Blended learning: Maintaining clinical placements for child nursing students during the COVID-19 pandemic

Service pressures have been increasing for a number of years (The Kings Fund, 2019; 2021). The COVID-19 pandemic highlighted the strain under which the NHS and other health and social care organisations have been operating (Dunn et al, 2021; NHS England, 2021b). The UK Government announced in 2019 that an additional 50 000 nurses would be in post by 2024 (The Conservative Party, 2019). This announcement, alongside pandemic-induced service changes, has meant placement providers and higher education institutions (HEIs) have begun working innovatively to increase clinical placement provision for student nurses (Carolan et al, 2020).

In one Community NHS Trust in the north of England, placement provision was reduced by 60% during the first COVID-19 lockdown. Subsequently, the placement circuit reopened at a much-reduced capacity. It became imperative that alternative methods of providing clinical placements were considered. One of the ways of increasing placement capacity was to introduce blended placements.

Blended learning as a concept has been widely utilised in UK educational settings (Garrison and Kanuka, 2004). Alongside more traditional methods of learning, digital, virtual and simulated learning environments have been used to support learners academically. Blended clinical placements for nursing students are relatively new. However, they provide enhanced student experiences, including through use of technology-driven learning. One of the advantages of blended placements during the lockdown was that students were able to undertake some clinical practice, while in the relative safety of the ‘home’ environment. By adapting to ‘working from home’, the COVID-19 risk to students, staff and patients/service users was reduced by limiting face-to-face contact substantially. This was particularly important for individuals who were shielding, or who were at higher risk of COVID-19 complications.

The aim of this placement was to maintain opportunities for child nursing students during the COVID-19 pandemic. The blended placement model used in the pilot gave students the opportunity to engage with virtual clinics alongside nurses in two services within the trust. Students also undertook digital-based learning to support patient-facing learning. Digital learning included ‘lecture-style’ taught sessions and self-directed learning. In some cases, students were still able to partake in face-to-face visits. This article describes evaluation feedback given by students and practice supervisors after completion of the pilot. It considers the implications for future blended placements.

Methods

A two-part 3-week blended placement was created using an iterative ‘plan, do study, act’ (PDSA) cycle (NHS England and NHS Improvement, no date.). The services selected to take part in the pilot were the 0–19 public health integrated nursing service (0–19 PHINS) and the integrated children's additional needs service. These services had practice supervisors who were familiar with student supervision and had the facilities to support the digital and virtual aspects of the blended placement.

A timetable was devised and refined by the placement learning facilitators and placement educator leads, which provided learners with opportunities to engage with a range of clinical teachings delivered by child health professionals via the Microsoft Teams application, in addition face-to-face service user contact was planned around the clinical teaching sessions each day. Within the timetable, sections were left unallocated to allow students to develop individual opportunities with their practice supervisor. Examples of these opportunities included podcasts, webinars and e-learning.

Timetables for the blended placement activities were emailed to the academic programme team, practice supervisors and students before commencement of placement.

All students on the placement were first-year child nursing students on a three-year degree programme, at a local university. Twenty-five students were allocated to the blended placement. The 25 students were split into cohort A (n=12) and B (n=13). Cohort A spent three weeks on the community blended placement before immediately undertaking a face-to-face placement in a children's hospital setting. Cohort B undertook the face-to-face children's hospital placement before undertaking the blended community placement. The cohorts undertook the community blended placement sequentially. No changes were made to the blended placement between cohorts to ensure parity.

Practice assessors were employed within the children's hospital and therefore were not directly involved with the planning and delivery of the blended placement. This pilot evaluation only considered the practice supervisors and learners based within the community.

Students were given access to placement specific IT software at the start of the placement to enable them to participate in virtual aspects of the blended placement. Students were given access to NHS electronic communication and services.

Prior to starting placement, all students were given general practice placement information by their university. The information was not specific to community services or blended placements. On commencement of the community placement, students attended a virtual induction day, setting out expectations including professional behaviours, digital etiquette and information governance. As blended placements were new to all students, time was set aside to answer student questions. Students engaged with their practice supervisor through online or face-to-face supervision session, and with the NHS trust placement learning facilitator during weekly ‘cuppa and catch up’ pastoral sessions.

Satisfaction of the blended placement was measured qualitatively, using locally devised questionnaires for students and practice supervisors. Questionnaires were administered using Google forms and emailed to students and practice supervisors. Those who did not respond to the questionnaire on first request were sent two email reminders by a representative of the Trust, and one email reminder by the students' university.

Ethical considerations

This improvement project was not considered research by the Health Research Authority. Ethical approval by a research ethics committee was not required, but approval to undertake the project was gained from clinical leads, service managers and the University of Leeds. Ethical considerations were deliberated by the project team, including the impact of placement changes on students and those facilitating learning in practice.

Findings

Twelve students and five practice supervisors responded to the placement questionnaire. Responses are presented narratively. The responses are headed under three themes, information sharing, perceived learning opportunities and student support.

Information sharing

Prior to commencing placement, students were given a range of information about their placement. Some expressed surprise that their placement would encompass virtual elements as there had been some expectation that they would be in face-to-face placement full time (n=4). Information about the placement was perceived as being given to students at short notice (n=3). Three students suggested that they understood the need for last-minute preparation due to the pandemic, others felt it was disorganised and there had been poor communication prior to the placement (n=4). All but two respondents felt that pre-placement preparation could have been improved. Student respondents noted they wanted to better understand how to get their electronic practice assessment documents (ePad) signed by practice supervisors that they only met virtually, as some of the ePad resources provided by the university were confusing (n=4). Some pre-placement sessions organised by the university were considered by students as focussing too heavily on non-community placements (n=3). Further information specific to the community and in particular blended placements would have been useful to these respondents (n=7). Practice supervisors were generally more positive about the university pre-placement preparation. Three Practice supervisors that were less certain about university-led preparation noted issues with accessibility of information specifically to ePad (n=1), lateral flow testing (n=1) and blended placements (n=1).

Students all found the trust induction to the blended placement useful, with 11 respondents agreeing that they felt it prepared them for the blended placement. Students gained an understanding of the services they would be working within (n=7), how the placement would work (n=5), points of contact throughout the placement (n=1), and how to access learning activities using the timetable (n=3). Positive aspects of the induction included the opportunities to ask questions throughout the day (n=2). However, there were still questions left unanswered regarding some virtual aspects of the placement (n=2), and understanding when or if students would meet their practice supervisor face-to-face (n=1).

Learning opportunities

Perceived learning opportunities included understanding more about community nursing, and development of knowledge that could be used in future practice (n=5). The knowledge students gained during the ‘lecture-style sessions’ supported their theoretical knowledge (n=6). One respondent noted their new knowledge related to local research-led practice, and another felt the blended placement was beneficial in understanding child development milestones (both placed in 0–19 PHINS). Not all students were able to see the value of their placements in relation to their studies, five student respondents felt it had little or no association with their education programme.

Two respondents stated they enjoyed having a blended placement so they could continue working on their academic assignments. Issues that were raised by respondents included not achieving NMC proficiency (n=7). Students were uncertain how they could demonstrate skills themselves during virtual consultations. They noted limitations of working with the practice supervisor virtually, and issues with technology that made learning more difficult. One respondent commented that no patient had yet turned up to a virtual clinic. Another noted that they had not been invited to rearranged appointments. Despite this, all but one respondent felt the blended placement enabled them to meet some learning outcomes.

Practice supervisors were more positive about the opportunities for students to meet learning outcomes in their responses. Three practice supervisors did, however, note challenges to assessment of meeting outcomes. One raised concern that blended placements may not give staff adequate exposure to ‘failing students’, and another noted that working with a student face-to-face promoted more opportunity for reflection and discussion, which was perceived as providing greater opportunity for learning. The most positive aspects of meeting learning outcomes were students' exposure to a variety of staff members, which would not have been possible during purely face-to-face placements. Practice supervisors gave a range of views about students' understanding of ePad completion. Three practice supervisors said that the student did not have an understanding of the ePad or how they would be assessed using it, two practice supervisors said their student had a good awareness of the assessment criteria and how to use the ePad.

Students felt that the timetable could be planned in future so that online ‘taught’ sessions did not clash with clinic times. Attendance at the online sessions was perceived as preventing some students from having face-to-face opportunities. One practice supervisor suggested that students considered the virtual sessions as optional, and where there were face-to-face clinics organised at the same time, students attended those instead. Another practice supervisor noted that it was impossible to monitor attendance at the digital sessions (signing off clinical hours remained practice supervisor responsibility). Student comments about the value of the online sessions were mostly positive, but one noted there was some repetition between talks, and another commented that the lack of interactive opportunities during lecture-style sessions was a barrier to learning (n=1). Practice supervisor respondents all suggested that the virtual sessions had complimented patient-facing activities. Three practice supervisors said that the virtual aspects enabled the students to consolidate their knowledge.

Students felt confident to use the software they had encountered previously at university as part of their placement, but additional knowledge about the placement-specific app, Accryx, would have been useful during the induction (n=2). One student felt that it would have been helpful prior to placement to know that they would have to download software to their computer.

Student support

Most students were very positive about their practice supervisors (n=11). Most felt well supported. Many practice supervisors organised face-to-face service user contacts around students' online timetables, which the students appreciated. Those students who got fewer opportunities to go out into practice were more critical of the blended placement in their questionnaire responses (n=3). In addition, respondents noted the opportunities for pastoral support provided by practice supervisors and the placement learning facilitator (n=10). One respondent felt more comfortable asking questions to their academic assessor (based in the HEI), and another had difficulties which remained unresolved and impacted how placement support was perceived.

There were many positives to undertaking a blended placement, including working with a variety of professionals, learning more about the community setting, and having opportunity to make face-to-face visits. The drawbacks were considered as a lack of support in self-directed learning, timetabling that did not fit with the services they were placed with; and lack of contact details for the people they would attend appointments with (as this was not always the practice supervisor). Some of the questionnaire responses suggested students discussed the blended placements between themselves. Some responses explained that ‘others’ received a better experience than the person making the comment. One student stated that virtual placements did not represent value for money. Practice supervisors found the blended placement enabled them to balance their caseload with the needs of the students more easily (n=2), they also mentioned that previously there were times where there would be little for a student to actively be involved with. Having preassigned digital work meant that they felt the students' learning was more directed (n=2). Three practice supervisors said that difficulties with digital technology was a barrier to supporting students on the blended placement.

Students suggested ideas for improving blended placements, these included some timetabled virtual sessions should run before clinic times, less self-directed learning, having separate virtual days and non-virtual days to give greater opportunity for organising visits with teams; ensuring that every day on placement when learning virtually should be fully timetabled. Practice supervisors also suggested improvements; various strands of the administration of the placement required development (e.g. clearer information for practice supervisor and student) (n=4), and separate days of digital and face-to-face time so that students were able to attend clinics more easily (n=1).

Discussion

Piloting a blended placement within children and young people's services was an opportunity to maintain the placement circuit during a time of increased service pressure. It also enabled trialling new models of placement learning. Using blended approaches within higher education has been shown to have positive effects (Garrison and Kanuka, 2004; McCutcheon et al, 2018; Sáiz-Manzanares et al, 2020). This pilot was able to show the potential for continued blended placements within two children's and young people's services.

Practice supervisors who responded to the questionnaire were particularly positive about the benefits to learning within the blended placement. Due to the low response rate, these responses cannot be generalised, and may not be transferrable across the placement. Nevertheless, it can be surmised that for some practice supervisors the ability to manage caseload alongside student learning opportunities was improved by including a virtual element within the placement.

Evaluation feedback suggested that students did not necessarily feel they had been afforded the same opportunities when attending virtual and face-to-face clinics as their peers. However, the way the timetable was constructed should have enabled all students on the placement to undertake very similar clinical experience. As this was not perceived to be the case by some respondents, managing expectations will be reconsidered for future cohorts. Where students felt they had missed out due to non-attendance at appointments, they will be supported to reflect on why service users may not have attended, considering factors such as socioeconomic circumstances, and environmental and physical considerations.

Despite practice supervisors having the taught session timetable, and an attendance register having been taken for each session, there was still concern about monitoring engagement with learning when the student was not under direct supervision of the practice supervisor. As one practice supervisor pointed out, this could be more of a concern when students may be failing. Clear guidelines should be implemented which facilitate practice supervisors to confidently determine whether all aspects of the blended placement have been undertaken satisfactorily by the student. However, it is important to recognise that students now take responsibility for providing appropriate evidence within their placement documentation. Additional training on the digital aspects of education could be beneficial for some practice supervisors and assessors.

The learning needs of Generation Z students have been well documented (Hampton and Keys, 2017; Chicca and Shellenbarger, 2018). Qualitative comments given by students attested to preferred learning methods. As a generation, students coming into higher education since 2013, are perhaps less likely to pay attention to detail, and to think critically about application of theoretical knowledge to practice (Hampton and Keys, 2017). However, students partaking in this pilot expressed usefulness of the knowledge gained, for future clinical experiences. Those that could not make theory/practice links between the ‘taught-sessions’ and clinical practice may need support of their practice supervisor/HEI to make those links.

Additionally, having time for ‘self-directed learning’ which is not clearly mapped to proficiencies can be confusing to learners. Timetables with perceived ‘gaps’ may feel like wasted time to learners who are used to having constant and immediate information available to them. Where students are expected to undertake learning for themselves, clear objectives relating to practice standards could increase the perceived relevance of self-directed work. Mapping all aspects of the blend in advance may support recognition of achievement for assessment. A drawback of this approach may be that by fully mapping outcomes to the placement experience could reduce students' engagement and involvement in their learning journey, minimising opportunities for students to direct their own learning.

Within this pilot pastoral needs were accounted for with the weekly ‘cuppa and catch up’ sessions. The sessions were well attended by both cohorts. The sessions provided an opportunity for students to reflect on their learning and connect more informally with Trust staff. It also gave opportunity for students to receive support and guidance (Chicca and Shellenbarger, 2018) and foster deeper learning (Carolan et al, 2020). Anecdotally, cohort A were more engaged with the sessions. However, feedback did not provide explanation for this. Cohort B had previously experienced a traditional placement, which may have had some influence on expectations and engagement. Therefore, there are opportunities to consider pastoral engagement in future.

Generation Z is known to have individualistic traits when it comes to their education (Hampton and Keys, 2017). While pragmatism was demonstrated by some student comments, others had strong views on not having an optimal placement experience compared to others. Additional preparation prior to placement may address some of the concerns expressed, to ensure student expectations are managed. Clear and timely information in small amounts may support both students and practice supervisors to make the most of the blended placements (Chicca and Shellenbarger, 2018).

The way information is presented regarding the ePad needs particular consideration. Despite students having pre-placement taught sessions, and online resources being available, not all students or practice supervisors were able to easily access or understand this information.

Some students were concerned that they did not have enough ‘hours’ of placement experience. The NMC Recovery guidelines state that up to 300 clinical hours can be undertaken digitally, virtually or through simulation (Nursing and Midwifery Council, 2021). Clear signposting on the blended placement timetable could alleviate some student worries about the number of hours they are undertaking while in a blended placement. What counts as a learning experience may affect how students evaluate clinical placements. Using Bloom's revised taxonomy (Krathwohl, 2002), some of the concerns about learning experiences, if framed positively, could have enabled students not only to apply their knowledge, but also analyse and evaluate. Analysis and evaluation involve higher cognitive processes (Krathwohl, 2002). Managing student expectations about what constitutes learning may support students to understand all learning opportunities afforded to them in practice.

Storytelling and engagement with personalised experiences are known to be a strong learning preference in Generation Z (Timpani et al, 2021). Meeting a range of staff virtually, and understanding others' experiences was well-liked by respondents. Where information was given about services, it is important that there is no repetition. It has been estimated that Generation Z has an attention span of 8 seconds (compared to 12 seconds in Millenials) (Billings et al, 2016), therefore when information is perceived to be irrelevant, engagement may be reduced.

It is also important to consider the previous 18 months, and how that has affected learning. Many nursing students have primarily (if not exclusively) been taught online during the COVID-19 pandemic response within the UK. ‘Zoom fatigue’ can reduce engagement, with similar phenomenon noted in other social media use (Dhir et al, 2018; Nadler, 2020). Many non-verbal communicative cues associated with face-to-face communication are absent from online communication which can make it tiring for presenter and learner (Nadler 2020). With this in mind, it is important that there is a balance of face-to-face opportunities and virtual opportunities. Learning exclusively online may also exacerbate anxieties and loneliness (Dhir et al, 2018), which is of particular concern for younger learners within HEI who have experienced a reduction in social interactions since the pandemic started (Bu et al, 2020; Elmer et al, 2020).

Practice assessors were not asked for feedback during this pilot, and in future iterations of this placement blend, understanding how practice assessors feel about the blended placement may illuminate further aspects for ongoing development.

Conclusions

The placement was successful in opening clinical practice to students during a period of increased service pressure and societal change. It provided learners with a new opportunity to meet specialist professionals virtually whom they may not have met during a face-to-face placement, and provided additional insight into services. A number of issues were raised by staff and learners as a result of the blended placement. Feedback was welcomed as opportunity to develop the placement. Many of the perceived issues can be overcome or minimised in future. Focus for change will be on information provision, considering the needs of generation Z learners. There are opportunities to develop this style of placement to meet student and workforce expectations.

KEY POINTS

• There is scope to develop blended learning placements for nursing education
• Generation Z learners have educational requirements that should be considered when designing blended learning placements
• Timely and specific information provision is essential to positive placement experiences
• Practice supervisors should be supported to facilitate digital and virtual placements

REFLECTIVE QUESTIONS

• What methods of alternative placement could your service offer students?
• How could you adapt information provision to support Generation Z learners in placement?
• What steps could you take to improve your knowledge of supporting students using digital or virtual tools?