This scenario provides an insight into the experience of Julie, a registered mental health nurse, who is supervising a third-year mental health nurse student in a community setting.

The practice environment

I have a third-year student mental health nurse, Milika, starting her placement with me. Milika is returning to the course after taking a year out from her programme.  She says she is feeling ‘out of her depth’ and lacking in confidence because of the time away. It is also the first time she has had a community-based placement. Milika states her preference for the routine of a ward environment and feels uncomfortable about the idea of visiting people in their own home and or in the community. She has doubts about how she will be able to meet the required standards of proficiency. She has however, reflected on some ideas of the things she’d like to learn from this placement:

  • To learn more about holistic, person-centred care
  • To be able to carry out a mental health assessment.
  • To learn how to support someone who is experiencing anxiety.
  • To find out about how an interdisciplinary team works in the community for the benefit of people
  • To learn more about medicine optimisation, including gaining confidence giving depot injections.

I set time aside on our first morning to orientate Milika to the building that the CMHT are based in. I introduced her to members of the nursing team, as well as interprofessional team members, including social work and occupational therapy colleagues. We talked through her expectations of this placement and discussed her reflections on her personal learning needs and objectives. She was apprehensive about resuming her course, meeting me, and a little underconfident about achieving the learning outcomes associated with this practice placement. We discussed objectives within her Ongoing Achievement Record (OAR) as well as her more personal learning goals, then considered and planned how they could be achieved.

I discussed my role and that of members of the interdisciplinary team with Milika, explaining how we worked together to assess, provide care, and support people at home or in community settings. Milika reflected on how caring for people in the community differed from her experience of working in ward environments.

I explained my role as one of her practice supervisors, and that of my line manager Tracy who would be her practice assessor. As Tracy was on leave that week, we arranged a tripartite meeting for the following Tuesday afternoon.

Milika was comfortable with observing me in my role for the first week, and then carrying out activities through indirect supervision to build up her confidence. This included working alongside me and other allied health professionals assessing the needs of people referred to the CMHT and working with us to plan care.

I have two people on my caseload that require depot injections. My colleague Dave is a nurse prescriber within the CMHT who runs a ‘depot clinic’ once a week, and so Milika agreed to talk with him and ask if she could attend the clinic each week over her 12-week placement. We agreed this would enable Milika to develop her knowledge and skills to understand medicine optimisation, including learning about a range of pharmacological interventions in mental health, such as depot injections, and apply this knowledge to the care of people.

After discussing Milika’s learning outcomes, we went to the weekly allocation meeting where people who have been newly referred to us are discussed and assigned to members of the team in accordance with their needs. Milika agreed to observe and participate in the assessment and care planning of two people referred to the team, following them through their interprofessional care pathway for the duration of her placement.

Just after this meeting I introduced Milika to Dave and left them to discuss the learning opportunities available to Milika when attending the depot clinic. Milika and I met later at the office to go on a home visit to see Ben who had previously agreed to let Milika join me.

Ben is 19 years old, an only child, and had been under the care of the Child and Adolescent Mental Health Services (CAMHS) since he was 12 years old.  He has recently been diagnosed with Bi-polar disorder. He often experiences periods of extremely low mood and episodes of feeling very elated that can last from days to weeks. At times he refuses to eat and sometimes harms himself by making cuts to his arms or legs. This is distressing for him and his family, but he explains it is often the only way he can feel he has control over how he feels. Ben is engaging in ‘talk therapy’ with a clinical psychologist and is taking medications to help stabilise his mood. He has Type-1 diabetes which was diagnosed at around 10 years of age. He often withholds his insulin injections to promote weight loss. He has had two admissions to a CAMHS inpatient unit and two admissions to a children’s ward related to self-injury, low body weight and diabetic ketoacidosis.

His care experiences have included being fed through a nasogastric tube and having changes made to his diabetes management, both of which added to feelings of being out of control and undermined his relationship with the staff caring for him. This resulted in him being reluctant to engage with health professionals. 

His experience of the CMHT since his last discharge from hospital six months ago, has been positive. Ben and I have a good therapeutic relationship and he also meets John, a Diabetes Specialist Nurse, regularly, who has a good relationship with him too. Ben agreed to a joint meeting with me and John to assure him we had a joined-up understanding of his diabetes and how his lifestyle and mental health impacted on his management of it. Milika joined us for this meeting, and then arranged to accompany John when he saw Ben at his next appointment.

The following demonstrates how Milika was able to meet some of her standards of proficiency and learning objectives through these practice learning experiences of one-to-one work with Ben, supported by John, and participating in the weekly depot clinic with Dave.

Putting the proficiencies into practice

The Standards of proficiency for registered nurses state the knowledge, skills, and behaviours that every nurse must have by the end of their programme. The standards are set out in seven sections called 'platforms'.

In addition, there are two annexes in these standards that state the communication and relationship skills nurses must have (Annexe A), and the nursing procedures (Annexe B) they must be able to do when they join our register.

Platform 1: Being an accountable professional

What Milika did:

Milika was open and honest about feeling ‘out of her depth’ after taking time away from the course and was reticent about being on a community-based placement. She expressed herself appropriately and was clear about how she was feeling and her concerns about the placement. Despite this, she had looked into the role of a community mental health nurse (CMHN) and thought about objectives she wanted to achieve. She had ideas of what she would like to gain from a community-based placement and was looking forward to learning about the wider interprofessional team.

What this demonstrated:

Given Milika’s openness she met proficiency 1.3 by showing that she understood and applied the principles of courage, transparency and the professional duty of candour recognising and reporting that her lack of confidence and competence might limit the care she was able to engage in. Milika was also working in line with the Code to preserve safety by working within her limits of developing competence. She recognised where she needed to learn more and engaged with her supervisors to plan this learning.

Platform 2: Promoting health and preventing ill health

What Milika did:

Milika participated in a joint meeting with Ben, his specialist diabetes nurse (John) and me. John met with Milika before the joint visit to discuss caring for people with diabetes, including the additional care Ben may need in terms of building trust, and supporting him to manage his diabetes when his mood was less stable. Milika considered this a valuable opportunity to learn more about person-centred assessment and joint care planning.

Under John’s supervision (both direct and indirect), Milika went on to work together to support Ben to manage his diabetes. Ben had previously attended a diabetes education programme, and now built on this with a co-produced a person-centred care plan developed between John and Ben, while considering Ben’s needs and lifestyle. It included increasing the monitoring of blood glucose, planning meals, and engaging in more structured and planned physical activity. Milika met with Ben for four consecutive weeks and felt she had learned much about Ben and his diabetes management. Ben enjoyed the regular meetings at his home and Milika felt she had supported him to feel more empowered to manage his diabetes and his lifestyle choices. Ben believed he had gained a greater sense of personal control and self-reliance which Milika felt pleased to have contributed to.

What this demonstrated:

After meeting with John, for the next four weeks Milika was able to discuss with Ben the impact his diet and exercise have on his mental, physical and behavioural health and wellbeing (proficiency 2.4). Ben had prior knowledge of healthy eating patterns but didn’t always follow them and at times withheld his insulin.  Milika was able to use appropriate communication skills and a strength-based approach (proficiency 2.9) within a motivational interviewing framework (Annexe A, 3.1) to support Ben to make informed choices about his own care.  

Milika recalled what she had learned about population and public health in a module she had recently attended at university. Ben wanted to understand more about his health, so she wanted to provide information in an accessible way to help him understand and make decisions about his health, life choices, illness, and care (proficiency 2.10). She shared some of the findings from public health data; for example, people with severe mental illness (SMI) like Bi-polar disorder have a shorter life expectancy by up to 20 years compared to the general population. She also told him that it is estimated that two in three deaths are due to physical illnesses which could have been possibly delayed or prevented. This led to a conversation around Ben’s lifestyle – including his diet, exercise, and his understanding of healthy living.

Ben had learned about the complications associated with diabetes from the course he had attended some time ago; however, he had not fully appreciated the risks he was taking in withholding his insulin and neglecting his diet. Milika and Ben spent time discussing ways in which he could manage his diabetes, and work towards making positive changes to support his wellbeing.  

Platform 3: Assessing needs and planning care

Ben’s mood was generally low. He has a poor self-image, few relationships with others and experiences anxiety in social situations. As a result, he does not go out or socialise often. He does not appear to be self-harming and his diabetes has been more stable over the last four weeks. He is prescribed Lithium Carbonate which he takes regularly, and he feels some benefit from this in terms of a reduction in his mood fluctuations and the frequency of panic attacks.  Ben expressed an interest in learning more about his recent diagnosis of Bi-polar disorder and whether it has anything to do with his diabetes.

Ben and Milika agreed some new goals that Ben identified he wanted to pursue:

  • To learn more about Bi-polar disorder and the links to diabetes
  • To learn about anxiety and how he can reduce feelings of social anxiety and panic attacks and enhance his social networks.

What Milika and Ben did:

Milika read about Bi-polar disorder and Type-1 diabetes as well as social anxiety and panic attacks to improve her knowledge; and shared what she had learned with Ben. Exploring the physiological, psychological, and social elements of anxiety helped Ben to understand his thoughts, feelings, and behaviours. It was through these discussions that Ben was able to recognise the link between low and high blood glucose levels and his mood.  He felt tired and lacked motivation when his blood glucose levels were low; and he would have a headache, need to go to the toilet more often, and struggle to ‘think straight’ and sleep when his blood glucose levels were high.

Together Milika and Ben practiced relaxation techniques, talked about the impact of negative thinking patterns, and set about doing some graded exposure related to his social anxiety (cognitive behavioural therapy techniques, see Annexe A, 3.6). This approach helped Ben to face some of his fears in a gradual way that ultimately led him to be able to meet a friend for a coffee. He felt this was great progress. 

What this demonstrated:

I met with Milika regularly to supervise and support the planning of care and interventions she was developing with Ben. Milika also kept in touch with John to ensure that we were all working collaboratively to support Ben’s diabetes goals.  She was encouraged to reflect on care that was jointly planned with Ben, and to explore underlying and underpinning human anatomy and physiology, genomics, pharmacology, and social and behavioural sciences. These all contribute to a holistic approach to planning and delivering nursing care (meeting proficiency 3.2). Milika knew and understood the importance of a person-centred approach to care, so collaborated with Ben to co-produce an assessment of his needs, setting of goals and development of a plan of care to address them (links to proficiency 3.4).

Milika’s greater understanding of diabetes and Bi-polar disorder, including the impact and treatment of these conditions as they relate to Ben, helped her to really appreciate the need for a holistic approach to care, and the complexity of nursing and social care needs when planning and prioritising care (meeting proficiency 3.13).

Platform 4: Providing and evaluating care

What Milika did:

In addition to working with Ben, Milika met with Dave (CMHN) on a weekly basis at the depot clinic where she was able to practice under direct supervision and administer depot injections to between five and nine people each week. She wasn’t aware that nurses could become prescribers. Dave recommended she investigate medicines administration and optimisation generally, to gain some insight into the additional knowledge and skills needed for safe, effective nurse prescribing. She soon learned that he was responsible and accountable for the assessment of people who used the service with undiagnosed and diagnosed conditions, and for decisions made about clinical management when required. Dave was able to independently prescribe any medicine within his scope of practice and relevant legislation. Initially, Milika felt intimidated by his vast knowledge and experience. Over time, through asking questions and reading about the medicines she encountered, she was soon able to discuss with Dave basic principles related to medicines administration. This included knowing what medication she was administering, why this medicine might have been prescribed (what the therapeutic range was for each of the injections she was giving), how, as well as what route and where it was being administered and the potential side effects. She and Dave also discussed the complexities involved in prescribing, for example, polypharmacy, different health beliefs and behaviours amongst users of service, and how these might influence the prescribing decision-making process and subsequent concordance.

Milika’s study around prescribing and psychotropic medications focussed on the five most commonly prescribed medicines that were administered to people at the depot clinic. She was particularly interested in the pharmacokinetics and pharmacodynamic, polypharmacy and the wide range of side effects that may affect people. This knowledge, she felt, would help her support users of the service to understand the effects of their medication better, improving concordance with their medicine regime. Although Milika had initially felt unsure in her ability to administer depot injections, she had gained knowledge and skills, enhanced her communication with users of the service, and colleagues and developed confidence in administering, coordinating, planning, and managing medicines.

What this demonstrated:

Milika was able to work in partnership with Ben, using a shared decision-making approach to manage his own care (meeting proficiencies 4.2, 4.11). In addition, she demonstrated the knowledge, communication and relationship management skills required (meeting all the first skills outlined in Annexe A) to provide Ben, and those attending the depot clinic, with accurate information to inform and support their decisions, and meet their needs before, during and after a range of interventions (meeting proficiency 4.3).

Throughout her placement Milika had acted professionally providing safe, evidence-based nursing interventions to meet people’s needs (proficiency 4.4). She was able to apply knowledge of pharmacology to the care of people, demonstrating the potential to progress to a prescribing qualification following registration (proficiency 4.17).

Platform 5: Leading and managing nursing care and working in teams

What Milika did:

Milika had attended the depot clinic regularly over the 12-weeks of her placement. She had improved her knowledge and skills in medicines optimisation and administering depot injections. Towards the end of the placement, Dave had suggested she should take a lead role in coordinating appointments for the people attending the clinic. Additionally, she learned about her role as an advocate, used a strength-based approach to her practice, and was able to liaise with GPs and other members of the interdisciplinary team.

Milika had spent time with John, to learn about diabetes management, including the effects of insulin, diet and exercise, and the complexity of managing this alongside Ben’s mental health condition.

What this demonstrated:

Milika understood and applied the principles of human factors, environmental factors and strength-based approaches when working in teams. She did this in a safe and effective way and managed the care of those attending the clinic. Demonstrating appropriate prioritisation, delegation and assignment of care responsibilities to others involved in providing care (proficiencies 5.2, 5.5).

Milika exhibited leadership potential using the ability to guide, support and motivate people, and interact confidently with other members of the care team. She effectively and responsibly used a range of digital technologies to access, input, share and apply information and data within the team and between agencies (proficiencies 5.6, 5.11).

Furthermore, Milika had met with John and gained an understanding of the roles, responsibilities, and scope of practice of other members of the nursing and wider interdisciplinary teams and learned how to make best use of the contributions of others involved in providing care (meeting proficiency 5.4).

Platform 6: Improving safety and quality of care

What Milika did:

One person did not turn up to the depot clinic. They were subject to a Community Treatment Order (CTO) which meant there was a possibility of him being recalled to hospital for his treatment. Dave took the opportunity for Milika to participate in clinical supervision where they had a critically reflective discussion about medicines non-compliance/concordance and the negative impact this might have on an individual’s therapeutic and health outcomes. It included consideration of other issues such as the ethics of having to comply, and practical constraints like the financial implications of attending for appointments.  Milika started to realise the importance of person-centred care, being non-judgemental and not blaming and criticising people for their behaviours but rather to find out what may underlie their decision making about whether they receive the treatment they are expected to comply with. Both Dave and Milika expressed concerns that without medication this person may become unwell. Milika was aware of the NHS Trust procedures in terms of CTOs and contacted the person’s Social Worker (their Care Coordinator -CC) and Responsible Clinician (RC) to inform them of the missed appointment and to discuss the possibility of the ‘notice of recall to hospital’ process.

What this demonstrated:

Through her time at the clinic and in managing this situation Milika was able to show that she understood and applied the principles of health and safety legislation and regulations to maintain safe work and care environments (proficiencies 6.1). She complied with local and national frameworks, legislation and regulations for assessing, managing and reporting risks, ensuring the appropriate actions were taken (proficiency 6.3).

Milika showed that she understood differences between risk aversion and risk management, and what may compromise quality of care and health outcomes (proficiency 6.10). Milika knew she was required to contact the CC and RC, this confirmed that she understood the role of registered nurses and other health and care professionals at different levels of seniority when managing and prioritising actions and care in the event of a major incident

Platform 7: Coordinating care

What Milika did:

Milika thrived over the 12-week placement. With practice supervision (both direct and indirect) she was able to meet her learning goals and had experienced many new and continuing learning experiences. This included working interprofessionally. She worked with John, a specialist diabetes nurse, and collaborated with him and Ben to support management of his diabetes. She had worked with a CMHN and nurse prescriber in a depot clinic and developed knowledge and experience of medicines management and optimisation while caring for people in the community. She experienced the implications of CTOs and some of the ethical and practical issues around them. She had assessed, monitored, and evaluated care, and had shown an understanding of the complexities involved when caring for people with health and social care needs in the community. In addition, she was aware of the forthcoming changes to the Mental Health Act and was able to discuss some of the potential benefits and risks of such changes.

What this demonstrated

Milika had worked in partnership with users of care services and others using the principles of partnership, collaboration and interagency working across relevant sectors throughout her placement (proficiency 7.1). She understands relevant health legislation and current health and social care policies, and the mechanisms involved in influencing policy development and change in England (meeting proficiency 7.2).

Working in partnership with Ben, Milika was able to recognise the need to respond to the challenges of providing safe, effective and person-centred nursing care for people who have more than one condition and complex care needs, as well as understand the intricacies of providing mental, cognitive, behavioural and physical care services in a home setting (meeting proficiency 7.6). She was able to monitor and evaluate the quality of care received by people with complex care needs, including Ben and other people receiving care through the depot clinic (proficiency 7.7).

Milika had learned principles and processes involved in supporting people and families in their home and community settings, with a range of care and social needs, with the aim of maintaining optimal independence and avoiding unnecessary interventions and disruptions to their lives (meeting proficiency 7.8).

Annexe A: Communication and relationship management skills

Milika recognised the need to work in partnership with Ben acknowledging his strengths and expertise. She asked him about the reasons for wanting to manage his diabetes differently and was able to link this to his health behaviours and his right of autonomy (something that Ben values). Over four sessions Milika actively listened to Ben and his concerns with empathy and non-judgemental positive regard. She was familiar with the principles of motivational interviewing which she used as a broad framework for the sessions which ultimately led to Ben feeling empowered to positively change some of his health behaviours.

Skills demonstrated:

2. Evidence-based, best practice approaches to communication for supporting people of all ages, their families and carers in preventing ill health and in managing their care

2.6 use repetition and positive reinforcement strategies

2.7 assess motivation and capacity for behaviour change and clearly explain cause and effect relationships related to common health risk behaviours including smoking, obesity, sexual practice, alcohol and substance use

2.8 provide information and explanation to people, families and carers and respond to questions about their treatment and care and possible ways of preventing ill health to enhance understanding

3. Evidence-based, best practice communication skills and approaches for providing therapeutic interventions

3.1 motivational interview techniques

3.6 cognitive behavioural therapy techniques

Annexe B: Nursing procedures

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages:

1.1 mental health and wellbeing status

1.1.1 signs of mental and emotional distress or vulnerability

1.1.2 cognitive health status and wellbeing

1.1.3 signs of cognitive distress and impairment

1.1.4 behavioural distress-based needs

2. Use evidence-based, best practice approaches to undertake the following procedures:

2.10 measure and interpret blood glucose levels

5. Use evidence-based, best practice approaches for meeting needs for care and support with nutrition and hydration, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

5.1 observe, assess and optimise nutrition and hydration status and determine the need for intervention and support

5.2 use contemporary nutritional assessment tool

Test your understanding

Questions to prompt reflection and discussion

For Milika to achieve her personal learning objectives and the programme outcomes in relation to promoting health and preventing ill health, identify two proficiencies that she still needs to learn and what learning opportunities would you consider might be available for Milika in your area to achieve this?

Examples could be:

Platform 2

2.3 understand the factors that may lead to inequalities in health outcomes

Through supervision Milika and I were able to discuss health inequalities and access to health care. For example, the impact of a mental health condition on lifestyle, for instance, Ben’s diabetes management being made more difficult by his fluctuating moods. Milika identified several key points in this discussion around the stigma attached to mental illness, and assumptions she had made in relation to Ben’s understanding of his condition after attending a structured diabetes education course. She was not familiar with this course and was able to discuss the aims with John and then appraise how Ben had utilised the additional knowledge in helping him to manage his diabetes. Milika was keen to support what Ben had learned further, considering his diet, exercise, and lifestyle choices generally, to reflect how Ben can develop better control of his blood glucose levels. This enabled Milika to meet the following proficiency:

2.7 understand and explain the contribution of social influences, health literacy, individual circumstances, behaviours, and lifestyle choices to mental, physical, and behavioural health outcomes

Milika was able to meet regularly with myself as her practice supervisor to discuss a variety of influences on Ben’s relationships with professionals and services, his health needs, and the importance of holistic personal care. As Milika’s practice supervisor I was kept up to date with current NMC Code campaign and the relevant research findings around the importance of working with Ben around both his Bi-polar disorder and diabetes.


If you are a registered nurse, you may wish to use this scenario and or some of the proficiencies as a guide to part of your continuing professional development (CPD) linked to your revalidation.