Post graduate clinical placements: evaluating benefits and challenges with a mixed methods cross sectional design

Sample sizes varied according to the measure and method of data collection used and are therefore reported individually in corresponding sections of the results. Ethical approval was granted for all aspects of the study by the London City Road and Hampstead Ethics Committee, reference 11/LO/1044. This included approval of written informed consent procedures which were administered to participants.

The original aims of the scheme were largely met. Our first aim was to provide an added value experiential element to a primarily academic course. Relatively high uptake figures, low dropout and positive focus group comments provide evidence that this aim was achieved. The second aim was to cater to student demand for clinical experience providing the perceived enhancement of future career prospects. Figures across four academic cohorts showed that this aim was also met. Students’ own evaluation confirmed that placements met expectations and that their perception of benefit remained after completion. Our third aim was to increase students’ knowledge of the clinical workplace and offer them the opportunity to build relevant transferable skills and confidence. Data revealed that in some cases this was met, although confidence did not improve as much as expected. Finally, we set out to create a symbiotic relationship between students (would-be future healthcare providers) and current clinicians working in mental healthcare services. Data did indeed reveal a perceived ‘mutual benefit’ according to focus group evaluation; however, this was qualified by the inherent limitations of students’ time and expertise.

Quantitative results highlighted that uptake from individual clinical services was lower than initial expressions of interest suggested. Those who did engage had uniformly positive experiences, suggesting that further research to explore initial barriers to participation would be helpful. Student drop out was extremely low (3 students, 4 %, maximum), and was accounted for by wider contextual and personal factors, suggesting that for the majority initial enthusiasm was matched by ongoing commitment. Analysis of resources indicated that the scheme contributed significantly to local healthcare services, by providing the equivalent of seven full-time posts annually. A full time entry-level UK graduate position (e.g. a clinically unskilled, unqualified research assistant or support worker) currently costs the service £37,620 (including employer contributions and an urban ‘weighting’ payment). Seven FTE thus contributed £263,340 to local healthcare services. This, of course, represents additional manpower devoid of any clinical expertise or qualification. However national healthcare services typically employ around 47 % (547,000) non-clinically qualified staff (2013 data; Health and Social Care Information Centre, 2014). In addition this financial contribution does not take induction, training, supervision, infrastructural or administrative costs into account, which further limits the impact. It is nonetheless an important emergent finding from our study that placement students made a significant contribution to mental healthcare provision; a finding that may aid other courses in implementing similar schemes.

Questionnaire evaluation revealed that both students and clinicians had positive experiences of the scheme; however the low completion numbers for some cohorts mean that some caution must be attached to data interpretation. Of particular note, the majority of students (85 %) across all cohorts reported that it had enhanced their clinical skills and would benefit others, which is perhaps in part testament to the positive characteristics of those professionals with whom they were most closely working, as Buchel and Edwards [17] suggest. Furthermore, students perceived that they had built clinical therapeutic relationships with their patients while on placement, which were at least as good as those typically reported by practising clinicians, as measured by a standardised clinical instrument. This suggests that, in the students’ view at least, the placement scheme largely met its educational objectives of supplementing academic learning about mental health disorders by enhancing translational skills, professional knowledge and relevant experience. Likewise, clinical placement providers also reported positive experiences. Of note, all providers felt that students had demonstrated a good appreciation of the knowledge and skills of their professional colleagues, had shown respect and eagerness to learn, and most considered student attitudes and overall performance to be good. One interesting point of discrepancy, however, was that fewer than half of clinicians felt that students had made a significant contribution towards the service. Thus, while overall resource contribution to the scheme was significant, at the individual level this was not necessarily the perception of clinical placement supervisors. This is perhaps not surprising, given the limited time commitment and clinical expertise of the students.

Qualitative findings triangulated with, but also added to, the quantitative results summarised previously. The more in-depth analysis, which is characteristic of qualitative work, provided important additional insights, with implications for how the scheme could be further improved. The theme ‘Mutual Benefit’ reflected many of the positive quantitative findings summarised earlier, confirming the contribution of a new resource to services and students’ positive perceptions of the added value of their learning experiences while on placement. ‘Professionalism’ reflected the relative naivety of the student participants to the standards and norms prevalent in the healthcare workplace. While the scheme was clearly instrumental in teaching these values, the data highlighted a potential need for more structured teaching around this topic prior to commencing placement. Interestingly, this same theme has been highlighted as important by research in the medical domain [3]. While noting the importance of the concept of professionalism, particularly in the context of misconduct risk within professional practice, Tiffin and colleagues nevertheless found it to be a particularly difficult construct to measure using standardised tests, which suggests that softer approaches might be more suitable. On the other hand, Chipchase and colleagues [18] have conducted a useful consensus analysis of 258 clinicians’ perceptions of what makes a suitably well-prepared student, recommending six themes (57 individual characteristics), including Professionalism, which could be used to help prepare students for placements ahead of starting.

‘Time Commitment’ arose as a theme for students and clinicians, in the latter case indicating a possible reason why other clinicians may not be participating, despite initial interest. In over-stretched, under-resourced services (a common scenario in current UK healthcare provision), concerns around potential time consuming extra supervision load may have been overriding the perceived potential benefits of having an additional pair of hands. It is worth noting that this theme is likely to be less applicable in contexts where courses have compulsory rather than optional placements, because the time on placement will be seen by both parties as an inherent part of the course, rather than an optional extra, meaning that both student and provider have little cause to consider questions of additional or unnecessary time consumption.

Perhaps the most illuminating theme was that of ‘Bureaucratic Problems’, which was a key issue raised by students and clinicians alike. Complex and lengthy procedures for obtaining necessary approvals prior to patient contact were perceived by most as challenging and potentially prohibitive. An obvious implication of this is the need for additional administrative resource, provided by the course itself, to coordinate and streamline these procedures. Substantial additional administrative support is required if academic courses are to offer successful additions of practical healthcare learning opportunities to students.

One domain which did not figure prominently in our qualitative data was that of confidence. Given that for many students this would have been their first exposure to the realities of patient contact and clinical challenges, we were somewhat surprised at the absence of this theme. Indeed, other work has shown that confidence is a crucial skill for which practice placements can provide the ideal development opportunity: after all, they importantly provide the relatively simple experience of interaction with patients and clinicians and the development, through exposure, of maturity and a sense of personal agency [10]. It may be that the relatively high competition for places on the course evaluated here (around four applicants per place) acts as an inherent self-selection mechanism, yielding only those more confident students. Nevertheless, future work in this area might seek to investigate confidence as an a priori topic of interest.

This study had some notable strengths, but also a number of limitations. Using a mixed methods design was a clear strength, as we were able to combine hard factual data with more in depth analysis of attitudes and perceptions. This combination served to both triangulate the findings, as well as identify areas for improvement that would otherwise have been missed. A further strength was the ability to track the development and stabilisation of the scheme over a number of years, providing a useful longitudinal insight into the development and sustainability of the new initiative, although this was compromised somewhat by missing data for some cohorts.

An obvious limitation was that we were not able to include a hard outcome measure of impact of the addition of the new scheme, such as subsequent employability, or successful entry to professional training (such as clinical psychology programmes). It is notoriously difficult to track students’ progress upon leaving higher education, meaning that any obtainable figures are inevitably biased by self-selection of respondents. Another important outcome measure, which future work might seek to address, would be to include an assessment of the scheme’s impact on academic grades, to address the question of whether there might be a trade-off between practical experience and academic performance. It would presumably be important to students and lecturers alike to know that grades were not being compromised by the additional time and energy being devoted to non-assessed, optional placement activity. Additionally, it would be informative in future work to assess students’ (and course providers’) perceptions about whether, and how, their practical experiences on placement complemented didactic teaching on their course. One might hypothesize that the combination of academic learning with the opportunity to observe and apply this in practice might provide bidirectional added value to both components of the educational experience.

A further cautionary note is that the findings we present are, of course, limited in scope to the particular programme concerned. Further, the placements were voluntary, which may introduce an intrinsic sample bias in terms of the students choosing to undertake these placements, although the majority of the student population took part. Furthermore there were a limited number of placements and in some instances the sample size pertaining to the evaluation data is small. Nevertheless we argue that the considerations raised by this work may be useful in informing the discussions of other programmes that either currently feature, or plan to implement, similar added-value professional experience schemes.

Future work should consider a more in-depth analysis of the pedagogy behind the learning processes while on placement. As noted in the introduction, it is crucial that educational developments are driven by sound pedagogical principles and data. A good example of such an approach is that offered by Delany and Bragg [9], in which focus group work revealed some very different conceptions of the learning process between the clinical educators and their physiotherapy students on practice placements. Educators focussed on conveying structured knowledge in a series of discrete steps, while students - although appreciative of filling their knowledge gaps - conceived their learning as a more dynamic process of identifying contacts and techniques to develop their understanding. Similarly, academic and clinical educators do not always agree on the most important attributes to be developed during placement attachments [8]. Aligning the learning expectations and objectives of practice placements across students, academics and clinical supervisors - and making these explicit to all parties - will be an important agenda for the future of added value postgraduate components. Finally, future work might benefit by embedding within a socio-cultural theoretical framework such as the social learning system (SLS; [19]). A SLS is a social network containing ‘communities of practice’ (CoPs; [20]) and within which learning takes place. Learning arises, within CoPs, from interactions between individuals and their personal experiences when these are shared around a common passion, interest or goal. The medical education literature provides good examples of the use of the SLS framework to enhance our pedagogical understanding of the learning process during placement activities and these might serve as a template for future work within similar nonmedical settings ([21–23]).

The addition of healthcare placements to academic postgraduate taught courses can improve desirability, benefit healthcare services and enhance students’ perception of their learning experiences. Well-positioned and supported placement learning opportunities can be a key differentiator for academic courses, over potential competitors. The methodology and findings presented here could be useful as a model for other courses wishing to supplement academic content with similar clinical experiential opportunities and provide some examples of how such enhancements can be usefully evaluated. However, the actual implications for student employability and achievement remain to be established.