Previous research relating to student veterinary nurse (SVN) support in practice has been published in the Journal of Veterinary Medical Education (Holt et al, 2021; 2022a). The aim of this two-part article is to disseminate the key information from this previously published work and draw on the combined experience of the current authors relating to the role of the clinical supervisor and the training practice team in the clinical learning environment (CLE).
Part one published in the previous issue discussed the role of the clinical supervisor when supporting students in practice (Holt et al, 2022b). Part two will discuss the training practice as a whole and how elements in the CLE can impact student training and development.
Training practice environment
The authors could find limited articles detailing the experience of SVNs in the CLE. The veterinary nursing profession could therefore look to the literature currently available in student human nurses' (SHNs) experiences of the CLE. A pedagogically supportive and friendly environment is vital in ensuring quality teaching and learning outcomes (Perram et al, 2016; Phillips et al, 2017). However, SHNs have reported that the CLE they experience does not always match the positive environment they would favour (Phillips et al, 2017). First experiences within a CLE will be daunting for most, and have been reported to create anticipatory fear in SHNs (Rajeswaran, 2016; Gray and Smith, 2000). The wider professional staff, who are present in the CLE alongside SHNs, can also affect the learning experience (O'Mara et al, 2014). An unsupportive atmosphere among the team, leading to poor relationships — including negative attitudes to the presence of SHNs — has also been found to cause feelings of inferiority in students (Rajeswaran, 2016; Kalyani et al, 2019). In addition, environmental factors such as a busy workload and too many students on the ward have also been reported by SHNs (Chuan and Barnett, 2012; O'Mara et al, 2014; Arkan et al, 2018). Failure to identify and address student concerns within the SHN CLE can lead to a decrease in professional growth and development (Kalyani et al, 2019). A 2021 RCVS Mind Matters Initiative survey of student veterinary nurses, recently graduated veterinary nurses, and clinical supervisors showed that 96% of respondents felt that bullying was a serious problem within the profession (Silverwood, 2021). This collective evidence should provide a rationale for the veterinary nursing profession to seek the opinions of SVNs relating to their CLE to highlight any areas of concern.
The negative impacts of a poor CLE can include reduced learning opportunities and confidence, poor mental health and dissatisfaction among SHNs, and have been shown to lead to increased attrition (Chuan and Barnett, 2012; O'Mara et al, 2014; Flott and Linden, 2016; Jamshidi et al, 2016). It is important to ensure that the CLE is managed positively to build confidence and encourage SHN engagement with learning opportunities (Jamshidi et al, 2016). Research involving a range of health profession training environments has shown that identifying areas of concern can lead to the development of appropriate improvement strategies (Perram et al, 2016; Habboush et al, 2019; Clarke et al, 2020).
Student experience feedback
It is clear that the responsibility for training in the CLE cannot solely lie with the clinical supervisor. To become an approved training practice (TP), a veterinary practice must meet specific requirements relating to physical and human resources and clinical caseload (Royal College of Veterinary Surgeons (RCVS), 2021). These aspects, such as how many consultations and operations are conducted each week, are tangible and are easy to check and evaluate during an accredited educational institute (AEI) internal quality assurer (IQA) approval visit using a visit check form. These forms may vary slightly between AEIs, but all will check systematically through the RCVS TP requirements. Currently, there is a lack of available research investigating the SVN satisfaction and experiences with the CLE. Although individual AEIs may gather SVN feedback, this is not systematically collected and may not be universally applicable. Holt et al (2022a) developed an instrument, the SVN Clinical Learning Environment Inventory (CLEI), to allow systematic evaluation of the SVN experience of the CLE.
The SVN CLEI was developed using three existing inventories in human nursing, which were adapted to suit the veterinary setting (Saarikoski et al, 2005; Newton et al, 2010; Chuan and Barnett, 2012). The inventory was then validated following 271 responses from SVNs using principal component analysis to produce the final validated inventory (Holt et al, 2022a). Appendix 1 provides the SVN CLEI, which contains 25 questions across three factors:
- Clinical supervisor support of learning
- Pedagogical atmosphere of the practice
- Opportunities for engagement.
The SVN CLEI has shown an acceptable level of reliability and validity during principal component analysis, in line with similar published instruments for SHNs (Saarikoski et al, 2005; Newton et al, 2010; Salamonson et al, 2011; Chuan and Barnett, 2012). Therefore, this can be considered acceptable to measure the student perception of the sociocultural aspects of the CLE. The new inventory can be used by AEIs or large practice groups (where student anonymity can be assured), to gain valuable insight into student perceptions and satisfaction with their clinical training. This will complement the TP visit form currently used by AEIs and also cover specific requirements for student feedback outlined in the RCVS standards framework for veterinary nurse education and training, standard three, student empowerment. Examples include requirements 3.13, 3.15 and 3.18 (Box 1). The SVN CLEI is currently only recommended for use in UK TPs, because of the adaptations and validation being conducted with only UK SVN training in mind and only UK SVNs completing the inventory for validation. TPs can refer to the SVN CLEI factors as a ‘check list’ to ensure they are providing appropriate support of the learning environment across all three factors.
Box 1.RCVS standards framework for veterinary nurse education and training. Sample of requirementsStandard 3 — Student Empowerment3.8: are allocated and can make use of supported learning time including blended learning and recording completion of RCVS Day One Skills for Veterinary Nursing when in practice3.13: are protected from discrimination, harassment and other behaviour that undermines their performance or confidence3.15: are provided with the learning and pastoral support necessary to empower them to prepare for independent, reflective professional practice3.18: have opportunities throughout their programme to give feedback on the quality of all aspects of their support and supervision in both theory and practiceStandard 4 — Educators and Assessors4.6: are supportive and objective in their approach to student supervision, assessment and progression, and appropriately share and use evidence to make decisions on student assessment and progression4.7: liaise, collaborate and action constructive feedback generated by colleagues, students and stakeholders to enhance their teaching and assessment and to share effective practice4.8: are expected to respond effectively to concerns and complaints about public protection, animal welfare and student performance in learning environments and are supported in doing so
Training practice engagement and support
TPs are accountable for the local delivery and management of the clinical learning element of accredited veterinary nursing programmes, in line with the RCVS (2021) standards framework. Through the IQA process, AEIs check that required standards are being met, emphasising the need for the practice to engage with the AEI. Part of this process requires the AEI to conduct a TP visit at least annually, but more frequently if a need for support is identified. Additional support may be offered if the practice is new to training, or a newly qualified clinical supervisor has been appointed. The role of an IQA is to standardise the student experience in the CLE, ensuring that all students have the same opportunity to succeed. The IQA will provide constructive feedback on how to achieve the required standards expected in the framework and the relevant documents to support this process. These documents facilitate a successful working and training relationship for all involved with SVN support and may include:
- Memorandum of understanding — outlining the agreement between the AEI and TP, and the expectations of the relationship
- Templates for student agreements and contracts — outlining the agreement between the student and TP and the expectations of the relationship
- Planning and student support guidance — individual AEIs are responsible for creating guidance on logging skills for the student and clinical supervisor to enable appropriate documentation of practical competency
- Witness sheets — support the SVN gathering evidence when the clinical supervisor is not present
- Templates — attendance records, behavioural tools, induction and planning, and tutorial records
- Other documents — additional support such as care plan templates or the World Small Animal Veterinary Association (WSAVA) nutritional guidelines.
Professional witnesses can be used to help manage clinical supervisor workload, in their absence for specific skills. Veterinary surgeons or registered veterinary nurses (RVNs) can contribute to the process by either demonstrating skills or observing the student undertaking individual skills and making competency decisions (Figure 1). Clinical supervisor and SVN planning, can identify cases and set up witnesses as required. Witness sheets can be used to document these direct observations on the student's online tool (Figure 2). Although only one clinical supervisor can be allocated to an SVN, witness sheets facilitate a more adaptable team approach and as a result SVN progress is not limited by the availability of just the clinical supervisor.
Practices are responsible for maintaining records and evidencing support for each student. These records should include weekly tutorials to write action plans based on the GROW model, discussed in part 1 (Holt et al, 2022b). Meetings should be recorded in writing with all parties signing to agree with the content, enabling later reflection and review.
During practice meetings, it is important to include SVN training as an item on the agenda to involve and engage the whole team with the ethos of a training culture. Student matters and feedback from the AEI can also be disseminated to the practice team, providing evidence of student support in the meeting minutes; a requirement for standards 4.6, 4.7 and 4.8, of the RCVS standards frame-work for veterinary nurse education and training (Box 1). Care must be taken to ensure that personal or sensitive matters are not shared with the wider team, unless the student has consented to this, and that a student's progress is not discussed in front of other students.
Collegial team support for the clinical supervisor and SVN
A strong support network in practice is a key factor in enabling nurses to thrive (Hill, 2022). Making decisions on SVN practical competency and understanding the role of the clinical supervisor can be daunting initially but there are several opportunities for the practice to provide support. A collaborative team approach is needed, with more experienced clinical supervisors mentoring newly trained professionals where possible.
The clinical supervisor and SVN can be supported effectively by having protected time to undertake training and record completion of RCVS Day One Skills (DOS) as per Standard 3.8 of the RCVS standards framework for veterinary nurse education and training (Box 1). It is appreciated that in a busy clinical setting, this can prove challenging to manage. Adding this time to the nursing rota can help to manage this and ensure that all staff are aware of the requirement. AEIs will check that this time has been evidenced and is therefore auditable as part of their IQA process. It is suggested that it is evidenced through practice rotas or documented directly on the SVN's online tool. Student and clinical supervisor feedback will also be taken into account in this process.
Student learning can be promoted by having a practice ethos of undertaking evidence-based veterinary medicine (EBVM), having clear guidance and protocols around patient and client support, and using veterinary terminology throughout the working day. Students are then better able to translate classroom teaching to clinical learning and reduce the disconnect between academic ideals and real-life applications, which has been reported in human nursing (Flood and Robinia, 2014). Applying an EBVM approach, including use of appropriate terminology, also ensures that the team stays current through continued professional development, which in turn, improves patient and client care.
Notice boards in working areas can be used to document skills currently being focused on by students, maximising the opportunities for students to gather evidence with the support of the whole team. Adopting a collegial approach to providing the student with timely constructive feedback and peer modelling to observe desired behaviours in the clinical environment will be beneficial for all parties in the CLE. Leading by example and being an effective role model for the student are important attributes in all staff members. Consider, for example, a student using a mobile phone in the clinical environment. It is more challenging to deal with this situation effectively if the SVN has witnessed other staff members exhibiting the same behaviour. Team members are role models for the student. Clear, consistent policies are needed, coupled with trust and effective communication, where team goals are clear to all. Positive role models and clear policies and guidance then facilitate timely, constructive feedback to students when their behaviour is unprofessional and/or undesirable.
Developing a positive culture
The global pandemic has significantly strained mental health and wellbeing, affecting people's work effectiveness, relationships with colleagues and connections to their world (Robinson, 2022). More than ever, a collegial, holistic team approach is needed to support SVNs. Being inclusive and involving students in team meetings and clinical discussions can build confidence and promote understanding. As students gain confidence, they can be encouraged to reflect on their involvement with cases, by an approachable team that affords students a safe space to engage with learning opportunities (Figure 3).
The RCVS standards framework for veterinary nurse education and training sets out the standard, values, knowledge and behaviours required of AEIs and TPs. Standard 1 relates to learning culture and expects that we prioritise the wellbeing of people. Ways for a practice to evidence that they have complied with this standard could include a nominated staff member for wellbeing, a wellbeing policy, wellbeing initiatives, and mental health first aider training (RCVS, 2021).
The findings of the 2021 Mind Matters Initiative (MMI) survey on mental health are extremely concerning — particularly the high levels of bullying, incivility and discrimination reported by participants (Silverwood, 2021). An effective pedagogical atmosphere with an aligned and empowered team where members support each other will help to develop resilience, promote wellbeing and increase work-place satisfaction. Good team morale, civility and positive attitudes within the workplace should be actively encouraged and modelled to make them the norm. The RCVS MMI provides resources and training for an effective starting point to improve the wellbeing of the team.
Practice benefits of supporting students
The inclusion of a clinical placement within degree programmes has been shown to bridge the gap between practical and theoretical knowledge, provide an understanding of career pathways, remove anxieties of the work environment, and enhance an individual's attractiveness as a job candidate (Wilton, 2012). It is important, however, for veterinary professionals to also understand the value that students can bring to their practice, regardless of their student pathway and status. In human nursing, the addition of students to the working environment is reported to have a positive effect on employed individuals' output and also the care that patients are receiving (Morrison and Brennaman, 2016). Given the similarities in professions, these benefits could also be contributed to the veterinary environment.
Literature currently highlights areas of job dissatisfaction within human and veterinary nursing, which may be alleviated, in part, by the increased utilisation of nurses in training, allowing students to more effectively connect with their professional identity (Robinson et al, 2019; Klaassen et al, 2020; Vivian et al, 2022). Within some human care services, ‘Experts by Experience’ are used to help support and monitor the service. Within the veterinary profession this idea could be adapted to use veterinary nursing graduates to support those that are currently undergoing training, allowing a more empathic training approach (Happell et al, 2021). By becoming closely involved with students in practice, RVNs are ensuring a hands-on approach to the training of future generations, enabling students to be supported by those that directly carry out the tasks and activities assigned to them (Education and Training Foundation, 2021).
Once an SVN is integrated within a practice, they not only provide an ‘extra pair of hands’ to an often busy and demanding environment, but they also provide opportunities for RVNs. Mentoring skills can be practised in a variety of situations, which in turn can contribute towards the personal and professional development of the RVN (Wilton, 2012; MindTools, 2022). Students, by nature, are individuals and coaching allows the RVN to share their knowledge, while learning to differentiate between learning styles to ensure that understanding of methodologies, technologies and challenges is comprehensive for all SVNs.
Students can bring new perspectives to problem solving that are not restrained by previous practice experiences. This combined with students' interest and passion can in turn bring about a renewed energy to the practice (Davies et al, 2011). The student's lack of experience allows them to ask questions that spark discussion within the team; while simultaneously students can become the teachers because they possess abilities to undertake quick and focused research, using evidence-based practice and integrating current academic knowledge (Davies et al, 2011). Collaboration of team members can also develop over these discussions, where ideas should be freely and fairly shared (Morrison and Brennaman, 2016). Business recruitment strategies can also be implemented (Lotay, 2021). Training of students within the practice can contribute to word-of-mouth branding via client and student reflections of encounters because the image that the practice portrays is heavily linked to service satisfaction and trust (Darti et al, 2018; Noor Un Nabi et al, 2022). Practices should be open about their utilisation of SVNs. Advertising their use would highlight the training to the client and value to the student. This aligns with the RCVS standards framework for nurse education and training point 1.4 — ensure clients have the opportunity to give, and if required withdraw, their informed consent to students involved in the care of their animals. Once the training has been successfully completed, the practice also has an opportunity to employ a qualified veterinary nurse, who has been nurtured throughout their training and that clients and team members have developed a relationship with.
The lead author approached two current clinical supervisors for their thoughts on the benefits of having student nurses in practice. The following statements provide their thoughts based on their personal experiences.
Georgina Haddrell, RVN, stated:
‘I think the benefits of having students in practice are it encourages discussion of cases, medications, procedures, as well as ensuring current staff are up to date with the latest skills and performing tasks to a high standard, ensuring skills are demonstrated to students in the correct way. I also think it can be empowering for staff to pass on knowledge and skills to others.’
Amy Homer, MScVAA RVN PGCertPain GradDipVN NCertACC PGCAP, stated:
‘If practices don't support students, we will end up with a much bigger lack of RVNs in the future. We all have a duty to support the next generation, and if we don't, we will be in a sticky situation. I also think that students can offer many benefits in terms of being taught the gold standard, which is not always the case in practice and so SVNs bring a new breath of fresh air to a practice — we all have to do our part.’
Conclusion
A training practice's responsibility to SVNs goes way beyond the provision of a clinical supervisor. The SVN and clinical supervisor must also be supported appropriately by the whole practice team to ensure that the RCVS standards framework for veterinary nurse education and training are met. This should include supporting a positive learning culture, which provides opportunities for the student to engage with the whole team for training, including clinical skill development, involvement with clinical discussions and contributions to team meetings. Use of EBVM and veterinary terminology will support student transition from the classroom to the CLE. Encouraging a positive work environment will also be beneficial for the whole team by improving overall wellbeing and morale. Students bring multiple benefits to the practice environment in return for the training and support they receive.
KEY POINTS
- The training practice team has a responsibility to provide a positive learning environment that meets the requirements of the Royal College of Veterinary Surgeons standards framework for veterinary nurse education and training.
- Research has shown that incivility in veterinary practice has been widely reported, so the training practice team must be mindful of fostering a positive work and learning environment, with all individuals working towards this goal.
- The practice team can be a great support for the clinical supervisor and student veterinary nurse. In turn, the presence of students will bring multiple benefits to the working environment.