Framework for Nursing in General Practice
6 Learning & Personal Development
A hallmark of a good employer can be seen in the importance that is attached to personal development and continuing education. The training and development of staff can bring significant benefits for both the employee and the employer and most importantly should result in improved standards of care for the patient. This is reflected in the new GMS contract which states that all staff should "have access to appropriate training, professional advice and continuing professional development" and "all practice-employed nurses are supported to participate in clinical supervision and appraisal". The quality and outcomes framework of the new GMS contract awards quality points for ensuring that practice nurses have an annual appraisal and personal learning plan.
As the boundaries of practice continue to expand, appropriate education to underpin role development is essential. It is clear from discussions with practice nurses that there is a need to identify more creative and innovative solutions to learning, that will support practice nurses in their ongoing training and development and equip them the right skills and knowledge to deliver the services required.
This chapter is based on standards 4.1 covering appraisal, personal development planning and access to continuing professional development and 4.2 covering opportunities for clinical supervision and reflective learning.
Many different titles have been given to the process of reviewing performance and identifying development needs, including appraisal, personal development planning and performance review. For simplicity and so as to avoid confusion, appraisal is used throughout this section, but the detail draws heavily on the Partnership Information Network (PIN) Guideline on Personal Development Planning and Review: http://www.show.scot.nhs.uk/psu/documents/PDPs%20&%20rev.pdf
The appraisal process is part of a continual process of planning, monitoring, assessment and support to help staff develop their skills and be more effective in their role. The annual appraisal interview sits at the heart of the process. There is evidence both within the NHS and industry that an effective appraisal process increases the effectiveness of the organisation.
The appraisal process should be seen as a positive approach to development. It is not:
About creating unrealistic expectations or rewards
A vehicle for evaluating/increasing pay entitlements.
To be used as a counselling exercise for non-learning and development issues.
A variant or sub set of disciplinary procedures.
A substitute for the reviewer's responsibility to provide ongoing feedback to staff.
The appraisal process
The appraisal process essentially has four key stages:
A self assessment by the individual of strengths and development needs
A structured discussion with the appraiser based on the self assessment
An agreed personal development plan which flows from the appraisal discussion
Action to meet the learning needs identified in the personal development plan.
A model self assessment and appraisal form developed from the PIN guideline is included on the CD ROM. Essentially this encourages the nurse to reflect on the period since the last appraisal, to review achievements, strengths and development needs as well as future career aspirations.
The formal appraisal is an opportunity for the practice nurse to discuss with the appraiser their own and the appraisers perceptions of achievements over the last year and development needs. The completed self assessment forms a starting point to this discussion.
It is very important that everyone involved has trust in the confidentiality of the appraisal interview and the documentation surrounding it. It is essential to foster confidence in the integrity of the process not least because it will encourage both appraisee and appraiser to be as frank and open as possible. The only exception to this would be where issues emerge which indicate that the appraisee is in breach of the NMC Code of Professional Conduct, or where issues are identified that might compromise patient safety
Appraisal interviews typically take 60-90 minutes. It is important that time is committed to the process if it is to offer an opportunity for positive discussion.
The outcome of the appraisal interview should be an agreement on objectives and development needs for the year. A record of the interview should be signed and copies kept by the person being appraised and on the staff file.
Who should be the appraiser?
There are a number of options, which practices and practice nurses may need to consider in order to get the best out of the appraisal process.
Possible options include:
1. A senior nurse within the practice team. This may be the best option where there is an identified nurse with responsibility for leading the team, or for appraisal of staff nurses or health care assistants. In order to work effectively, the practice would need to be prepared to support development plans identified from the process and the appraiser would need to be well informed on the practice's plans and priorities.
2. Practice manager or GP. This option has the benefit of ensuring that the practice nurse's objectives fit within the overall practice plans and giving a practice commitment to development plans. However, expertise in professional nursing issues will be lacking, which may make it more difficult to agree an appropriate development plan or to appropriately explore and challenge the nurses self assessment.
3. A senior nurse external to the practice. This option is essentially similar to the GP appraisal model and would ensure appropriate professional input to the process. However, the nurse appraiser is unlikely to know the practice well, so would be unable to agree appropriate objectives with the nurse and could not commit practice funds to meeting any agreed development plan.
4. A combination of 2 and 3. This option essentially would involve a professional component of the appraisal taking place with an external appraiser, with a discussion within the practice to agree the coming years work objectives and to sign off the personal development plan.
In considering these, the most important points to consider are:
The nurse needs to be confident in the person identified as appraiser
The practice must have confidence in the appraiser if they are to commit to meeting the identified development needs
The appraiser needs to be prepared to take on the role and should have had some training as an appraiser.
Local NHS Boards will have available training for both appraisers and appraisees and should make this available to practice staff in order to support the development of practice nurse appraisal.
Personal Development Plan
The personal development plan is the most important output from the appraisal process. It is a record of what the individual nurse needs to do in order to effectively fulfil their role. It is important that plans are reasonable and achievable rather than extensive wish lists. They should be directly based on the strategic direction and plans of the practice and reflect the needs of the practice and patients. Obviously personal development plans will also reflect the individual nurse's own career aspirations and there may need to be an agreement between the nurse and the practice on which aspects of the PDP each will support.
A model PDP template is included on the CD ROM. This is derived from the PIN guideline and clearly separates those development needs that are associated with the current role and those that are about the individual's career aspirations. The PDP should be signed off by both the practice and the nurse and copies kept by each as a means of reviewing achievement of the plan.
Action to meet the identified learning needs
This final stage of the process takes place throughout the remainder of the year. Much of the rest of this chapter is devoted to identifying varied approaches to learning and development and making connections to available resources and education. The emphasis should always be on identifying learning opportunities that best meet the needs of the nurse as identified in the PDP. These may not always be attending a formal course.
Protected time for learning
The new GMS contract highlights the importance of supporting learning and development through giving protected time to all team members. Agreeing a personal development plan forms a good basis for deciding on appropriate time out for learning. A big challenge for many practices in negotiating time out for learning is the lack of adequately trained relief staff. Some Boards have started to develop practice nurse banks, although coverage remains quite poor. NHS boards working with local practices should consider the potential to further develop a cohort of practice nursing bank staff to enable practice nurses to take time out for learning. In practice this may mean that existing part time practice nurses would undertake bank duties as well. To be effective practices would need to be open to this model and enable their staff to work elsewhere.
Professional requirements for education
Pre-registration education prepares nurses for initial registration. Continuing professional development is linked to the registration renewal process through the NMC Post Registration Education and Practice (PREP) standards. The PREP requirements are a statutory requirement for all nursing staff. In order to meet the standard nurses must undertake at least five days
(35 hours) of learning activity relevant to their practice during the three years prior to their renewal of registration, maintain a personal professional profile of this learning activity and comply with any request from the NMC to audit compliance with these activities. Furthermore, all registered nurses need to have completed a minimum of 100 days (750) hours of practice during five years prior to renewal of registration.
Any experience can result in learning, the important point is that it is adequately documented in a Personal Professional Profile (PPP). NMC highlight the following points in relation to CPD:
it doesn't have to cost any money
there is no such thing as approved PREP (CPD) learning activity
there is no need to collect points or certificates of attendance
there is no approved format for the personal professional profile
it must be relevant to the work the nurse is doing and/or plans to do in the near future
it must help the nurse to provide the highest possible standards of care for her/his patients.
A model form for maintaining a PPP is attached in the annexes derived from an NMC example. Further guidance is available in the PREP handbook: http://www.nmc-uk.org/nmc/main/publications/thePrepHandbook.pdf
It must be remembered that the PREP standard of 35 hours learning over 3 years is a minimum standard and achieving it does not necessarily mean that the nurse is competent to practice, particularly where roles have expanded and evolved. All practice needs to be underpinned by appropriate education and nurses should never undertake work that they do not feel competent to safely perform.
The role of NHS Boards and CHPs in supporting practice nursing development
Although practice nurses remain the employees of individual practices, who have the responsibility to provide them with appropriate education, there is an important role that NHS Boards and the emerging CHPs can play in supporting practice nursing development. Firstly they can open up in house education provision to practice staff. Many NHS boards have already done this with consequent benefits in terms of sharing experience and understanding as well as improved practice nurse education. Secondly, there is a potential role in providing professional leadership to practice nurses. This topic is explored further in chapter 5. In relation to education and development that role might include contributing to the appraisal process, advising practice nurses and practices on appropriate education and facilitating learning opportunities, in particular clinical supervision, which would need to be organised at CHP or Board level.
Methods of learning and personal development
Knowledge, skills and competence can be acquired from a variety of formal and informal learning activities. Identifying and attributing appropriate value to all these experiences is an
important step in any CPD process.
Four aspects of learning opportunities are outlined below:
Formal learning opportunities
Competence based learning
Experiential and work based learning
Self directed learning
It is important to recognise that none of these are mutually exclusive. For example, self directed learning and work based learning will often be part of formal learning opportunities. They have been separated out to illustrate the wide range of opportunities to learn.
Formal learning opportunities
Formal learning opportunities are those leading to some form of academic or professional award. Programmes may vary from distance learning programmes, through short courses to undergraduate or post graduate degree programmes. The range and depth of potential topics varies too widely to discuss in detail. A summary of some of the main Scottish programmes leading to a formal qualification that may be of relevance to practice nurses is available in Annex B. In addition, all Scottish universities offer a range of short modules on a wide variety of relevant topics. Further details are available from the universities.
Specialist Practice Qualification in General Practice Nursing
There is a specialist practice education programme in general practice nursing. This is a degree level programme leading to a recorded qualification on the NMC register. It can be taken over one year full time, or up to four years on a part time basis. It is currently the only professionally accredited programme of its type for practice nurses and provides a sound theoretical and practical basis for practice at specialist level. Unlike district nursing and health visiting, it is not a formal requirement to hold the qualification in order to practice. In Scotland, the programme operates at three universities. The programme provides a firm foundation for practice nursing, although given the vast scope of practice nursing roles it cannot hope to encompass the range of specialist clinical areas that practice nurses increasingly need to be proficient in. The NMC is currently reviewing post registration nurse education and will make recommendations in due course. These will need to be considered in planning any future development for practice nurses.
Competence based learning
Competence based learning starts with a description of the competencies required to be proficient in an area of practice and provides a means for the practitioner to identify current knowledge and skills against the competencies and to identify any gaps, which can then be filled in a variety of ways. The benefit of competence based learning is that having the competence is equally valid, no matter how it was acquired, so competence gained through practice, personal learning and experience carries the same weight as that acquired through formal education.
NHS Education for Scotland has developed competencies in a range of areas directly relevant to practice nurses. These frameworks are entitled "A Route to Enhanced Competence". Topics include:
Nurse Practitioners working in Minor Injury units, A&E & Community Hospital Casualty Departments
Caring for patients with epilepsy
Caring for patients with diabetes
Caring for older people
All of these frameworks set out competencies necessary to be proficient in the defined area and use a portfolio route towards demonstrating that competence. The benefit of this approach is that it can be largely work based and focuses on identifying existing strengths then filling gaps in competence.
The NES portfolio route essentially defines five steps:
1. Review experience and practice to date identifying existing knowledge and skills against the competencies set out.
2. Appraise level of competence and identify existing strengths and development needs
3. Agree an appropriate training programme to meet identified needs
4. Set goals and devise an action plan in partnership with a facilitator, who has expertise in the field.
5. Provide evidence of achievement using a portfolio of evidence.
The full range of competency frameworks and a portfolio are available from http://www.qacpd.org.uk. RCN have also developed a range of competency frameworks available from http://www.rcn.org.uk.
In addition, recent work on developing multi-disciplinary primary care out of hours services published by NHS Education for Scotland as "Out of Hours a Framework for Care", http://www.nes.scot.nhs.uk/multi sets out a range of competencies, many of which will be directly applicable to practice nurses and provides direct links to appropriate educational programmes to meet the competencies, where they exist.
Experiential and work based learning
Experiential and work based learning have been an important drivers in nursing education in recent years and often make up part of formal education programmes. However, they can equally well be used alone to develop new skills and competence. This section explores a variety of means that can be used to support work based or experiential learning.
An experienced nurse mentor can be assigned to a new practice nurse or where a nurse is taking on new duties. The mentor can facilitate personal and professional development through encouraging reflection, identifying gaps in knowledge and skills and providing structured feedback to enable the nurse to develop and expand their practice with safety and confidence
Work shadowing is designed to allow practitioners undergoing professional development to gain knowledge and understanding about the work of a colleague in a similar position in order to enable them to understand better their own context, situation, position, tasks and job purpose. The value of this type of learning is in providing the practitioner with a very real insight into the role of a particular post.
Secondments are a useful way for nurses to gain valuable experience without giving up their current post. They offer opportunities to acquire new skills, qualifications and facilitate professional development. Practices should look upon these favourably because of the potential value of the skills that can be gained and brought back to the practice.
Significant event analysis
The Quality and Outcomes Framework of new GMS rewards practices for undertaking significant event reviews. Involving practice nurses in the process will introduce different professional perspectives on an incident as well as contributing to the whole team's education.
Problem or random case analysis is a learning activity which is commonly used with GP registrar training. It is often undertaken informally with between GP partners and registrars and peers This is a powerful learning tool and can both promote shared learning and help to identify learning needs.
Practice based audit
Audit activity is a useful way of considering clinical and operational issues within the team. Reviewing findings provides a good opportunity for the team to learn together as well as highlight further learning needs for the team or individuals.
Self -Directed Learning
Self directed learning is a process whereby the learner takes the initiative and responsibility for the learning process. It requires no formal teaching input and can be facilitated by a range of methods and resources. The internet provides a powerful resource for educational purposes. Annex C lists a range of web based educational resources that may be of interest to practice nurses. It is not exhaustive but provides a useful starting point for both reference and education.
Reflective practice can be described as the cornerstone of continuous professional development. Participating in reflective practice will help the nurse to identify learning and evaluate her/his current practice. It will also enhance self-awareness and confidence and can help to evaluate current practice. The NHS QIS publication "A Practical Guide for Nurses and Midwives Working Towards The Quality Practice Award" ( http://www.nhshealthquality.org/nhsqis/files/qpaguide.pdf ) provides useful background on reflective practice. Reflecting on actions and incidents and recording the reflections in a diary is one way of demonstrating learning. It is important that reflective diaries remain confidential to the individual, but themes and issues identified can provide a useful basis to support clinicaal supervision. Clinical supervision provides a more structured focus on reflective learning, by enabling nurses to reflect on incidents with peers.
The new GMS contract states that nurses should have access to clinical supervision. "Clinical supervision aims to bring practitioners and skilled supervisors together to reflect on practice, to identify solutions to problems, to increase understanding of professional issues and, most importantly, to improve standards of care". (NMC 2002). Although the NMC has not made clinical supervision a statutory requirement, they strongly endorse it as a means to assist practitioners to develop skills, knowledge and professional values throughout their career and working lives and as an important component of good clinical governance.
Essentially clinical supervision is a regular opportunity for structured confidential discussion either individually or in small groups with a supervisor who is a professional peer. Whilst there is no right or wrong model of supervision, the NMC have set out a series of principles that should underpin any system of clinical supervision:
Clinical supervision supports practice, enabling the nurse to maintain and improve standards of care.
Clinical supervision is a practice focused professional relationship, involving a practitioner reflecting on practice guided by a skilled supervisor.
The process of clinical supervision should be developed by practitioners and managers according to local circumstances. Ground rules should be agreed so that the nurse and supervisor can approach clinical supervision openly, confidently and are both aware of what is involved.
Every practitioner should have access to clinical supervision. Each supervisor should supervise a realistic number of practitioners.
Preparation for supervisors should be flexible and sensitive to local circumstances. The principles and relevance of clinical supervision should be included in pre-registration and post registration education programmes.
Local evaluation of clinical supervision is needed to assess how it influences care and practice standards.
Implementing clinical supervision
It would not be easy, if indeed possible, for an individual practice to implement clinical supervision alone. To be effective, supervision requires the supervisor to be someone outside of the usual day to day working arrangements. However, most NHS Boards have developed clinical supervision to some extent. Any development of clinical supervision for practice nurses could most appropriately take place at CHP level. However, it should also be clear that clinical supervision would require active support from practices, both in supporting time out for their nurses (typically an hour every 6-8 weeks) and in a reciprocal agreement supporting their own nurses to supervise other practice nurses.
In addition to learning needs identified as part of a personal development plan, there are a number of areas where all professionals need regular updating. Some of these are set out in the Quality & Outcomes Framework of the GMS contract. They include:
Practices need to have systems in place to ensure that these regular updates take place or else link into local NHS Board training on these issues.