The wicked problem of healthcare student attrition.

The early withdrawal of students from healthcare education programmes, particularly nursing, is an international concern and, despite considerable investment, retention rates have remained stagnant. Here, a regional study of healthcare student retention is used as an example to frame the challenge of student attrition using a concept from policy development, wicked problem theory. This approach allows the consideration of student attrition as a complex problem derived from the interactions of many interrelated factors, avoiding the pitfalls of small-scale interventions and over-simplistic assumptions of cause and effect. A conceptual framework is proposed to provide an approach to developing actions to reduce recurrent investment in interventions that have previously proved ineffective at large scale. We discuss how improvements could be achieved through integrated stakeholder involvement and acceptance of the wicked nature of attrition as a complex and ongoing problem.

"My mentor didn't speak to me for the first four weeks": Perceived Unfairness experienced by nursing students in clinical practice settings.

AIMS AND OBJECTIVES: To explore the perceived unfairness experienced by student nurses during their undergraduate clinical placements. BACKGROUND: It is important that student nurses feel supported by practice staff during their clinical placement education experiences. However, it has been reported that learners can feel ignored, unsupported and bullied by others in the clinical environment and this has a detrimental effect on their learning. It is important to understand the student nurse perspective and explore ways in which their feelings of belongingness might be enhanced in the clinical area. DESIGN: A descriptive narrative approach was used to explore the qualitative data generated by the survey and interviews. Limited closed-question survey data were acquired to explore a selection of quantified survey responses about placements and mentorship. METHODS: A survey was conducted with 1,425 student nurses from adult and mental health degree nursing pathways, across nine institutions in the North West of England, UK. Unstructured interviews were undertaken with 22 student nurses from across these nine institutions. The data generated from both methods (free-text survey responses and interview) were thematically analysed. RESULTS: There were times when student nurses felt that they had been treated unfairly by various members of the healthcare team during their clinical placements. Unfairness was related to being ignored and unsupported or being used as an "extra pair of hands" and having their supernumerary status ignored. Student nurses want to have feelings of belongingness in the clinical area and value enthusiasm for teaching from mentors. Certain positive mentor qualities were identified through the data in this study. These have been used to inform a tiered model of mentorship, to inform future thinking about student nurse education. CONCLUSION: Student nurses can feel like they are being treated unfairly in the clinical area in numerous ways. Identifying ways in which mentorship practice can be developed to adequately support education is important. This can lead to satisfaction and development on both sides of the student/educator relationship. RELEVANCE TO PRACTICE: Exploring student nurse perceptions of their learning is important when attempting to enhance educational practice in the clinical setting.

The influence of role models in undergraduate nurse education.

AIMS AND OBJECTIVES: To explore the concept of role modelling in undergraduate nurse education and its effect on the personal and professional development of student nurses. BACKGROUND: Effective educative strategies are important for student nurses, who have to cope with learning in both clinical and university settings. Given the contemporary issues facing nurse education and practice in the United Kingdom (UK), it is timely and important to undertake pedagogical research into the concept of role modelling as an effective educative method. DESIGN: A descriptive narrative approach. METHODS: Unstructured interviews were conducted with 14 current/recently discontinued students from Adult and Mental Health branches of nursing degree programmes in the north-west region of England, United Kingdom (UK). Data were thematically analysed. RESULTS: Students valued exposure to positive role models in clinical and university settings and viewed them as beneficial to their learning. Exposure to negative role models occurred, and this provided students with opportunities to consider the type of nurse they aspired to become. In some cases, students' exposure to perceived poor practice had an adverse effect on their learning and led to negative feelings about nursing work. Clinical staff might be perceived as more relevant role models than those in the university setting although there were still opportunities for academic staff to model professional behaviours. CONCLUSION: The study found that role modelling is an effective way to support learning and led to student satisfaction across both clinical and university settings. The findings support the use of role models in nurse education, and further research about conscious positive modelling of practice is required. RELEVANCE TO PRACTICE: Exploring the use of role models is important when examining ways in which the quality of nurse education might be developed.

Supporting physiotherapy learners in practice settings: a mixed methods evaluation of experiences of physiotherapy educators.

BACKGROUND: Practice-based education is an essential component of pre-registration physiotherapy programs, and there is a need for a contemporary review of practice-based educational experiences. PURPOSE: The aim of this study was to explore physiotherapy practice educators' experiences of supporting learners to inform considerations for future workforce development. METHODS: This was a mixed methods sequential explanatory study based in the United Kingdom (UK). Phase one of the study utilized an online survey disseminated via the Chartered Society of Physiotherapy (CSP) professional networks. Phase two consisted of three semi-structured focus group interviews with participants who expressed an interest via completion of the online survey. All were registered or associate CSP members who actively support practice-based education. RESULTS: A total of 208 participants completed the online survey and a sub-set of 15 participated in online focus groups. Quantitative survey data were analyzed using descriptive statistics. Initial thematic analysis of qualitative data from both phases was undertaken by one researcher. Subsequent analyses were carried out independently by the remaining research team, and comparisons were made to agree on codes, categories, and themes. The practice educator is vital in developing the future workforce (30%, n = 61, strongly agree). Identified challenges included supervising more than one learner (34%, n = 67 not at all experienced) and using technology to provide alternative placement models (45%, n = 87 not at all experienced). CONCLUSION: Practice educators need accessible opportunities for professional development. Practice-based education should be embedded as an integral component of all staff roles. A team approach is essential to developing the future physiotherapy workforce.

Birley Place: a virtual community for the delivery of health and social care education.

Virtual simulation can provide high-quality learning experiences through innovative and engaging activities while also overcoming some of the constraints associated with physical simulation. We developed a virtual community, called Birley Place, to facilitate simulation-based learning activities. Adopting a novel approach, we modelled the virtual community on the large metropolitan city in which our institution is based. Publicly available health and population data were used to ensure that the homes, businesses and services in the community were representative of distinct socioeconomic areas of our city. The residents of the virtual community were also matched with the real-world areas based on health and lifestyle data. Our virtual community is used to facilitate learning activities across our health and social care degree programmes. In this article, we summarise how we developed Birley Place, before providing one example of how it is used to facilitate the delivery of a large-scale interprofessional education project. Birley Place is an innovative tool for delivering online and virtual simulation. The use of this virtual community facilitates learners' understanding of the connection between settings and health status.

"Feel the fear and do it anyway" nursing students' experiences of confronting poor practice.

AIM: The two aims of this study were, first, to explore nursing students' experiences and perspectives of reporting poor care and second, examine the process by which they raised concerns. BACKGROUND: The nursing literature is replete with studies which explore nursing students' experiences of clinical placement. However only a small number explore students experiences of challenging poor care and how this is enacted in the practice setting. SETTING AND PARTICIPANTS: Fourteen nursing students from undergraduate pre-registration nursing programs across three universities, two in the United Kingdom (UK) and one in Australia. DESIGN AND ANALYSIS: This paper reports findings from narrative interviews about students' clinical experiences of reporting poor care. Data were audio recorded, transcribed verbatim and analyzed using a constant comparison approach. Emerging themes were identified, discussed and verified by the researchers. RESULTS: Four montages from the narratives highlight the overarching themes: bullying, patient advocacy, lack of empathy and poor care. They demonstrate how, driven by an ethical imperative, students speak up when they witness poor care despite the difficulties of doing so: in some cases, the students in this study were prepared to continue speaking out even when initial concerns were dismissed. CONCLUSION: Both practice and university teams have a responsibility to support students' development as ethical and courageous practitioners, able to recognize when care falls below an acceptable standard.

'She would wash the patients as if she was scrubbing a dirty plate in the sink': Exploring nursing students experiences of care delivery.

BACKGROUND: While much is known about nursing students' clinical placement experiences in general, less has been reported about their specific encounters with poor care delivery. A few small-scale qualitative studies have been undertaken, which suggest that nursing students do witness poor care but often decide not to act on what they see. This study sought to explore a wider international perspective on this issue. AIMS: To explore nursing students' experiences of the care delivery practices witnessed during clinical placements and to provide descriptions of poor care. SETTING AND PARTICIPANTS: Nursing students from undergraduate pre-registration nursing programmes across three universities, two in the United Kingdom (UK) and one in Australia. DESIGN AND ANALYSIS: A qualitative/quantitative survey design was utilised, and data were descriptively analysed. RESULTS: Two hundred and sixty-five students participated in the study. Overall the results were positive. Nevertheless, the participants did provide multiple and recurring examples of poor nursing care which related to a lack of compassion, poor communication, unkind and indifferent provision of personal care, and patient safety. Reporting of poor care was viewed as difficult and many participants highlighted potential repercussions should they take this course of action. CONCLUSION: This research provides contemporary international insights into care delivery practices from the perspective of a large number of nursing students. The results, although mainly positive, outline multiple examples of poor and ineffective practice. While the precise prevalence of these remains unknown, educators, practitioners and students should consider how best to address them when they occur.

PLATO: A practice education tool to support learning and professional development.

It is important that nursing students are adequately supported during their clinical practice placements in order to promote effective learning and reduce student attrition. Educators have an important role and this paper offers an interactive tool, 'PLATO', (The Practice Learning and Teaching Orientations Tool) to support them to meaningfully engage with learners in the practice setting. To enable such engagement, four personal orientations are presented, (role model, advocate, legitimiser and respecter) which enable educators to explore their role, across both local and wider contexts. PLATO recognises the multiple and varied influences on practice education and supports educators to develop their practice in a positive way.

Students' perceptions of their learning experiences: A repeat regional survey of healthcare students.

BACKGROUND: Student experience is an international concern and recent research has focused on initiatives to improve students' learning experiences and ultimately reduce attrition levels. OBJECTIVE: To determine similarities and differences between students' perceptions of their learning experiences between 2011 and 2015 in relation to campus-based learning, placement-based learning and personal circumstances. DESIGN: A repeat online survey in 2011 and 2015; using a questionnaire developed from thematic analysis of narrative interviews with a subsample of the target population. SETTINGS: Nine universities in the North West of England. PARTICIPANTS: A total of 1080 students completed the survey in 2011 and 1983 students in 2015 from a target population of all students studying on commissioned pre-registration healthcare education programmes. METHODS: An online survey was made available to all undergraduate students studying on Health Education funded programmes within the region and survey respondents were invited to give demographic information and rate their agreement to statements on four-point Likert-type responses. RESULTS: Responses to a repeat survey of healthcare studying in the North West of England in 2015 were strikingly similar overall to those of an original 2011 survey. Although the students were positive overall about their experiences, a number were dissatisfied with some aspects of their experiences - particularly in relation to initial support on campus and whilst studying on placement. Four years on from the original survey, despite a considerable investment in improving students' experiences across the region, there appears to be little change in students' perceptions of their learning experiences CONCLUSION: In the short-term monitoring of student experience needs to be continued; and links to attrition (potential or actual) noted and acted upon. However, given that attrition from these courses has been a long-term problem and the complexity of its resolution a recurrent finding in the literature; new ways of framing and resolving the problem need to be considered.

What are reasonable expectations? Healthcare student perceptions of their programmes in the North West of England.

BACKGROUND: Concerns about current levels of attrition from some healthcare programmes have emphasised the need to gain a greater insight into students' expectations and experiences. OBJECTIVES: The aim of this study was to determine how students in the North West of England perceived their studies and to identify the factors that could contribute to students' dissatisfaction. DESIGN: A mixed methods sequential exploratory study. SETTINGS: Nine universities in the North West of England. METHODS: Phase one used narrative interviews with a purposive sample of 24 students to investigate their expectations and experiences. Data from these interviews were analysed using a thematic framework and direct quotes from key themes were incorporated into online survey for phase 2. Survey respondents were asked to rate their agreement to statements on a four-point Likert-type response format. There was also an opportunity to leave comments through open questions relating to each theme. RESULTS: A total of 1080 respondents completed the online survey in phase 2. The majority of students reported positive experiences of their course. There was strong agreement in the importance of the role of the personal tutor and of a supportive placement mentor. Some students indicated that the workload and academic level were a shock at first. Students identified difficulties around the cost of placement travel and the impact of placements on family life. Financial hardship was a frequently cited issue that students attributed to thoughts of discontinuation. CONCLUSIONS: Most students had positive learning experiences which meet their expectations. Students who have unmet expectations report poor placement experiences, lack of support, unexpectedly high workloads and financial difficulties. Clear guidance on the role of personal tutor and placement mentor is recommended.

Should I stay or should I go? A study exploring why healthcare students consider leaving their programme.

BACKGROUND: Attrition in healthcare programmes is a growing concern internationally. Students leave for a variety of reasons but it is difficult to understand the complex interactions that eventually lead to attrition. OBJECTIVES: The objectives of this study were to identify the factors that prompted students to consider leaving their programme, and to make recommendations regarding strategies to reduce attrition. DESIGN: One aspect of a larger survey, which itself was part of a larger sequential mixed methods study. SETTINGS: Nine universities in the North West of England. METHODS: An online survey developed as part of a mixed methods sequential exploratory study was completed by students on nursing and allied-health programmes. The detailed responses obtained for a question relating to if the students have ever considered leaving their current programme were analysed both quantitatively (content analysis) and qualitatively (framework analysis). RESULTS: 1080 students completed the survey (an estimated 11% response rate); of this group 999 students answered the question 'have you ever considered leaving your current programme?' 465 students (47%) indicated that they had considered leaving and provided detailed comments explaining the circumstances that induced them to deliberate whether or not to stay. A thematic analysis of the data found three distinct themes: dissatisfaction with academic workload and support; difficulties associated with clinical placements, and personal concerns and challenges. A significant number of student comments combined two or more of these themes. A number of students also detailed why they decided to stay. CONCLUSIONS: Those students that had considered leaving frequently described how a combination of diverse factors accumulated to lead to them contemplating leaving their programme. Strategies to reduce attrition in healthcare students need to consider the student lifecycle from recruitment to graduation, to set reasonable student expectations and ensure that a career within healthcare is both desired and valued.

'The placement was probably the tipping point' - the narratives of recently discontinued students.

Much has been written on student attrition from healthcare programmes and we know that it is often multifactorial. However in order to reduce attrition we need to gain a greater understanding of how multiple factors impact upon and compound one another to prompt a student to decide to leave. The purpose of this study was to explore healthcare students' experiences of university and the circumstances that initiated their decision to leave their programme. Sixteen students that had recently left healthcare programmes within the North West of England were interviewed by telephone, using a narrative prompt to facilitate them to tell their stories. All the students gave detailed narrative accounts that described their learning experiences, growing dissatisfaction and subsequent attrition. In the majority dissatisfaction and difficulties around clinical placements acted as a tipping point that precipitated departure.