We recruited 29 students and 22 faculty members for interview to help us to test the initial programme theories (table 1).
Table 1: Study participants by status (student or faculty) and by programme of study
Programme
|
Students
|
Faculty
|
Adult Nursing
|
5
|
2
|
Children’s Nursing
|
1
|
1
|
Mental Health Nursing
|
2
|
2
|
Learning Disability Nursing
|
2
|
1
|
Midwifery
|
1
|
2
|
Physiotherapy
|
4
|
3
|
Radiography
|
2
|
2
|
Pharmacy
|
5
|
5
|
Medicine
|
7
|
4
|
Total
|
29
|
22
|
The CMOcs extracted from our data which are relevant to readiness for clinical practice are presented in Appendix 2. They are grouped into those relating to interventions for learning clinical skills and those relating to programme changes in clinical placements. Each CMOc explaining why the intervention worked or did not work for certain groups of students is illustrated in Appendix 2 by one or more quotes which are drawn from across the healthcare programmes. For ease of understanding causation in each CMOc statement, the intervention is identified in the statement, and the causative elements in both the intervention and the wider pandemic context are denoted by (C) to make clear what is causing the outcome(s) (de Weger et al., 2020). Participant ID after each quote indicates the participant’s profession, whether they are faculty or student with year of study.
Learning clinical skills
Demonstration of the skill and explanation of theory were moved online followed by skills practice either online (for consultation skills) or in-person on training manikins, on peers, on household members, or directly on placement. In situ classes were for small socially distanced groups with no touch rules except for student pairs or ‘bubbles’. All participants gave explanations of how aspects of this worked (or didn’t work) for them and student colleagues, condensed into 18 CMOcs.
Learning skills theory and watching demonstrations online, then practice in person (CMOc 1.1)
Watching skills videos and learning the theory online relied on mechanisms of retention and retrieval when students came to the in-person practice. This worked for some skills (theory-heavy, less complex tasks) but not for others (more technical, less theory). Students came better prepared to practical sessions but found it difficult to go through some of the skills theory separate from the skill.
Skills learning moved from classroom to placement (CMOc 1.2)
Nursing students except for year 1 continued on placements but due to COVID-19 had to reduce in-person classes. Some skills were therefore allocated to be learned online or by written theory then applied directly in clinical placements for practice. It worked to an extent if the placement provided practice but the mechanisms of practicing skills in a safe environment and the personal reinforcement of feedback were missing, resulting in some students feeling unprepared to do skills on placements.
Skills classes in person but socially distanced and no touch rules for demonstration of skills (CMOc 1.3)
For physiotherapy and pharmacy students social distancing rules meant that staff were unable to demonstrate on students. Instead, students were permitted one partner to practice with and had to observe from a distance. This was universally felt to be a relatively ineffective learning experience by both students and tutors as it lacked the important mechanisms of effective demonstration and hands-on correction.
Peer examination (CMOcs 1.4.1 to 1.4.3)
Medical and physiotherapy students were ‘bubbled’ with the same students to peer examine. This worked for medical students learning examination techniques. Strict pairing for physiotherapy students meant they did not fully understand the subtle variation in anatomy, and when one student was self-isolating for 2 weeks they and their pair both missed practising.
Skills practice at home was also advocated. This worked if students lived with other students on the same course when they had already learned the skills, as they could hone technique and gain confidence. If the skill was new, the mechanism of expert corrective feedback was missing.
Smaller skills groups (CMOcs 1.5.1 and 1.5.2)
Social distancing requirements due to COVID-19 made smaller skills groups mandatory. This was universally successful for students getting more practice and more feedback, thereby increasing their confidence and feelings of preparedness. It did however mean the same cohort of students required more groups, with extra work for tutors including cleaning down between groups.
Consultation skills classes moved online (CMOcs 1.6.1 and 1.6.2)
For medical and pharmacy students, online consultations and handovers worked well. The observing tutor and class could become ‘invisible’ by switching their cameras off which enabled the interacting students to imagine the interaction was one-to-one. This was less daunting for students with lower confidence levels. Online didn’t however feel quite authentic when simulating an in-person interaction.
High-fidelity (authentic) simulation (CMOcs 1.7.1. to 1.7.3)
Various high-fidelity simulations already being used for in-person simulations in radiography (a simulated Xray facility) and medicine (in-person SIM man, simulated on-call) were augmented by virtual simulations in pharmacy (a virtual patient and simulated pharmacy), medicine (Oxford Medical Simulator) and radiography (a virtual control panel with shared controls via the online platform). The important mechanisms were authentic experience and practice, learning from feedback, and learning decision-making by having to decide. These simulations worked for junior (radiography) students who were more prepared when starting placements than students who learned theory only online. Senior students were prepared to take responsibility. Virtual simulation for medical and pharmacy students is less authentic than in-person simulation as it works by clicking buttons rather than speaking and laying hands on the patient, choosing from set questions rather than asking the questions you want to. Despite this, it was appreciated by pharmacy students (who were getting no other patient contact). It was deemed less educational than in-person SIM for medics but good to reinforce learning. Simulation was noted not to authentically match the workplace noise, smells and pressures. Junior students may be partly prepared for placements by simulation but not completely and may be shocked by reality. Pharmacy and physiotherapy students who missed placements were expected to need more support in their first jobs to find their feet.
Reduced or absent skills practice (CMOcs 1.8.1 to 1.8.5)
Although the initial plan was to increase simulation, this was not practically possible as COVID-19 rules restricted in-person teaching for universities. Staff self-isolating, home schooling and being needed in the clinical workplace also affected some courses more than others. Rather than the intended increase in simulation to replace placement activity, the reality for some programmes (physiotherapy, pharmacy and nursing) was less classroom skills practice time per student. Vulnerable students had skills remediation when they were no longer locked down but too late to get much practice. These students and their tutors noted the important loss of skills practice and feedback resulting in students feeling less prepared for placement. Outcomes were some proficiencies not getting signed off, reduced confidence and apprehension at the thought of qualifying and an expectation of needing support on starting work as graduates.
Clinical placements
The programme interventions to provide safe clinical experience for healthcare students were multiple and altered with time, responding to the changing risk levels and to the way the local healthcare trusts were working. The data contained 189 explanations from participants about what aspects of in-person and virtual clinical placements they felt had worked or not to prepare them or their student colleagues to be ready for their future clinical work and why. The commonly-occurring (robust) and plausible explanations are presented in 25 CMOcs 2.1.1 to 2.6.4:
Efforts made by programme leads to fill the gaps in the clinical experience required by regulatory bodies (caused by COVID-19 disruption to placements) (CMOcs 2.1.1 and 2.1.2)
The first COVID-19 lockdown caused a significant loss of placement exposure for some students before remediation started. Nursing students who had to accumulate placement hours, were required to experience particular clinical settings and to get competencies signed off this was a source of stress. Despite various interventions, remediation was partial, patchy and often ad-hoc. Students with children to home-school were particularly affected. Students and their teachers expected additional support to be required (and provided). Topic-based remediation (for medical students) was easier to provide than hours-based remediation (for nurses). Year 1 nursing students had theory 100% of the time to replace their 50% missed clinical placements. This was not a success even in the context of COVID-19, as student nurses felt they needed placements to become clinically prepared.
Placements were still expected to provide the required clinical experience despite COVID-19 (CMOcs 2.2.1 to 2.2.3)
The patient mix, clinical activity and restriction of student access altered on some placements more than others. In the context of unchanged assessed intended learning outcomes and regulatory body requirements, the pressure of getting 29 nursing proficiencies signed off was a concern to mental health and learning disability nurses whose placements were not providing these opportunities. Radiography students were permitted to self-source placements which worked for those who could. For schools not permitted to send students on placements (pharmacy and physiotherapy) the extent of missing clinical experience and assessment opportunities and lack of confidence in using their knowledge was considerable and some were felt to require remediation (possibly some after qualification).
Students were made useful in the workforce (when on placement and also by encouraging deployment and volunteering) (CMOcs 2.3.1 to 2.3.4)
In the context of the need for work-ready graduates in the pandemic, final year medical assistantship placements, patient care on nursing placements and deployment of final year nurses on extended placements all facilitated work-readiness. The mechanisms were students performing the tasks of the healthcare professional (rehearsal), putting theory into practice, tailored to the patient and receiving constructive feedback from seniors (checking and rectifying). This consolidated the students’ skills of knowledge, reasoning and decision-making. The outcome for deployed students was to become more confident and skilled when they joined the workforce after graduation, especially if they had been deployed in the location where they were about to have their first job. Students also reported sometimes helping out relatively unsupported because the pandemic had caused staff sickness and burnout. Although this put pressure on the students concerned, they were able to experience practice almost as they would when qualified and they valued the experience of taking responsibility.
Deployment and volunteering worked well to make students clinically prepared. Those students who did healthcare jobs paid or as volunteers gained exposure and were given responsibility as healthcare team members so they felt confident, satisfied training requirements although there was some competition between their educational needs and the workforce gaps they were filling. Some earned money as well as supporting the health service. Those who didn't (vulnerable, having caring responsibilities, lacking opportunity) were expected to lack confidence.
Alterations to placement activities due to COVID-19 (CMOcs 2.4.1 to 2.4.10)
New and detailed inductions of students familiarizing them with the COVID-19 clinical environment generally worked well to prepare them for what would be different on placements. However, for physiotherapy students who had no prior clinical exposure, clinical theory was felt not to ‘click’ until they met patients face to face, when their learning now had meaning. Students appreciated experiencing the realities of working in the health sector in the COVID-19 pandemic "people are stressed and people are worried, and people are understaffed and overworked". Students explained that this made them better prepared for working in the real world.
Social distancing rules (2m distance) and hospital rules of only one visitor per patient meant that student numbers and duration on placements were reduced, especially for junior students. This gave them limited experience and exposure and impacted students’ experiences of some clinical areas.
Altered hospital case-mix affected all students but was especially difficult for radiography who had set assessed imaging and for physiotherapy who needed to learn to do body-system procedures.
Reduced clinical supervision and feedback by clinical staff during the COVID-19 pandemic affected the learning experience. Students acknowledged that this is part of the nature of the role and being able to adapt to that environment is part of training, but it was viewed as impacting students negatively in two situations – workplace assessment (some students found this problematic) and in medical student bedside teaching.
Remote consulting expanded in the COVID-19 pandemic and this had an impact on students on community placements in GP, Physiotherapy, Community Mental Health and Pharmacy where students were barred from home visits and consulting was mostly remote unless it was deemed essential to examine the patient. The context included new IT systems which were not working perfectly initially. Students learned by doing thorough histories by phone and gained IT skills but were not getting physical examination practice and missed patient contact, so their expectations of preparation for practice were not always met.
Virtual placements (CMOcs 2.5.1 and 2.5.2)
Pharmacy, physiotherapy and radiography students (and to a small extent medical students) had substitute virtual (group discussion with clinicians) placements to provide simulated clinical decision-making practice and exposure to clinical scenarios. They were felt to have some value but were only partial preparation as they lacked the hands-on nature of real practice. Junior students got more out of virtual placements and felt better prepared by them for subsequent placement practice of the basic topics rehearsed. Conversely, senior students and their tutors felt that virtual placements left them lacking in hands-on patient management skills and it was felt that pharmacy, radiography and physiotherapy graduates will need support. International students were particularly affected if they had a higher proportion of virtual to in person placements than their peers due to being out of the country. Also students who were struggling were thought to be going undetected on virtual placements.
Support for student wellbeing on placement (CMOcs 2.6.1 to 2.6.4)
University support services during the COVID-19 pandemic were appreciated but the challenge was considerable. Exposure at work and in the family to people very ill and dying with COVID-19, students having to cope with wearing full PPE and with the social isolation were among the main contexts which had effects on mental health and resilience. Support offered from student welfare (by email) and by supervising tutors and peer support had mitigating effects, but the university process for absence/extenuating circumstances was not perceived as geared towards the challenges faced.
Provision of COVID-19 testing and vaccination reduced fear of attending placement. In the early pandemic the fear of transmitting COVID-19 was greater for students with elderly family members at home, students with caring responsibilities, ethnic minorities and more vulnerable groups. Reassurance was provided by information and availability of COVID-19 testing and vaccine, role models and by habituation for those with a job outside the home. Later in the pandemic the realization that COVID-19 can't be avoided was a mechanism which operated positively in the context of provision of PPE, COVID-19 safety rules and training. When students were exposed to the hospital environment they generally felt that their wellbeing was prioritised, which enhanced their performance and learning experience during placement and trained them to work safely in a pandemic.
Risk assessments for students disadvantaged the medium- and high-risk individuals in terms of clinical preparedness, but was necessary to protect against COVID-19. Students assessed as vulnerable had some substitution of learning activities for placements and remediation later but they and their tutors felt that missing hands-on learning and the impact on motivation left larger gaps in their preparedness and they will therefore need extra support on starting work in acute areas.