Sample

Purposive sampling (where researchers choose a sample based on their knowledge of a study topic and population) was selected as this is a non-random technique typically used in qualitative research. All nursing, allied health professional, midwifery and nursing associate students across the researchers’ trust who were currently on clinical placement were invited to participate in the project via email and through the trust’s weekly updates. It was emphasised that participation was voluntary and that all students who volunteered would be included.

Overall, 53 healthcare students from a range of professions including nursing, midwifery, allied health professions and those on trainee nursing associate apprenticeships agreed to take part. The majority (51%, n=27) were nursing students.

Data collection

The method chosen by the researchers for data collection was a series of focus groups. According to Flynn et al (2018), focus groups are efficient, economical and enable interaction between participants. The project researchers hypothesised that a focus group discussion would reflect the ‘real life’ conversations that the students might engage in, and were viewed as more representative of natural conversation than individual interviews (Wilkinson 1998). Focus groups are also a pragmatic data collection method considering that the busyness of the clinical environment can affect the availability of participants for other methods such as individual interviews (Flynn et al 2018).

A total of 14 focus groups were conducted over six weeks between July 2020 and September 2020. Each one lasted 1-2 hours, and each of the healthcare students attended one focus group only. The size of the groups varied depending on the number of ‘did not attends’ at each group. Because the project was undertaken during the coronavirus disease 2019 (COVID-19) pandemic, the focus groups were socially distanced.

The focus groups were conducted by researchers within the trust, including the authors of this article. The researchers used questions that were designed to begin a group discussion, then prompt further conversation. Examples of these questions included: ‘Can you talk to us about your experiences here at the trust?’ ‘What is it like being a learner in the trust?’ ‘What does a good mentor look like?’ and ‘How can we make your experience better?’

The questions were adapted for each group according to how many attendees there were and their responses.

Data analysis

Focus group data were transcribed during the focus groups and fully anonymised to remove participant information. Transcripts were read independently by three of the researchers (RP, AT and CW), who met to devise an analytical framework. This involved data being grouped into themes and a preliminary analysis being presented to the trust’s senior leadership team as a basis for an in-depth discussion. This process entailed a combination of deductive and inductive data analysis, which enabled a collaborative and transparent approach to extracting meaning from the data (Bonner et al 2021).

Ethical approval

Ethical approval was not required because the project was regarded as a service evaluation rather than research. However, ethical guidelines were followed out of respect and fairness to the participants. All 53 healthcare students gave their consent to participate in the focus groups. The researchers guaranteed that all data would be analysed anonymously and that information about the participants would remain confidential.

Being part of a team

In relation to the theme of ‘being part of a team’, the participants described positive experiences of clinical placements such as being welcomed by the clinical staff at the beginning of a placement, being referred to by their name, being thanked or praised, and being given time for debrief sessions.

Several comments from the participants demonstrated their wish to ‘belong’ and feel included as part of a team:‘They knew I was coming because my name was on the board.’ ‘It’s like a family, nice feeling. Can go to anyone.’

Many participants also emphasised the importance of praise, feedback and being given time to debrief with clinical staff:‘Good feedback made my day.’‘Following an emergency, the band 7 asked me if I had any questions, and wanted to clarify and complimented me. This gave me a good feeling.’

The participants also identified some negative experiences in relation to being part of a team, such as being referred to as ‘the student’ rather than by their name, a lack of planning for their arrival, being treated with a lack of respect or being treated differently to members of the permanent staff team, not being ‘wanted’, and not being listened to. For example, one participant stated:‘Being called “the student” feels insulting, like they’re not even interested in us…we have a name.’

Some of the participants said that while they were usually taught the importance of teamwork during their courses, teamwork was not always evident on clinical placements. Participants spoke of feeling like ‘a spare part’ and being ‘not welcome’. They discussed having to prove their worth on clinical placements to gain acceptance, which had a negative effect on their confidence, competence and ultimately their mental health.

Support

For healthcare students, learning on clinical placements requires effective support to develop their confidence and competence, and to ameliorate work-related stress. Positive experiences that participants described under the theme of ‘support’ included experiencing effective practice supervision, being provided with the opportunity to ‘be a student’ – such as being given time to focus on learning – experiencing active learning, clinical staff supporting their learning, and the placement area having an infrastructure that was designed to accommodate students.

Several participants expressed their appreciation for the pastoral support offered during the COVID-19 pandemic, with one stating:‘What’s been really good about the pastoral support is that somebody comes to us and checks on us, even if it is a phone call.’

Several participants identified trust as an important factor, relating how they wanted their clinical placement supervisors and assessors to trust their ability, with some suggesting that this could even influence their future job choices:‘Some supervisors need to loosen the reins.’ ‘A good [placement] experience made my job offer decision, the atmosphere helped with my choice.’

The approachability of the clinical staff was identified by some participants as an important factor in relation to whether or not they felt supported on their clinical placement. One participant commented:‘There are some I’m scared to approach or ask for anything, it makes me uncomfortable.’

Many participants also felt that some nurses were insecure about taking nursing students on placement because of concerns about their own extended skills, for example chest auscultation and venepuncture, which could be disempowering and deskilling for the participants. In addition, some participants expressed having to be ‘chameleon-like’ to engage and ‘fit-in’ with their placement supervisor or assessor’s personality to develop a positive perception of themselves.

Other negative experiences identified in relation to the theme of support were being expected to ‘work and not learn’, experiencing suboptimal mentorship, encountering a lack of support for academic work, and being expected to work solely as a healthcare assistant. Examples of participant comments included:‘A mentor can make or break you.’‘Doing observations all day is a bit annoying.’

Being unprepared

The challenges in applying the theory learned in universities to clinical settings is well documented in the literature, and is often referred to as the theory-practice gap (Zeiber and Wojtowicz 2020). In this project, participants frequently focused on the challenges around preparing for their clinical placement in terms of knowing how to find the hospital or ward, how to travel there and what they perceived to be the lack of clinical skills teaching during their academic programme, as well as the lack of support available from their university and the trust.

Participants also reported feeling anxious about getting their ‘off-duty’ rota in sufficient time to organise their academic commitments, as well as understanding where their placement ward or unit was located and the transport options. Participant comments included:‘Starting a placement is really hard as it’s really hard to get through to the wards and find out your shifts.’ ‘I get really anxious before the start of the placement, and it helps if I can visit and get my shifts in advance and get the correct telephone numbers of the wards, which can take ages.’

Participants also reported feeling unprepared when undertaking clinical skills on placements and some commented on the effects a suboptimal practice experience could have:‘It would be good to have more skill sessions so that they show us the proper way to do things rather than learning poor practice… the skills library doesn’t have the same equipment as the trust… we are taught by people who are out of date.’ ‘People who have had a bad time won’t come back to the hospital.’

Focusing on learning

During the focus groups in this project, many of the participants spoke negatively about their experience on clinical placements where they were expected to work as healthcare assistants rather than learn new skills. Participants emphasised that they were willing to work as part of the team, but they wanted these opportunities to include learning rather than simply focusing on tasks. Henderson and Eaton (2013) suggested that barriers can arise where healthcare students feel the workplace culture does not recognise the importance of their learning. In addition, if healthcare students feel unsupported by clinical staff, this can negatively affect their performance of clinical tasks (Uren and Shepherd 2016). Galvin et al (2015) detailed the effects of stress on mental health that nursing students experience when undertaking clinical practice learning, citing individual and organisational factors such as suboptimal performance, high sickness rates and high attrition levels. Galvin et al (2015) found that a significant source of stress for students was experiencing negative attitudes from staff during clinical practice placements.

Skill acquisition

The participants in this project recognised the need to be adequately prepared by being taught the appropriate clinical skills before the placement started, such as injection techniques and basic wound care. This was supported by Porter et al (2013), who found that final-year nursing students believed that being competent in clinical skills could lead to acceptance by staff and an effective placement. However, it should be acknowledged that teaching skills in the classroom does not guarantee that a healthcare student will be confident in using these skills in clinical practice.

There is a growing evidence base supporting the need for healthcare students to be future-oriented, with clinical placements aimed at enhancing students’ adaptability and preparing them for their careers. Ultimately, if healthcare organisations are to meet the demands of an ever-changing population, they need to recruit healthcare students who are fit for practice on registration. Ensuring that students have a positive and innovative experience of pre-registration education that incorporates effective clinical placements will promote confidence and competence, and subsequently enhance recruitment by providing a workforce that can be easily assimilated into healthcare teams.

Bolstad et al (2012) recommended re-imagining how learning environments are organised, resourced and supported, which influenced the researchers of this project when they were considering a change in practice.

Change in practice

The researchers used the themes identified in this project to inform a change in the organisation of clinical placements in the trust. This involved attempting to enhance the quality of practice-based learning, as well as addressing the lack of empowerment experienced by many healthcare students when on clinical placements.

The data from the project was used to engage in dialogue with the trust’s senior management team, thereby promoting a wider understanding of the healthcare students’ experiences of clinical placements. However, designing an innovative practice-based learning experience and embedding best practice can be challenging and requires adequate resourcing in terms of clinical staff, as well as consultation with multiple stakeholders such as university departments and multiple hospital sites (Theobald and Campbell 2016).

Following completion of the project, the researchers met with those who had implemented student-led wards in Sweden. These wards demonstrated the benefits of enabling healthcare students to lead practice, as shown by positive reports from patients, supervisors, educators and healthcare students. For example, students reported how actively leading patient care enabled them to increase their confidence and competence (Lidskog et al 2009, Manninen et al 2014, 2015). Further evidence from Sweden has suggested that to meet the increasing demand for placing healthcare students in the clinical environment, a sustainable model that does not compromise the quality of patient care is essential (Dyar et al 2019). In Australia and the US, student-led areas known as dedicated education units have also been developed, which are run jointly by universities and healthcare providers (Pryse et al 2020).

For the authors, the findings from this quality improvement project and the accumulated evidence informed their trust’s decision to implement a student-led clinical learning environment.

Limitations

The limitations of this project were that it was conducted in one large trust with multiple sites and specialties, and therefore the results may not be generalisable to other settings. The project had multiple components and there may have been bias in relation to the interpretation and analysis of the data, leading to a focus on student-led clinical learning environments without further consideration of alternatives.