Protecting the NHS investment; supporting the preceptorship of newly qualified staff. A consultation on the way forward
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1 Protecting the NHS investment; supporting the preceptorship of newly qualified staff. A consultation on the way forward June 2009
2 Protecting the NHS investment; supporting the preceptorship of newly qualified staff. Contents Background 1 What is Preceptorship 2 Benefits of Preceptorship 4 Barriers to effective Preceptorship 5 Exclusions 6 Models of Preceptorship 7 Role of preceptor 9 Preparation of preceptor 10 Role of new registrants 11 Period of Preceptorship 12 Role of NHS organisations 12 Role of the SHA 13 Expected outcomes 15 Governance 16 Consultation questions 18 Conclusion 19 Appendices 1. Agenda for consensus building event 2. Expected programme products - 0 -
3 Protecting the NHS investment; supporting the preceptorship of newly qualified staff. 1 Background 1.1. This paper explores how the NHS Northwest Strategic Health Authority (SHA) supports preceptorship of newly qualified nursing and midwifery staff within the North West, setting out local principles and models of preceptorship, the current investment levels and proposes how the SHA could take forward the investment over the next 3 years The SHA anticipates that this document forms the basis of its strategy to support the transition of newly qualified staff to confident practitioners but in light of minimal formal research evidence found on certain aspects wishes to consult with stakeholders on 8 key questions relating to this strategy to confirm its position The Next Stages Review has committed to provide 3m over the following 3 years ( ) to support the preceptorship. The key purpose of which is to support the transition of a newly qualified healthcare professional to develop the competence and confidence to function as an independent health care professional. The preceptee s specific learning needs may vary significantly within the context of the clinical environment in which the newly qualified practitioner will practice but it is the view of the SHA that many common themes exist It is recognised that the healthcare system and subsequent workforce in the next 3 years will continue to transform to meet the changing economic climate, the NHS constitution, the increased expectations of staff and healthcare users and the opportunities created by advancing technology. In addition the regulatory environment that governs both workforce development and service delivery will continue to evolve to assure the public of the quality and safety of their care they will receive from health and social care services In developing this approach to preceptorship the SHA has taken account of the anticipated changes highlighted in 1.4, considered evidence from beyond the specific descriptor of preceptorship, as limited evidence has - 1 -
4 been found that solely related to preceptorship. By applying the broader perspective, taking account of mentorship, internship and coaching relationships, then a greater depth of evidence is found. It is also recognised that this evidence base will continue to change and strengthen as more formal studies commissioned by the Nursing and Midwifery Council, Departments of Health in the home countries and others begin to report Any preceptorship system approach therefore must be flexible enough to respond to these changes. To ensure this flexibility this document has been developed in partnership with the following stakeholders: SHA workforce and nursing teams Department for Health Skills for Health academy National Workforce Commissioners network 2 What is Preceptorship 2.1. When first qualifying as a registered healthcare practitioner, many people find the transition from being a student to an accountable individual practitioner a daunting prospect. Although they are competent and knowledgeable, it is both felt and evidenced that the support and guidance of more experienced professional colleagues is beneficial to the enablement of this transition Whilst it is acknowledged that newly qualified health care staff have successfully completed extensive and rigorous programmes of study in accordance with the requirements of associated Professional and Statutory Regulatory Bodies, there is significant evidence associated with high levels of anxiety, mistakes, complaints and attrition during the vulnerable early months of working for new practitioners. Preceptorship allows new registrants to adapt to professional practice within a highly supportive environment and is premised on increasing an individual s confidence and self belief, enabling autonomous practice whilst minimising any risk of psychological harm to the individual or physical harm to the healthcare user
5 2.3. The Nursing and Midwifery Council (NMC) also consider that preceptorship may be beneficial to those who have returned to practice after a break of five years or more and those who enter a different area of practice. Equally that it may also apply to those entering a different area of practice by virtue of a new registerable qualification, for example a registered nurse who subsequently qualifies as a health visitor Formal preceptorship is dependent upon new registrants having easy access to a named individual who is on the same part of regulatory register, be that with the NMC or Health Professionals Council (HPC), who can be called upon to provide guidance, help, advice and support. Through this supportive relationship with the more experienced practitioner a new registrant identifies personal development needs, receives support in undertaking or consolidating clinical activities and is able to reflect on their development. This named individual does not necessarily need to be working on the same clinical area as the new registrant The SHA acknowledges that, for many, the nomenclature for the skills used to enable this supportive relationship, is varied and in many cases interchangeable with those associated with high quality coaching, mentoring, clinical and educational supervision, although each will have subtle differences. It is the intention of this SHA to use the term preceptor as an individual possesses any/all of these appropriate skills to deliver the supportive transition from newly qualified practitioner regardless of their professions terminology Although predominantly used in nursing, the concept of preceptorship is being recognised by other professional groups to various extents. It is the position of the Strategic Health Authority (SHA) that any programmes or activities it undertakes to support preceptorship will continue to have this multi-professional focus The acknowledged benefits of this supportive relationship sees it as required best practice of employers within nursing fields by the Nursing and Midwifery Council. Any approach developed by the SHA must not abdicate the employer from this best practice obligation
6 2.8. Subsequently the SHA will seek to develop with partners a multiprofesional preceptorship system, founded upon the development of four key inter-related concepts; confidence, autonomy and consolidation of clinical skills and affective support (see para. 6.1) which it believes underpin this transition period of a healthcare professionals career It will aspire to universal coverage of access this system for SHA funded students who are employed in clinical services with the Northwest Health economy regardless of whether an NHS funded care service or independent/charitable care service. Question 1a Do you agree with the principle that the SHA intends to adopt that only programmes or activities that have this multi-professional focus will be eligible to receive support? Question 1b Do you agree to the principle of universal coverage? 3 Benefits of Preceptorship 3.1. If, as stated in paragraph 2.1 the key purpose of preceptorship is to support the transition of a newly qualified healthcare professional and their ability to develop the competence and confidence to function as an independent health care professional then the SHA asserts significant benefits can be gained from having a formal preceptorship system. These include but not exclusively; Reduced sickness/absent rates to the Northwest health economy Reduced turnover and subsequent costs associated with recruitment Improved decision making skills and clinical judgement Reducing patient safety risks 3.2. Through a supportive relationship with a more experienced practitioner the new staff member is required to identify personal development needs, receive support in undertaking or consolidating clinical activities and reflect on their development. While a preceptee s specific learning needs - 4 -
7 may vary significantly within the context of the clinical environment in which the newly qualified practitioner will practice, there does seem to be a common set of learning requirements which organisations anticipate need to be attained. These are discussed further under section There is a significant wealth of literature that outlines the benefits of this supportive relationship, although the SHA recognises that much of this is encompassed within the diverse nomenclature surrounding the various skills that enhance this supportive relationship (para 2.5) and same can be applied to the mixed terminology globally that surrounds programmes that cover the transition from newly qualified healthcare practitioner to a confident, competent practitioner. This includes, not exclusively, New Graduate Scheme, Transition programmes Internships etc. Question 2 Taking account of the limited evidence, do you agree with the benefits that the SHA argues are delivered through preceptorship? Question 3 Can you provide examples of any benefits that you have evidenced within your organisation? 4 Barriers to the effective transition 4.1. In exploring the barriers to the effective transition the SHA has taken account of the limited evidence available specifically in the primary care setting. Of the formal research evidence available globally some evidence exists that suggests that key constraints include: workload and time delivery approach within organisations specifically the lack of formality availability and commitment of preceptor access to educational resources 4.2. SHA cannot require organisations to make changes in service delivery and design solely to address these barriers. It will though look to develop flexible products that can enable both the organisation and the individual - 5 -
8 to mitigate against these constraints and so improving the efficiency and productivity of the preceptorship programme. 5 Exclusions This paper excludes any period of preceptorship that relates to healthcare professional staff who have entered a different area of practice including those who enter a new area of practice by virtue of an additional registerable qualification. This also includes return to practice and international students who are funded seperately 5.2. The SHA recognises that a significant number of local Universities have developed formal education programmes to support preceptorship and has purchased these to support those staff, newly qualified who were unable to acquire employment. In light of the barriers identified in paragraph 4.1 it will not be looking to directly procure these programmes rather deliver a system that enables a local decision is made over best fit to the newly qualified staff members Upon the appointment of all new members of staff, it is a requirement for an employer to induct them into the organisation ensuring that both Mandatory and Statutory training needs are met. Commonly the aspects which are expected to be included within induction training programmes are: Promoting understanding and values of the employer organisation, including but not exclusively, organisational vision, customer care, local population needs, equality and diversity etc Specific health and safety issues including but not exclusively, manual handling, infection control, information governance, fire etc Administration and operational issues, payroll, trade and professional body relationships, shift and duty patterns 5.4. It can be expected that these core issues are required by all new employees of the organisation and as such is not expected to be funded by the SHA in development of this preceptorship system
9 5.5. Each NHS organisation will have specific methodologies for delivering this training which will usually be through a range of theoretical delivery, ie policy handbooks, the Northwest Virtual Learning Environment and practical training through their own local training centres. Question 4 Do you foresee any significant risks associated with these exclusions? 6 Models of Preceptorship 6.1. During preceptorship practitioners are required to adapt to professional practice within a highly supportive environment. For the successful completion of preceptorship four key inter-related concepts; confidence, autonomy, consolidation of clinical skills and affective support, must be achieved. These can be defined as: Confidence: the preceptees positive belief in their ability to function successfully at the role for which they have been employed Autonomy: the ability of the preceptee to act without recourse to the supervisor/preceptor except in the normal escalation of both operational and professional issues that arise from their employment Consolidation of clinical skills: the safe function of core aspects that arise from their employment including but not exclusively the administration of medicines (nursing), ethicolegal issues, clinical governance / quality monitoring and enhancement, documentation and the reporting of incidents and occurrences, the management of violence and aggression, admission and the safe discharge of patients Affective Support: the ability to provide support for the new registrant to address the psychological impact of the transition from student to autonomous health care practitioner
10 6.2. As identified in paragraph 3.3 there are numerous models of delivering preceptorship both locally and globally. These include programmes, not exclusively, such as: North America - Nursing Internship and or Residency Programmes. These formal programmes seek to build upon the skills developed within pre-registration programmes through a blend of classroom learning, practical rotation and supervisory support. These programmes normally of 1 year in length have been shown to reduce first post attrition and are argued to have a significant return on investment benefit New South Wales and Western Australia Newly Qualified Graduate Programme. Similarly to the North American model, these one year programmes are based on the principle of the new graduate receiving additional support and supervision from the employer within the first year of employment and a need to achieve key objectives throughout the programme. These can be salary related in a similar model to the UK KSF gateway approach model. Various approaches are utilised in its application with some having significantly less rotational experience. It is also not a standard programme across all Australian Territories or States as some choose not to offer the programme Scotland (UK) Flying Start. This programme was developed for NHS Scotland again and focuses on supporting the transition from the newly qualified graduate to the competent staff nurse. Recently further review of student outputs from Scotland have demonstrated no significant challenges for students in achieving the transition and this too must be considered by the SHA when developing its proposed investment plan for There are less formal programmes which blend induction and preceptorship such as staff nurse development programmes. These are personalised to the local organisation and can still cover a range of subject areas. One example can be found in a Northwest Mental Health Partnership Trust which has developed a new starter pack that contains - 8 -
11 information and achievable and measurable competencies in the following areas Assessment Care Planning Team & Primary Nursing Medication Mental Health Act Integrated Care Pathways Administration & Management 6.4. In the non nursing domain, a similar approach using an online methodology can be demonstrated in the induction e-learning programme for Foundation Year 1 Doctors with North Western Deanery which could be considered again as a blend of this induction and preceptorship. Although in this induction model new doctors are expected to complete a series of e-learning programmes and assessments during key phases of their induction and to report their progress within their electronic portfolio They are also provided with a supportive learning environment and clinical supervisor The SHA acknowledge that many other examples of good practice exist that support the good practice of preceptorship across the North West and these models are suggestive of the range of options that exist Additionally in this paper the SHA proposes that all 3 core aspects identified in paragraph 6.1 are embedded within the exemplars and can be mapped across so offering a methodology for testing any programmes proposed by Trusts. 7 The role of the Preceptor 7.1. Regardless of the models and approaches to Preceptorship, it is important to understand the contribution that the Preceptor makes to the successful transition of a new employee to the work environment Part of the role of the preceptor is to identify potential learning opportunities for the new staff member, help locate learning resources and provide support to work with and review development, to this effect - 9 -
12 the SHA argues that preceptorship as a process needs to be formally recorded One of the key issues in preceptorship is that preceptors may not always be aware of the learning resources available and how best to position their use within the context of preceptorship There is often little guidance about how best to structure a learning event and how to use objective assessments to assess the preceptees development, and how to meaningfully relate learning to practice. Frequently the experience for the preceptee will be directly related to the ability and the awareness level of the preceptor. The SHA outlines in paragraph 12.4 how this may be addressed There is an opportunity for NHS North West, through the clinical practice strategic workstream, to support preceptorship standards and consistency by providing access to a common (core) organized set of quality assured, generic learning resources which might be used by preceptors to support the preceptee s development. These are described later in paragraph Preparation of the Preceptor 8.1. Whilst there are no formal qualifications associated with being a preceptor, the NMC consider individuals need preparation for the role. Such preparation will ensure the preceptor demonstrates the attributes required in paragraphs This preparation may not necessarily be of the formal nature but should ensure that the preceptor: has sufficient knowledge regarding the practitioner's education and practical experience (including the content of the return to practice programme for those returning after a break) to be able to identify the practitioner's current learning needs is able to help the practitioner to apply knowledge to practice
13 understands how practitioners integrate within a new practice setting and what problems this can present for the individual and the team acts as a resource to facilitate the practitioner's professional development understands that, from the moment a practitioner is first admitted to the register, they are professionally accountable for all their own actions and omissions - the preceptor cannot be accountable on their behalf The SHA is not proposing to commission a discrete stand alone Preceptor preparation programme as it considers that this preparation can be found in a range of solutions. For example, current awareness programmes, mentor programme, coaching, clinical supervision and teaching programmes.. This is reinforced by its position highlighted in paragraph There is evidence to show within both formal and informal preceptorship programmes that, the bond with and motivation of, the preceptor has a significant impact on the successful of the transition of the new registrant and that preceptorship is most effective when the preceptee choose their own preceptor and that they have a good and trusting relationship. 9 The role of the new registrant 9.1. For successful transition to occur there are clear responsibilities for the preceptee. These include: practise in accordance with their relevant professional code of conduct: standards for conduct, performance and ethics; identifying and meeting with their preceptor as soon as possible after they have taken up post; identifying specific learning needs and developing an action plan for addressing these needs; ensuring that they understand the standards, competencies or objectives set by their employer and are required to meet;
14 reflecting on their practice and experience; seeking feedback on their performance from their preceptor and those with whom they work Drawing upon the experiences of service users and the evidence from internship, coaching and mentoring programmes it is also expected that the preceptee will be required to select their own preceptee and assure their employer that they have access to preceptorship. 10 Period of preceptorship To date only the NMC strongly recommends that as good practice all new registrants should have a formal period of preceptorship. It is also suggested that this should be about four months in duration but this may vary according to individual need and local circumstances (NMC 2006). In September 2009 however the council agreed to support the overarching principle that preceptorship would become mandatory following initial registration. Issues relating to objectives, period required, protected learning time, nature of assessed outcome and potential links to renewal of first registration are still to be explored It is less clear if any other regulator is going to require this of their registrants The SHA will not seek to define any specific time rather it will look for employers to ensure that any national guidance is adhered to. 11 The role of NHS employers The role of the employer therefore will be to ensure that best recruitment practice is adhered to for all employees including an early period of organisational induction ensure that their new employee has identified a preceptor to support their transition. It is considered best practice that they articulate their arrangements to prospective employees
15 identify a local model that ensures that the principles of preceptorship identified in paragraph 5.1 are delivered enable experienced employees to be receive training that would enable them to become potential preceptors. This is consistent with the employer responsibilities as outlined in the NHS constitution track and record progress of new employees to completion of their induction and preceptorship then continued regular performance reviews. 12 The role of the Strategic Health Authority The SHA will monitor through the Learning and Development Agreement (LDA) the number of newly qualified staff recruited by Health and Social care organisations who are in receipt of MPET funding In supporting good educational governance and assuring any investment into the training through the LDA of new qualified staff, the SHA will develop criteria based on paragraph 6.1 that can assess the extent that organisations are supporting the preceptorship of these newly qualified staff. This will include, but not exhaustively: Maintenance of personal and professional standards and development Undertaking evidence based practice Ensuring safe clinical care Effective communication with patients, relatives and the multi-professional team Patient assessment and care planning Safe and effective drug administration where required Undertaking common clinical procedures Information governance Decision making and dealing with difficult situations
16 12.3 The SHA will continue to commission those programmes that can contribute to the development of mentorship and supervision skills of clinical staff through existing post qualification contracts Furthermore for the SHA propose to Use a similar approach to the personalisation agenda set out in the Next Stages Review for patients with long term condition to support the new registrant. This process, akin to the individual learning account for non professional staff will be called a Preceptees Account for Learning (PAL). The PAL enables the individual practitioner to be allocated a personalised allowance through their employing trust to secure specific support that would be tailored to their individual needs. This would be approximately 550 per trainee (based on an average of 2850 new qualifiers per financial year). This could be used to enable staff to have additional time out in part days to obtain alternative experience, secure a learning resource to support them for example subject specific expertise or purchase a module of education or through the employer, with the agreement of the preceptees, develop a formal support network. The SHA will use the first post destination information from Professional Education and Training Database to inform this allocation methodology Enable, through the approach in , greater system alignment with both the output of the MPET review, part of the Next Stages Review implementation programme and the requirement of the NHS operating framework that all NHS Trusts who receive MPET funding are required to have a learning and development agreement Commission the development of guidance for preceptors that will inform them of the availability of local resources to support their preceptee Extend the current scope of programmes on the North West VLE to underpin the delivery of preceptorship and seek to align with the Electronic Staff Record and National Learning Management System
17 Commission and test a network of virtual preceptors supported by an electronic portfolio and communication and educational media identified in Commission ad hoc programmes, such as action learning sets, that enable organisations to reflect and subsequently develop their local infrastructure and approaches so maximising the effectiveness of support to the new registrant Undertake a preceptorship consensus building event in October 2009 that both reflects the international models and their potential application within the Northwest and the findings of this consultation. This will Trusts to review local approaches and underpin the action learning sets identified in paragraph (A draft agenda for the event is attached in appendix 1. ) 12.5 Throughout the products identified in paragraph 12.4 the SHA will be promoting the principle set out in paragraph 9.2 that preceptor selection is owned by the preceptee The product identified in paragraphs will form the basis for supporting newly qualified staff who are not directly employed by the NHS. A summary of all anticipated products can be found in appendix An overarching programme plan that captures all of these products will be available for stakeholders through the SHA website. Question 5 What challenges do you perceive with the application of a learning account methodology set out in paragraph to preceptorship? Question 6 Do you agree with the principle set out in paragraph 12.5 of incorporating the support for newly qualified staff within the preceptorship work programme? 13 Expected outcomes from this approach By supporting preceptorship in this manner the SHA will expect to recieve evidence of:
18 formal preceptorship of those staff with whom it has already made significant investment into their preparation as a registrant common goals and outcomes required by new employees applied by health and social care employers equitable access across local health communities for new registrants reduced first post attrition longer term cost benefits as identified in paragraph In developing this evidence base it is considered that the SHA is in a greater position to influence the regulatory agenda and continue to develop the workforce quality agenda across the North West. Question 7 Are there any risks that have not been highlighted, preventing the SHA achieving these outcomes? 14 Governance structures Significant resources both fiscal and staffing are anticipated to be invested into delivering this programme, requiring demonstrable organisational commitment both from the SHA and service providers. This requires the SHA to deliver a transparent and robust governance system The governance system will focus on the following areas: Programme oversight and scrutiny Financial assurance User experience Quality control of product suites Communication of and transparency in reporting progress
19 14.3. Programme oversight and scrutiny will be provided through the regional nursing workforce board. This board meets quarterly and consists of the following stakeholders: NHS Directors of Nursing x Director of Workforce HE representatives x Practice Education Facilitator x Lay member x The regional nursing workforce programme board will be supported by a secretariat of the following: SHA nursing directorate member x SHA workforce directorate member x Skills for Health academy member x Programme project manager Financial governance will be assured through: the electronic expenditure plan including onsite audits by the regional nursing workforce programme board secretariat. This is likely to be aligned with existing Educational Governance processes publication of expenditure plan and quarterly report of spend against plan to the Nursing Workforce Programme Board and the Directors of Nursing network external quarterly reporting to Department of Health appliance of the SHAs standing financial instructions and orders
20 14.6. The SHA is required to report quarterly to the Department of Health on progress User experience will be assured through existing Educational Governance processes although it is anticipated that each programme product line will enable user experience testing to be embedded within it. The programme manager will be responsible for collating an annual report that summarises these experiences As stated earlier the SHA intends to develop a suite of products that underpin this programme. It is anticipated that each product will be delivered using good project management techniques and discreet project steering oversight. As with user experience it is anticipated that each programme product line will embed quality assurance testing within their project plan and maintain a quality log. The programme manager will be responsible for collating and reporting progress and quality issues to the Nursing Workforce Programme board Transparency and clarity of process is the overriding principle that will underpin this programme. As identified regular reporting will be made to the Nursing Workforce Programme board supported by regular briefing to the key stakeholder groups. These briefings will be made available online through the SHA website and are included in the SHAs freedom of information publication scheme. In addition summarised progress reports will be made available to forthcoming conferences and stakeholder events. Question 8 Are there any governance processes outlined sufficiently robust to assure delivery of the programme as described? 15 Consultation questions A summary of all the consultation questions are outlined below. Question 1 Do you agree with the principle that the SHA intends to adopt which sees only programmes or activities that have this multi-professional focus being eligible to receive support
21 Question 2 Do you agree with the benefits that the SHA argues are delivered through preceptorship? Question 3 Can you give examples of any benefits that you have evidenced within your organisation? Question 4 Do you foresee any significant risks associated with these exclusions? Question 5 What challenges do you perceive with the application of a learning account methodology to preceptorship? Question 6 Do you agree with the principle of incorporating the support for newly qualified staff within the preceptorship work programme? Question 7 Are there any risks that have not been highlighted preventing the SHA achieving these outcomes? Question 8 Are there any governance processes outlined sufficiently robust to assure delivery of the programme as described? 16 Conclusion Although preceptorship has been recognised as beneficial for a significant time, the application of approach and access has not been consistent for new employees to the NHS It is highly probable, following the recent consultation by the NMC that further stronger regulator guidance is to be developed The SHA has identified significant resource to support the application of preceptorship so that the NHS in the North West is seen as an employer of choice and best practice The SHA wishes to be in strong evidence driven position to influence the national agenda In taking forward this consultation on the proposed approach it is believed that a system will exist that provides fair and equitable access, increased employer and employee accountability and most importantly a safer environment for patients in the receipt of health care in the North West
22 Appendix 1 Preceptorship Conference Global Perspectives on Supporting Newly Qualified Nurse and Midwives Date Autumn 2009 Opening Jane Cummings Speaker from NMC/DH 2 Speaker from Australia (1 Victoria and 1 New South Wales) Possible 1 Federal Government perspective and 1 State Government Perspective structure. 1 Speaker from US Lessons Learned from the Application of Preceptorship to Medical Trainees Flying Start NHS Primary Care Speaker from Scotland Graham Congdon Edge Hill Formal Academic Programmes to support Preceptorship. Workshop on SHA proposals for NW Preceptorship Guidelines. Cost including venue, catering for delegates plus travel/accommodation for speakers: 15k
23 Appendix 2 Anticipated Preceptorship products By 31 March 2010 the SHA will have enabled the following products to be available: A payment system that invests into NHS organisations directly the number of preceptorship accounts for learning in accordance with their anticipated newly qualified staff. A criterion based assurance system aligned to the learning and developing agreement performance management A suite of guidance available for both preceptor and preceptee A suite of programmes available through the NW virtual learning environment that can support the development of further knowledge in the new registrant pertinent to their experience An e-portfolio system aligned to the national learning management system or local infrastructure including personal development plans/ksf A network of virtual preceptors Cross organisational action learning sets
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