills? What are the some of the main problems associated with community placements? Evaluate Do you appreciate how the students learning experience can be positively affected by the use of a narrative framework? Act Read the article when you have a spare few minutes in the day. Make some notes on what you have learned, then visit the online test ( to complete this subject. The whole test, which involves reading this article and answering the online questions, should take you 90 minutes to complete. Finally, download your certificate to show that you have completed this JCN e-learning unit as part of your CPD portfolio. Revalidate Finally, upload your certificate to the JCN Revalidation Zone, the new, free resource to help you manage your revalidation portfolio online safely, securely and all in one place. So, register today at: use of a narrative framework as an undergraduate learning tool for advanced practice. A team of community matrons used this tool to support the experiential learning of a group of second-year student nurses. Developing this learning opportunity required meticulous JCN 2016, Vol 30, No 4 65

5 planning, but applying the narrative framework to advanced practice and leadership resulted in a safe and innovative learning experience, which enabled students to consider, talk through and examine complex care supported by the development of analytical skills and fluency in professional language. Anecdotal evidence has shown that the early experience of advanced practice can accelerate the development of students reflective skills and ability to make an informed judgment. Nurse education has a duty of care to maintain and improve the student learning experience. JCN REFERENCES Bruner J (1986) Actual Minds, Possible Worlds. Harvard University Press, Cambridge, MA Bruner J (2006) In Search of Pedagogy Volume 1. Routledge, London Clark A (2010) How to compile a professional portfolio of practice 2: structure and building evidence. Nurs Times 106(42): Clarke P, Swider, S, Bigley M (2014) Nursing leadership and health policy: a dialogue with nurse leaders. Nurs Sci Quart 26(2): Costin Y, Dodd S, Drakopoulou H, Briga M (2013) From the zoo to the jungle narrative pedagogies and the enterprise education. Industry and Higher Education 27(6): DH (2004) Improving Chronic Disease Management. DH, London DH (2005) Case Management Competencies Framework for the Care of People with Long-term Conditions. DH, London DH (2006) Caring for people with long term conditions: An educational framework for Community Matrons and Case Managers. DH, London Drennan V, Goodman C, Manthorpe J, Davies S, Scott C, Gage H, Iliffe S (2011) Establishing new nursing roles: a case study of the English community matron initiative. J Clin Nurs 20: East L, Knowles K, Pettman M (2014) Advanced level nursing in England: organisational challenges and opportunities. J Nurs Manag 23(8): Gazarian P, Fernberg L, Sheehan K (2016) Effectiveness of narrative pedagogy in developing student nurses advocacy role. 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Available at: www. nmc.org.uk Oliver D (2014) Preventing hospital admission: we need evidence-based policy rather than policy-based evidence. Br Med J. Available at: www. bmj.com/content/349/bmj.g5538 Paul H (2008) Towards a narrative pedagogy for interactive learning environments. Interactive Learning Environments 16(3): Quality Assurance Agency (2014a) QAA Code of Practice. Available at: ac.uk Quality Assurance Agency (2014b) QAA Benchmark Statements. Available at: Quality Assurance Agency (2014c) The Framework for Higher Education Qualifications in England, Wales and Northern Ireland. Available at: ac.uk RCN (2010) Advanced Nurse Practitioners. Available at: data/ KEY POINTS This paper has reported on the use of a narrative framework as an undergraduate learning tool for advanced practice. A team of community matrons used this tool to support the experiential learning of a group of second-year student nurses. The creation of this learning opportunity required meticulous planning, but applying the narrative framework to advanced practice and leadership resulted in a safe and innovative learning experience. This enabled students to consider, talk through and examine complex care supported by the development of analytical skills and fluency in professional language. Anecdotal evidence has shown that the early experience of advanced practice can accelerate the development of students reflective skills and ability to make informed judgments. Nurse education has a duty of care to maintain and improve the student learning experience. assets/pdf_file/0003/146478/ pdf Roland M, Paddison C (2013) Better management of patients with multimorbidity. Br Med J 346: 2510 Ross S, Curry N, Goodwin N (2011) Case management: what it is and how it can best be implemented. The King s Fund Available at Tantam D (2002) Psychotherapy and Counselling in Practice: a narrative framework. Cambridge University Press, Cambridge Vandermause R, Townsend R (2010) Teaching thoughtful practice: narrative pedagogy in addictions education. Nurse Educ Today 30(5): WHO (2002) Innovative Care for Chronic Conditions: Building Blocks for Action. Available at: int/chp/knowledge/publications/ icccglobalreport.pdf (accessed 25 July, 2016) 66 JCN 2016, Vol 30, No 4