There are about 450,000 care home beds in the UK, thrice the number of acute hospital beds. Yet, student nurses receive the majority of their clinical placement learning in acute hospitals. Nurses’ competencies in care homes are poorly defined and there is a perception that it is a less skilled branch of nursing, therefore, a lower status career.
This is despite the care home population having increasingly complex care needs relating to the combination of multimorbidity, dementia, mental health, and the need for palliative care.
There is currently a crisis in the recruitment and retention of nurses in care homes. This is alarming, given that student nurses currently receive most of their education in acute care settings even though care homes play a vital role in delivering health care, with three times as many beds as there are in the NHS.
Care homes/Supported living Schemes (SLS) as an environment for learning is usually classed to be an ‘emporium’ of learning opportunities, a place where students can thrive and develop. So, the next question – What to include? The questions that are sometimes raised are, “what is the benefit of student placement in a care home? What could a student possibly learn in a care home?”
We believe that students benefit from two placements in a care home, first when they start on their journey of learning and development, and second when they are about to complete their placement.
Care homes/SLS are communities where people live and people work. As a learning environment for the new learner, they offer an introduction to compassionate, ‘person-centred care’ and ‘person-centred approaches’ care and support that are holistic and rights-based. Care homes/SLS provide environments that allow the student to consider what it is to be a nurse in a community setting. To start and develop their critical thinking, problem solving through assessment and evaluation, and work with the people they support, helping them identify their outcomes.
Our care homes and SLS services are managing people who have mental health support needs and also providing services to forensic and complex care needs clients. We work closely with Community Mental Health Teams/ Forensic Teams to supervise and monitor the management of people effectively in the community.
This includes monitoring and supervising people who are under Section 37/41 of Mental Health Act 1983 and the conditions set by MOJ (Ministry of Justice). We also work with community team to monitor and supervise those who are under CTO (Community Treatment Order) conditions as set by the clinical team. We have a close collaboration with Probation Officers to monitor and manage high-risk offenders safely in the community.
Additionally, our services also support people who are under Jigsaw/ MAPPA Teams to manage their risks effectively in the community. Close liaison with ASB (Anti-Social Behavioural) Team and Neighbourhood Police Team to address and manage any anti-social behaviour in the community.
Care homes/SLS offer a great opportunity for the student nurse to start to learn these skills in an environment that is less busy, less acute, where there is time to spend with the people who live there.
Furthermore, they will gain an insight into teamwork and how Registered Nurses in care homes provide professionalism, leadership, and management. They will learn how care homes/SLS are part of the Community Health care teams, work in partnership with Primary Care and the Health and Social Care teams, and work with GP practices and Social Work teams. They will learn about CQC and its legislation. Provide leadership to make sure people’s wellbeing is protected and to improve their experiences of the health and care system.
Care Homes are regulated by CQC who monitors, inspects and regulates services to make sure they meet fundamental standards of quality and safety. CQC carries out the inspections on five aspects of care which including Safe, Effective, Caring, Responsive, and Well-led.
The CQC follow the essential standards of quality and safety consisting of 28 regulations (and associated outcomes) that are set out in two pieces of legislation:
Mental capacity act 2005, Deprivation Of Liberty Safeguards (DOLS) and how this is applied, how important it is to understand, and what capacity means. The importance of a rights-based approach and how people who live in care homes/SLS are supported to have their rights upheld through the legislation set out above.
The care home/SLS environments are where a student on their placement can build their confidence about how care and support are provided for those who are no longer able to look after themselves and require an additional level of support. The student will also look at how assessment tools are used to ensure that care and support are individualized to each person to ensure that the most appropriate service is provided.
Local authorities also carry out regular inspections and monitoring to assess the effectiveness of services provided by both care homes and SLS projects. This inspection is to focus on different aspects of care for people who use the services to monitor the quality of services provided, whether it’s safe, and meeting the required standard.
Observation, ADL Skills, and Communication
To learn the art of observation – whether assisting or supporting a person in doing their activities of daily living or talking with the person, all the time the nurse is observing; How is the person’s mental state presentation? Is the person confused? Is their mouth or skin dry? Are their eyes clear? Do they look comfortable? Do they look like they are in pain? Is the person eating and drinking? How are they coping with their ADL, budgeting, maintaining their tenancy, Do they have any insight into their mental health, If not, it is important to learn to question why and try to work out what is going on for that person, through observation, listening, watching and communicating.
This is where the student can learn the importance of communication, in its various forms, and how to assess while communicating. These are the skills that we need to learn and to understand what is being presented by the person. It is the critical thinking, clinical decision making and problem-solving that are key to their development.
Evidence-Based Practice (EBP) Critical Evaluation – Practise Effectively
The knowledge that we gain through academic study consist of learning how to use evidence-based practice to help provide care and support and to learn how to critically evaluate a situation, create a plan and agree on outcomes. A care home/SLS is a great environment to start learning how to do this, learn the importance of assessment and evaluation.
Students will be able to work in line with the best available practice in our Care Homes / SLS. They will also participate in daily staff handovers, regular communication with MDT Teams and External Agencies. Working with their PAs and PSs, they will be able to gain more insight into delivering quality care and support. Having the ability to delegate tasks to Mental Health Support Workers will surely help our students to learn from their PSs and PAs’ responsibilities and accountabilities.
Care homes/ SLS will allow students to be part of pre-admission assessments, discharge planning, devising person-centered care/support plans, and risk assessments as per individual needs and risks. Students will be able to be part of the 1 to 1 session (daily, weekly, monthly, or when required) to assess any concerns or to evaluate their progress. These 1 to 1 sessions will enable to recognize mental health deterioration, physical health issues, emotional/ social issues, financial problems, and assessing any other potential risks as per the individual’s background through Mental Status Examination (MSE). Students will also be able to monitor substance misuse by carrying out UDS screening, alcohol breathalyzer test, etc. A student will also learn the importance of social and psychological support. The importance of keeping active, feeling competent, and having relationships.
Nutrition and Hydration: They will learn about the importance of nutrition and how meals are one of the most important social activities, but equally important is to ensure that the person is well nourished. Learning how to use assessment tools in relation to nutrition and interpreting these to ensure that the person is receiving adequate food, nourishment, and hydration. Learning what to do on an individual basis where a person is not eating well.
Promote Choice Dignity and Respect (Prioritise people)
Practical skills will be observed and practiced, such as assisting a person to wash and dress, ensuring that the person’s dignity and comfort are maintained, a procedure that needs to be completed efficiently and smoothly, compassionately in the least invasive way.
Understanding, a thorough assessment that any care and support should promote choice, dignity, and independence. While assisting or observing any procedures, the student will see universal regulations for infection control in practice, be it in a care home or SLS environment.
A student will encounter complex medicine regimes and learn the importance of safety regarding medication administration, supervising, ordering storage, and disposal. They will understand medication management’s importance, including monitoring the effects and side effects of medications and review. They will learn how to support people living with diabetes, hypertension, high cholesterol, obesity, etc. These include understanding how to monitor blood glucose levels and the management plan for high/ low blood sugar levels. Also guiding and supporting them to make lifestyle changes, teaching them about recognizing symptoms, encourage and support to seek medical help when required. They will learn how to record vital signs, the importance of recording and reporting abnormal measures, and how to respond and react.
In our Care Homes/SLS, students will be able to learn how to raise concerns and be reactive when there are any emergencies. They will be able to follow policies and procedures to ensure that the service users are kept safe.
PAs and PSs will support their students to access our internal Software Management System, Carex. They will be provided access to each service users’ individualized Care/Support Plans with comprehensive risk assessment/management plans.
Students will also be able to assist PAs and PSs on how to carry out assessments for the potential service users, the admission process, developing care/support plans, and devising risk assessment/management plans together with the service users, their families/friends, and the MDT.
Leadership and Management (Promote Professionalism and Trust)
A student coming to the end of their training can hone their leadership skills further. Students who are undertaking a management placement in a care home will witness clinical decisions made by the accommodations’ nurses who draw on all their knowledge and evidence base to ensure that their residents are safe, supported, and cared for.
Leading a team of Health Care Support Workers, dealing with events that will happen throughout the day. Having to prioritize, organize, respond to emergencies and manage, are a real test of a person’s leadership and management skills. They will get an opportunity to use their knowledge to make clinical decisions, to think critically, and have those all-important clinical discussions with their peers to ensure that the people they are supporting remain well, promote wellbeing and ensure safety.
They are skilled in assessment and evaluation, critical analysis, and clinical decision-making. They need to be professional at all times and ensure the safety and wellbeing of their residents. They need to have knowledge of long-term Mental Health conditions and how these are supported as people living in care homes/SLS come with many co-morbidities and will need to be supported to live with these, promoting wellbeing and preventing ill health.
The learning opportunities for students are many and varied, and when considering the Future nurse: Standards of proficiency for registered nurses’ (NMC, 2018), it is clear that a care home/SLS offers a perfect environment for student nurses to gain experience in these areas.
This being said, the environment needs to be one that is welcoming, where the standards are excellent and the team is well trained, an environment that promotes a learning and development culture for all. We are proud to be able to offer our Care Home/SLS as a learning environment and we are also proud of the experience that student nurses have with us.