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Ambitions to boost nurse numbers by increasing the size of the student cohort are surely doomed to fail if the shortage of good quality clinical placements is not addressed
Clinical placements are a vital part of nurse training, with students spending half their degree course on the front line learning what the job entails.
Nursing Standard. 38, 8, 51-54. doi: 10.7748/ns.38.8.51.s19
Published: 02 August 2023
The Nursing and Midwifery Council (NMC) requires nursing students to complete 2,300 hours on clinical placement. But the system is under huge stress, and there are moves to reduce the number of placement hours required.
Universities are reporting increasing difficulties securing enough placements, while the cost of living crisis is putting a huge strain on students.
And with the government aiming to increase the number of nurses being trained by 80% to 53,500 by 2031-32, according to the newly published long-term NHS workforce plan, the system is set to come under even more pressure. But just how bad is it, and what are the solutions?
University of Central Lancashire deputy head of preregistration nursing education Tyler Warburton says: ‘We don’t have enough clinical placements – it’s as simple as that. We could not increase the number of students to the levels we need because there would not be the placements.’
He believes greater flexibility is needed in terms of the number of hours and settings than can be used.
The placement hours requirement in nurse training is around twice that for other professionals, such as physios, occupational therapists and paramedics, and it is difficult to arrange a placement in a setting that does not have a registered professional on site, due to complex rules and restrictions in place.
The rules are ‘too complicated’ to be practical, he says, and this is a problem for learning disability nursing students in particular.
‘We should be thinking about providing a rich, holistic, quality learning environment, rather than just ticking off the number of hours.
‘At the moment low staffing levels and budgets on the front line are affecting the quality of placements. Students are understanding, but they are frustrated.
‘If students are unhappy or have a problem with their placement they should talk to their supervisor or practice assessor at the placement. There are also practice education teams at trusts they can escalate concerns to.
‘If that does not resolve it they have the option of talking to their personal tutor and each university will have processes for serious problems, such as suboptimal care. But the key problem is that it is often not possible to move students – because there are no spare placements to offer them.’
Newman University, Birmingham head of placements Matt Aldridge acknowledges it can be challenging finding placements for students, but says the key is looking for creative solutions.
‘What is important is looking at new opportunities and new ways of offering placements across the whole sector – this is going to be particularly important if we are going to increase the number of nurses in training as suggested,’ he says. ‘Close and effective partnership working, especially around innovation of placements, is crucial to meeting the demand.
‘We’ve been approved by the Nursing and Midwifery Council to provide the maximum 600 hours of simulated learning. There has been a major investment to create a suite of virtual clinical environments, including a hospital ward, emergency room, a flat for home care and an immersive environment room that can place students into virtual reality settings such as on the roadside or operating theatre.
‘We see simulation not as a replacement for practice, rather as an opportunity to provide opportunities for preparation and consolidation of practice learning and to bridge theory to practice. The university has also worked with one of its local trusts to use the collaborative learning in practice (CLIP) model for placements.
Mr Aldridge says: ‘It entails allocating a higher number of students than usual to a practice environment with the close support of a dedicated clinical educator, which doesn’t replace the model of practice assessors and supervisors, but rather provides augmented learning support. This allows students to have greater autonomy, enhances nursing care and enhances the overall student experience.’
But he also says there needs to be a degree of realism about placements and expectation management. ‘It is not going to always be about high-tech treatments and advanced skills – attending to patient’s hygiene needs, toileting, feeding and communication are central aspects to all nursing care and need to be mastered by all learners.’
RCN students committee member Louise Hyett-Collins says the quality of placements is suffering and too often nursing students are treated as staff rather than supernumerary.
‘We don’t have enough clinical placements – it’s as simple as that. We could not increase the number of students to the levels we need because there would not be the placements’
Tyler Warburton, deputy head of preregistration nursing education, University of Central Lancashire
‘The lack of supernumerary status is a huge issue due to staffing levels, as well as some nurses having a more traditional view that students learn best from hands-on experience. While this might be true to a certain extent, that doesn’t mean we are free labour. We’re there to learn, not to be exploited. This is a difficult issue for students to navigate as you’re at the mercy of a nurse who will be responsible for your assessment.
‘If your face doesn’t fit, or you rock the boat by complaining, they can make life very difficult. We’re reliant on the goodwill of qualified nurses to teach us, help organise learning opportunities, write our assessment documents and sign proficiencies.
‘Lack of supervision goes hand-in-hand with lack of supernumerary status. I’ve heard many stories of students feeling scared to speak up about this, but also worried about risk to patients. Many students feel unprepared for qualification because they’re not getting enough support.’
A nursing student, who wishes to remain anonymous, says:
‘Although all the staff on the ward were friendly, it was soon clear that if I wanted to learn anything it would be a battle.
‘The regular routine for nursing students on this ward was to work with the healthcare assistant as another unpaid healthcare assistant.
‘To learn anything from spending time with a nurse was very difficult. I had to ask numerous times to shadow my mentor on drugs rounds and be involved in nursing procedures. This was usually met with silence or noncommittal noises.
‘I missed learning opportunities because I was answering buzzers as a healthcare assistant rather than shadowing my mentor.
‘I was prevented from attending pre-booked insight days with other departments and professionals because the ward was too short-staffed to let me go.
‘I raised a concern through official channels – the practice education facilitator and my university – and was told I should be more proactive and hunt down my own learning opportunities. I eventually got signed off on the proficiencies I needed, but it was a daily battle. It affected my mental health and stress levels.
‘If this had been my first placement or if I was less tenacious, I might have considered quitting my degree.
‘I was away from home, living in NHS accommodation and working 13-hour shifts for free with limited support and learning nothing.
‘I understand why students quit when they are experiencing this repeatedly.’
Mental Health Nurse Academics UK education standing group lead Greg Rooney says: ‘It’s absolutely the case that lack of capacity is restricting any increase in student numbers. If we are to increase training places as expected, something needs to change.’
Mr Rooney describes the health and care system as ‘on its knees’ and says that while staff rightly have to prioritise direct patient care, this means the placement suffers. ‘All too often, students report that supervisors and assessors find it difficult to find time to devote enough time to supervision and facilitating learning.’
He says the problem is also linked to the ‘postcode lottery’ in training provided to staff who work closely with students. ‘While the NMC does have standards for learning, we have no national standard to prepare supervisors and assessors.
‘Some organisations devote a lot of time and resource to preparing and supporting supervisors and assessors, while others less so.’
Finances are a major problem too. A Twitter poll by the RCN students’ committee at the end of 2022 showed money was the biggest issue nursing students were facing. General living costs from food to travel expenses were mentioned by a number as the most problematic.
A recent survey by RCN Scotland of more than 1,000 students found two thirds (66%) had thought about leaving their nursing course because of money worries, with some saying they regularly do not eat so they can feed their children.
The number of nursing students who leave before the end of their programme is not routinely published. But data previously obtained by Nursing Standard suggested as many as one in three students do not complete their degree.
And the Council of Deans of Health (CoDH) believes the cost of living crisis is even a factor in the fall in the number of applications to nursing courses. This year saw a 17% drop in the number of applicants to courses in the UK – a fall the RCN said is of deep concern, especially given the staffing crisis and the NHS long-term workforce plan recommendation to significantly boost training places in England.
Mr Rooney has noticed a trend among students trying to do extra-long shifts to reduce travel expenses and allow more time to work part-time.
‘Sadly, it’s not uncommon to witness students struggling to stay awake in class or even on a placement. It is a big worry.’
The NHS long-term workforce plan says universities will be supported to adopt ‘at pace’ the NMC’s standard to allow 600 hours of simulated learning to count towards practice hours, helping expand capacity.
A nursing student, who wishes to remain anonymous, says:
‘It quickly became clear that I was expected to slot into the team and share their workload – with me there, staff took the daily tasks list and split it seven ways instead of the usual six.
‘The workload involved personal care, hoisting, cooking, shopping, mopping floors and lugging heavy bags of laundry down two flights of stairs. Obviously learning the basic care skills is vital to being a competent nurse, but you also need to learn the role of a registered nurse and this placement did not afford that opportunity.
‘The behaviour of staff on my first day and throughout told me that students were routinely used as free labour and no one saw any issue with that. My lack of supernumerary status became even more obvious when I was denied my request to accompany staff and residents when they left the care home for enrichment activities. The reason? I was ‘needed’ and they wouldn’t have enough staff if I also went out.
‘It wasn’t just the care home that I experienced a lack of supernumerary status, it also happened on a ward too. There was no opportunity to administer medication, I was not invited to multidisciplinary meetings or to observe or participate in patient admissions or procedures.
‘I don’t know of any nursing students who aren’t happy to help with patients, being hands on is how you learn the practical skills the best. But being denied learning opportunities because you are unofficially being used to cover staffing shortages is not okay.’
Mr Rooney believes there needs to be a fundamental rethink in the approach to placements, pointing out the NMC insists on about twice the number of placement hours than required for other professionals, such as paramedics and physiotherapists.
‘The NMC still seems to favour the old-fashioned approach, with an emphasis on quantity over quality. Recently, it has relaxed things by allowing simulated learning in university to offset some placement hours.
‘This, in my view, misses the point. I’d rather see much greater emphasis on quality. If every hour on placement was a highly effective learning hour, students would require far fewer hours in total and we could then increase student numbers.’
He, like Mr Warburton, says there needs to be more flexibility to allow placement hours in settings that do not have registered professionals on staff.
‘There are some great services, such as women’s refuges and mental health horticultural centres, we could work with. The staff are motivated and provide excellent innovative care and students would learn a lot from them.’
The NMC has defended its approach, but says it plans to evaluate how the system works.
NMC nursing education adviser Julie Dixon says: ‘This will include establishing the ideal mix of practice learning opportunities that will best equip students to join the register and improve people’s health and well-being.’
NHS England (2023) NHS Long Term Workforce Plan
For more articles and advice to support your clinical placement experiences, go to rcni.com/nursing-standard/students/clinical-placements
