Introduction

The time that student nurses spend in practice, which constitutes 50% of the student programme, shapes their development into the professionals of the future (Francis, 2015). In March 2020, at the start of the Covid-19 pandemic, the Nursing and Midwifery Council (NMC) issued emergency standards – Emergency Standards for Nursing and Midwifery Education (NMC, 2020) – which enabled second- and third-year student nurses to ‘opt in’ to a period of paid employment while continuing their pre-registration programme (Baldwin et al, 2020). This supported the clinical workforce at an unprecedented time and enabled continued progress towards registration for student nurses.

During the Covid-19 pandemic, the clinical practice facilitation team at London North West University Healthcare NHS Trust received a higher number of complaints than usual from student nurses relating to conflict in their practice learning environment. London North West’s clinical practice facilitation team sits within the clinical education branch of a wider learning and organisational development team at the trust. Its main focus is the support and development of pre-registration learners across its three hospital sites.

It is recognised that the pandemic was a difficult time in healthcare practice for all professionals, both physically and psychologically. The literature describes staff experiencing “increased levels of anxiety” and a “heightened sense of vigilance” (Baldwin and George, 2021; Grailey et al, 2021). This resonates with the work of Godbold et al (2021) in the context of 16 pre-registration nursing students who ‘opted in’ for the final year of their programme during the first wave of the Covid-19 pandemic. They reported their experience of the physical effects of wearing personal protective equipment and the psychological hypervigilance relating to personal safety. While the pandemic may also have increased anxiety and hypervigilance among student nurses in this trust, the increased rate of reported conflict was nonetheless an important issue that needed addressing.

Following the receipt of complaints, which were approximately four times higher than the previous year, the trust’s clinical practice facilitation team investigated each of the complaints further. On every occasion, the student was facilitated to have a meeting with the clinical placement supervisor to explore the issues. All students were offered support from their university through the wellbeing team, their academic assessor and their personal tutor. The meeting involved the use of the organisation’s bullying toolkit, which consists of investigative tools to identify the issue, people involved and possible solutions. In all instances investigated, there appeared to be a common theme – a breakdown in communication. When students were given feedback about their knowledge, skill, proficiencies and professional behaviour, it was often misinterpreted and not perceived as being supportive.

Clarke (2009) identified a trait that, when there is a combination of supervision from a teacher and feedback to students, this often results in the student feeling targeted. To date, several studies have reported on nurses experiencing bullying and the wide-ranging recommendations to address this, which include changing organisational culture, encouraging reporting, bullying awareness seminars, healing the negative consequences of bullying, policy change and educational intervention (Fernández-Gutiérrez and Mosteiro-Díaz, 2021; Gamble Blakey et al, 2019; Seibel and Fehr, 2018; Kang, 2018).

The clinical practice facilitation team considered the different options and the outcomes of the students’ lived experiences and felt that an educational intervention could address the current issues around the miscommunication of feedback. This could be offered to all pre-registration nursing students as part of the induction process and to their practice assessors and practice supervisors (PAs/PSs).

The clinical practice facilitation team discussed the findings of the complaints with all university partners and agreed a collaborative approach to support positive communication in the practice learning environment (PLE). As a result, a training resource was developed targeting nursing students and PAs/PSs with an aim to improve the delivery and receipt of feedback between student nurses and their PA/PS.

“When students were given feedback, it was often misinterpreted and not perceived as being supportive”

Development of the training resource

The Giving and Receiving Feedback (GRF) training resource is based on the principle ‘it’s not just what you say, it’s how you go about saying it’. It was developed to improve interaction between students and their PA/PS and promote effective communication while supporting student nurses in practice, based on the learning needs of both students and clinical practice colleagues.

The training resource is a PowerPoint presentation created using evidence-based theories and interactive resources, citing information from sources published in healthcare education settings. It was designed to provide flexibility in its use with the option to use it either as an eLearning module or delivered as a face-to-face training session (in person or via video conferencing).

Initial feedback was sought from members of the trust’s wider clinical education team and key stakeholders, based on which the GRF training resource was further revised and refined. Some of the changes included tailoring the resource to meet the needs of diverse learner groups (who may have additional needs), thereby ensuring equity and inclusion. A member of the trust’s Independent Staff Insight Group (ISIG) and the Disability Inclusion Network (DIN) were consulted to make the necessary changes to ensure that the resource was as inclusive as possible. The ISIG and DIN in the trust are made up of a diverse group of people from across professions and specialities, who represent the interests of the workforce and focus on issues relating to equality, diversity and inclusion.

An evaluation tool was also developed, which included quantitative and qualitative assessment of the content, its practicality and implementation into practice, the level of interaction and the length of time of the session. The evaluation tool invited suggestions on content of relevance to both students and PAs/PSs, as well as the quality of the session in terms of the speaker’s knowledge of the topic, equity and inclusion.

The GRF training resource was then piloted with two groups of student nurses (n=66). The feedback from this pilot was instrumental in refining the presentation further. The topic ‘barriers to effective feedback’ and the associated videos brought about a vibrant discussion and prompted the addition of the topic ‘consideration of cultural aspects when giving and receiving feedback’. It was acknowledged that effective communication should take place without compromising on diversity. This was particularly important given that 70% of the staff in this trust are from Black, Asian or minority ethnic backgrounds, 2% have declared a disability (at the point of recruitment), and 2% identify as LGBTQ+.

Additionally, the length of the presentation was altered to allow more time for discussion, which resulted in the training session becoming more interactive. Following these changes, the GFR training and the evaluation tool were piloted with a third group of students (n=23), where learners were able to reflect on their past experiences and make meaningful contributions during the session. The content of the training resource was adjusted in line with the NMC’s standards for student supervision and assessment (NMC, 2018), and included the trust’s HEART values (honesty, equity, accountability, respect, teamwork) before finalisation.

The process for developing the GRF training resource is outlined in Fig 1.

Overview of the resource content

The training resource clarifies the aims of the session and covers the following topic areas:

• Importance of feedback;
• Types of feedback;
• Models for giving feedback and its application to practice;
• Barriers and facilitators for giving feedback effectively;
• Consideration of cultural aspects;
• How to receive feedback;
• Debrief post-feedback;
• Resources for support and wellbeing.

When giving feedback, it is important to plan it in advance to ensure that it is tailored to the individual, as one size does not fit all. Literature on models of feedback suggests concentrating on the individual’s behaviour as observed, and this involves being specific and factual (Hardavella et al, 2017).

While there is a lot of literature about giving feedback, it was important to also include evidence-based suggestions for how to receive feedback so that communication could be improved between both the ‘giver’ and ‘receiver’, to achieve the desired change. The training is interactive and uses a combination of different training methods. Due to the Covid-19 pandemic, the training so far has been delivered virtually via a video conferencing platform and incorporates virtual role play of real-life examples, practice scenarios, opportunities for discussion and group work, and videos demonstrating effective and ineffective verbal and nonverbal communication while giving and receiving feedback.

It was recognised that staff wellbeing is paramount to the delivery of high-quality, professional, compassionate and effective care (West et al, 2020). The importance of debriefing post-feedback and resources to support wellbeing were, therefore, incorporated into the training.

Training implementation

The GRF training is currently being rolled out to all student nurses as part of their induction at the trust and is integrated in the induction programme. So far, 11 sessions have been delivered to 218 students since 1 November 2021. More of these sessions are proposed to be rolled out during student practice forums, which take place periodically throughout the year.

The roll-out of the GRF training to PAs/PSs will take place gradually and plans are underway for it to be introduced through the PA and PS forums from March 2023. Plans include making the training available as an e-Learning resource for the target groups. A proposal was made to incorporate the training resource into the trust’s Nursing and Midwifery Preceptorship Programme, which is aimed at newly registered practitioners and includes newly qualified and overseas nurses and midwives, which was accepted. This roll-out began in July 2022.

Evaluation data is being collected after every session, and an initial review was carried out after six months to ascertain whether further revisions are necessary. Preliminary evaluation data from 73 participants in the six-month review (held in May-June 2022) suggests that the sessions delivered were interactive and inclusive (100%) and were rated ‘excellent’ by 77% of participants and ‘very good’ by 23%. Participants reported that the most helpful aspects were understanding what to expect from feedback in clinical placements, understanding cultural differences, and learning techniques for giving feedback. Suggestions for improvements included the request for further written resources following the session. This is now being considered by the team and a downloadable resource pack will be made available to all participants. No further revision to the training content was necessary at this stage. A plan has been put in place for robust annual evaluations to ensure that the training continues to meet the needs of the workforce, is based on latest evidence and is delivered to the highest standards.

Anticipated outcomes

The GRF training resource is likely to improve communication between student nurses and practice personnel. A programme model was devised, providing a visual overview of the problem, how it was addressed, the expected outputs, outcomes and related impact. The short-term outcomes anticipated by the authors included:

• Changes in learning, knowledge and attitudes;
• Improved knowledge and awareness of effective ways to give and receive feedback;
• Reduced misunderstandings from poor communication.

Giving and receiving constructive feedback from PAs/PSs provides opportunities for student nurses to make improvements to their practice and enhance learning. If this is carried out effectively, in the long term it is likely to improve professional relationships, thus improving job satisfaction, which would result in better experiences for students and practice personnel.

Having a supportive practice learning environment has the potential to benefit the trust and the NHS by improving communication skills within the nursing workforce, reducing the number of complaints, improving retention and increasing professionalism.

Reflections and learning

The process of developing the GRF resource and implementing the training has been a great learning opportunity for the clinical practice facilitation team. It highlighted the importance of piloting, collecting feedback and further refining the resource before finalisation. It also provided an opportunity to reflect on one’s own practice and styles for giving and receiving feedback. Based on the learning, the team created some top tips for giving and receiving feedback (Boxes 1 and 2), which others may want to consider in their own area of practice.

Discussion

Recently, a number of papers have discussed innovations within the practice placement settings. These include offering student nurse placements with clinical research teams to promote research in nursing and to help develop quality improvement, service evaluation and audit skills (Brand et al, 2022; Menzies et al, 2022); and placements within general practice where students could participate in virtual consultation sessions and develop skills in health promotion and ill-health prevention (Edmonds et al, 2022).

In this article, the development of an innovative training resource for giving and receiving feedback has been discussed. This training was developed in response to an increased number of complaints relating to breakdown in communication reported by student nurses at a time of extreme uncertainty and pressure within the NHS resulting from the Covid-19 pandemic. The development of the resource has gone through a piloting process, where it was refined before implementation. The factors critical to making this happen were the proactive nature and vision of the clinical practice facilitation team to find a solution to the problem at hand. Skills and knowledge to develop an effective training programme, along with managerial and professional support, were also key enablers.

Offering this training to student nurses will result in them being equipped with the skill of giving and receiving feedback effectively at the start of their nursing careers. The resource will not only equip the learner with knowledge on how to give and receive feedback, but also on how to respond to and act on the feedback they receive, thereby reducing negative interactions in the workplace. Frequent high-quality feedback is critical in clinical learning situations (Plakht et al, 2013), so this training can help students to respond rather than react to feedback, use active listening skills, and adopt an assertive style of communication, thereby promoting the development of emotional intelligence.

Offering feedback is considered a life skill that can be used in a variety of personal and professional contexts. According to Archer (2010), a cultural change is required so that feedback is embedded implicitly and explicitly in all activities. Although designed for student nurses and clinical practice colleagues, this resource could be rolled out more widely across the healthcare sector. It has the potential to improve student nurses’ experiences in practice placement, and demonstrates the big impact subtle changes in verbal and non-verbal communication can have on professional rapport and relationships.

Conclusion

Giving and receiving high-quality feedback is a vital component of professional development and improvement of knowledge and skills. It encourages reflective learning and – in conjunction with effective communication – creates a safe and nurturing environment for student nurses to thrive. On completion of their study, students are equipped with the knowledge and skills to have further compassionate conversations. It is, therefore, the responsibility of every registered nurse to play a part in supporting and shaping the future nursing workforce.