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Community: the fifth field?

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Practice nursing is a rich training ground Practice nursing is a rich training ground

Practice nursing is one of the only nursing groups without a clear route into the profession. When Lord Willis was conducting research for the Shape of Caring Review1 he found that practice nursing was a sector that was not being used for nurse education and training. 'It is such a rich training ground for students and that's an absolutely essential area if we are going to develop more community and primary based healthcare,' Lord Willis told IN.

The Shape of Caring Review lists a number of recommendations that can improve nursing education and training to create a more robust workforce for the future.

A recommendation that will resonate with practice and community nurses is the proposal to widen the fields of undergraduate nursing education (adult, children, mental health and learning disabilities) to include practice and community nursing.

The idea aims to increase the number of newly registered nurses going straight into practice and to dispel the myth that practice nursing is a profession for more experienced nurses.

Yvonne Sawbridge, a senior fellow at the University of Birmingham and a former nurse, says: 'I've heard people say that they want to become practice nurses but aren't clear what the route into it is. It is not traditionally seen as a career to go into straight from registration and because of the current model of general practice there is no incentive to take on newly registered nurses, pay for their training and then have them leave after two or three years.

'I think expanding the fields of nursing to include practice nursing will help that and encourage more students to go straight into practice. There is no reason why they can't.'

Lord Willis says that he has asked the NMC to look at the four fields of nursing model with a view to adding a fifth strand of primary and community nursing1 to create a nursing workforce that is more versatile.

It seems this change would be welcomed by practice nurses and educators. The Council of Deans of Health also previously called for debate on the four fields of nursing.2 However, issues around clear routes, lack of placements and mentors would need to be addressed in order to ensure that this change would produce highly-skilled and competent practice and community nurses.

Delivering generalised care

A proposed model of education put forward in the Shape of Caring Review is that students undertake two
years of general nursing training and then a third year in a chosen specialism such as children's mental health and learning disabilities and, if approved, practice and community nursing. The idea behind this, says Lord Willis, is to ensure that all nurses have a standard set of skills applicable to any setting before they complete a year focused on their chosen specialism.

'We are currently producing mental health nurses who are not very confident in dealing with physical health problems such as taking blood, and adult and children's nurses who don't feel confident in dealing with mental health. The reality is that they are not mutually exclusive. So we need to try and develop a nursing workforce that has a much greater depth of understanding of both physical and mental health,' he says.

Jackie Smith, chief executive of the NMC, thinks it is a possibility that the fifth field could be implemented.'We will be taking our time to consider that,' she says. We do welcome the recommendations in the report. The NMC is currently doing an evaluation of its pre- registration standards for nursing which will finish in the autumn. That's the point at which we will decide whether to adopt the recommendation set out in the Shape of Caring Review.'

Practice nursing framework

As well as the introduction of practice and community nursing into undergraduate training, HEE is also working on a career and development plan for general practice nursing. The framework will be based around the four central pillars of practice described in the advanced practice toolkit3: leadership, facilitation of learning, research and development, and clinical practice.

The Shape of Caring Review states that this model would still 'allow for continuation of the current four fields of practice, complemented by a new field of community nursing that would incorporate district nursing, GP practice nursing, school nursing and health visiting'.

However, Ms Sawbridge says: 'Health visiting, school nursing, district nursing and practice nursing couldn't be more different. To equip people to come off a registered nursing course to be able to do each of those equally would need a lot of thinking through. Although you could argue that midwifery is direct entry so maybe health visiting could be.'

Marie-Therese Massey, a senior lecturer in adult nursing at Sheffield Hallam University and chair of the RCN's Practice Nurse Association, says that she has been involved in some of the meetings around the creation of the framework, and the findings are due to be released within the next few months.


One of the key issues in ensuring that education for students reflects the diversity of practice and community nursing is to ensure that more placements are available for students at an earlier stage.

Jessica Corner, chair of the Council of Deans of Health, says: 'We are increasingly trying to figure out how best to support training and to increase community placements and the proportion of students that go over to the community.' Ms Corner says that there is already a requirement for universities to provide placements in the community but that there are obstacles. 'These may be because payment for placements hasn't yet followed the need,' she says.

Ms Sawbridge agrees with Ms Corner. 'I used to be a director of nursing and primary care and not everyone knew about all the different fields of nursing. If they can't get a practice nurse placement then they don't really know what it involves.

'Practices receive more money to have medical students and trainee GPs than they do for nurse placements. Some money has been given with some funding freedom for placing nurses in the community and in practice but it's not very much and it's not likely to cover [a practice's] costs.'

As well as a lack of placements in general practice, mentorship and preceptorship in general practice were other areas that were identified as needing improving.

As well as requiring support from GPs and practice managers to facilitate students, practice nurses themselves can play a key role in supporting students. The Shape of Caring Review identifies that 'we need to radically rethink our mentorship philosophy, and whether the current model is fit to support student learning in high-quality learning environments'. The RCN is currently working on reviewing mentorship for all nurses, not just nurses in primary care.

'Practice nurses themselves should be prepared to become mentors or do mentorship courses to be able to give their time and expertise to student nurses. It can only be successful if the people on the ground accept that if they want a competent future workforce they will have to play their part,' says Ms Massey.

'Increasing the fields of nursing to include practice and community nursing is good, but it needs some thinking through. Good preceptorship would be crucial and that's really hard in practice nursing,' agrees Ms Sawbridge.

GPs have a clear period of mentorship after graduating, yet practice nurses do not, says Marie Hill, senior lecturer in practice nursing at City University. 'It's important to have the academic rigour of a good programme but also to have competent mentor support within a general practice setting ,' she says.

Lord Willis says that he has asked for a 'radical overhaul of the preceptorship model', which would mean that all nurses would receive a year of preceptorship straight after graduation.

Recognising that practice nursing training is in need of an overhaul is the first step in fixing it. Bringing in new nurses is crucial to ensuring that community care, public health and early intervention is secure for the future. But practice and community nursing is in danger of losing a large proportion of the workforce within the next ten years. The challenge will be making the most of their experience, expertise and knowledge to provide quality mentors and preceptorships to those just beginning their careers.


1. Raising the Bar. Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants. March 2015.

2. Council of Deans of Health. December 2014

3. Advanced practice toolkit

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