Clinical placements are an essential element of all pre-qualifying healthcare programmes. In the UK, nursing and midwifery placements currently account for 50% of programme hours, equating to 2300 hours of clinical placement during training (Nursing and Midwifery Council (NMC), 2018a). Internationally, there is evident variation in the number of hours allotted to practice learning. Nursing students in Australia and Canada undertake 800 hours (Australian Nursing and Midwifery Accreditation Council, 2019; Canadian Association of Schools of Nursing, 2022), in South Africa they undertake 2800 hours, while in New Zealand they undertake between 1100 and 1500 hours (Miller and Cooper, 2016). Many countries (Australia, Canada, Finland, USA, the UK) have included completion of these placement hours in their requirements for registration (American Nurses Association, 2021; Canadian Nurses Association, 2015; Nursing and Midwifery Board of Australia, 2016; Anderson et al, 2018; NMC, 2018b).
Nursing courses in the UK have witnessed a significant (32%) rise in applications (Universities and Colleges Admissions Service, 2021). One forecast suggests that the global nursing education market will grow 5.6% over 2020-2027 (Data Bridge Market Research, 2022). This increase in interest and future nursing supply should be welcomed, but placement capacity is now the key factor precluding growth in supply, with universities having to limit nursing student numbers entering due to insufficient placement availability.
To achieve required hours, placement allocation in nursing has historically adopted a rotational approach, with students rotated around a range of clinical learning environments, each placement having a particular clinical focus or specialty. However, evidence suggests that such an approach limits students' understanding of the whole patient journey, including the range of services that patients access, because placements are compartmentalised and frequently unrelated to learning (Campbell, 2008). Additionally, although the rotational approach can expose students to a range of clinical experiences, the constant new starts in unfamiliar clinical settings lead to poor student confidence, anxiety and insecurity (Campbell, 2008).
An alternative to rotational placements that is increasingly being adopted is a hub-and-spoke approach, whereby students are allocated to a home-based or ‘hub’ placement, from which they ‘spoke’ out to short bite-size placements, adding breadth to the overall placement experience. The hub-and-spoke model has its origins in the transport industry, most notably aviation, where the use of resources (flights, fuel and personnel) was substantially improved by introducing a main base with satellite points for travel (Lin and Kawaski, 2012; Elrod and Fortenberry, 2017). The healthcare sector has adopted this organisational model over the past 25 years in a number of places. Examples include health service provision in parts of the USA (Elrod and Fortenberry, 2017), hub-and-spoke dispensing for European community pharmacies (Rechel, 2018) and the hub-and-spoke model for practice learning for nursing students (Roxburgh et al, 2012), who describe the hub-and-spoke model process as follows:
The student is allocated to their Mentor (hub) and allocated by that mentor to other areas/mentors (spoke) to ensure the student achieves a variety of experiences and skills that allows them to achieve the NMC Standards of Proficiency. The (Spoke) mentors provide feedback and assessments to the main Mentor (Hub).
Pilots of this model were implemented as early as 2009 in Scotland (Roxburgh et al, 2012), followed shortly with pilot projects at universities in England. For example, the University of Wolverhampton adopted hub-and-spoke by allocating students to one hub placement per year, with students returning for three separate blocks of placement during the academic year, throughout which they were supported by the same mentor (Thomas and Westwood, 2016). Students were allocated to ‘spoke’ placements, lasting 1–4 weeks, the aim being for the spoke placements to reflect patients' journey across healthcare settings (Thomas and Westwood, 2016).
Notwithstanding this, the hub-and-spoke approach to student placements has not been universally adopted in the UK. Establishing the model requires additional organisation, placement providers mapping the students to spoke placements according to their specific learning needs, while ensuring that a high-quality learning experience is achieved (Millar et al, 2017; Heath et al, 2021) and that students have an enriching experience rather than being used as an additional ‘pair of hands’ (Thomas and Westwood, 2016: 26). Evaluation of the hub-and-spoke model suggests that the student experience is enhanced (Thomas and Westwood 2016; White and King, 2015). There is also evidence suggesting that ‘hub-and-spoke models’ increase placement capacity (Roxburgh et al, 2012; East Suffolk and North Essex NHS Foundation Trust, 2023). It is therefore timely to explore the evidence base for hub-and-spoke placement allocation models to determine whether this approach has the capability to increase placement capacity, while concomitantly enhancing the students' learning experience.
Research question/aims
The aim of this review was to summarise and synthesise the empirical literature in order to provide a comprehensive understanding of hub-and-spoke placements used to train undergraduate nurses and explore whether this approach increased placement capacity.
A secondary aim was to evaluate the strengths and drawbacks of hub-and-spoke placement models.
Methods
Design
A systematic scoping review was used to explore the topic, as the overarching aim was to identify and summarise the research conducted in this area, along with the strengths and weaknesses of the hub-and-spoke approach, rather than answer a single, specific research question. Such a review can be an important step in understanding an area of interest when it is complex and has not been previously reviewed (Arksey and O'Malley, 2005). The review therefore was undertaken with the following steps: identification of area of interest, systematic literature search, data extraction, quality appraisal, data synthesis and presentation. In addition, the PRISMA checklist (Page et al, 2021) and ENTREQ reporting guidelines were followed (Tong et al, 2012).
Search strategy
A systematic search was undertaken in 2021 using Scopus, CINAHL, OpenGrey, Medline and Health Management Information Consortium (HMIC). The resulting papers were hand-searched for specific references that may have been missed. Search terms were developed to reflect the concept in question. The final terms were: ‘hub and spoke’ OR ‘home base’ OR home-base AND student OR nurs⋆ OR pre-reg⋆.
Inclusion and exclusion criteria
The search returned 418 results, which was reduced to 281 after duplicates were removed. Two authors conducted an initial title and abstract screen; papers were included if they reported on primary research pertaining to placement allocation models, which included a hub-and-spoke approach. Twenty-nine papers were identified. The reference lists of these articles were searched, with one further paper included, resulting in a final total of 30 papers. These were assessed against the following inclusion/exclusion criteria, leaving 11 papers for final review.
Inclusion criteria
- Papers that reported on primary research
- Studies that included pre-registration/nursing students in the sample
- The placement model(s) included a hub-and-spoke approach.
Exclusion criteria:
- Studies from the USA
- Studies that reported on a clinical (ie healthcare delivery) hub-and-spoke approach.
The authors excluded papers from the USA because of the substantially different healthcare system and training model. This resulted in the exclusion of only one paper (Kruger et al, 2010). The authors opted to include papers from elsewhere in the world, in countries that have healthcare systems comparable to that of the UK. This resulted in the inclusion of one study from Australia (Craig, et al, 2014).
Data extraction and synthesis
Data from the included studies were extracted by two of the authors (RE, SW) and categorised according to the source, country of where the research took place, study aims and objectives, research methods/design and sample information, main outcomes and quality appraisal scores. Categories were kept broad due to methodological differences within and between studies, and therefore summary measures were not possible.
Quality appraisal
Due to the variety of papers included, the MMAT critical appraisal tool was used to give a sense of the quality of the included empirical studies (Hong et al, 2018). This is a multifunctional tool that can be used to appraise quantitative, qualitative and mixed-methods studies. Studies are scored on five criteria and the results can be aggregated to provide an overall score for each study and for each methodological category; higher scores indicate generally higher quality studies. In this review, the scoring is indicative only, and used to provide a sense of the quality of the research being produced in this field. Many of the studies included were descriptive in nature and therefore have been given a zero score for quality; however, it should be noted that this is only in relation to the reported research design quality and not the output quality (ie findings) per se.
Results
Quality appraisal results
The quality of studies varied substantially, with six scoring 75% (Roxburgh et al, 2012; Craig et al, 2014; Roxburgh, 2014; McCallum et al, 2016; Thomas and Westwood 2016; Millar et al, 2017) and five studies scoring 0% (Arnott 2010; Millar, 2014; White and King, 2015; Humphries et al, 2020; Heath et al, 2021). This means that, while a little over half of those included in this review were of acceptable quality, others did not meet any of the MMAT criteria. There were no discernible differences in scores by methodology; quantitative and qualitative studies scored 75%, while a number of mixed methods and qualitative studies scored 0%.
Descriptive study results
Almost all studies included in this review were from the UK (n=10), with one study conducted in Australia; all studies were undertaken over the past decade. Eight studies used qualitative methods, two used mixed methods and one study used quantitative methods. The majority of studies recruited nursing students (n=727), two studies also included mentors (n=39; one study did not report mentor sample size). One study recruited an interdisciplinary sample of medical/healthcare students (n=79).
Most studies focused on research questions related to the hub-and-spoke placements themselves, that is, student and mentor perceptions about the placement, their implementation and establishment, and the evaluations of students who had experience with the model. A number of studies suggested that hub-and-spoke placements had indirect clinical benefits, however only one study focused specifically on this question. These results are discussed below.
Implementation, establishment and exploration of hub-and-spoke models
Although there was overlap, studies that examined hub-and-spoke models were generally designed in one of three ways. Two studies reported on the implementation of hub-and-spoke models, what was learnt in the implementations and the challenges they faced. Four studies offered a more general evaluation of hub-and-spoke models, while three studies compared different hub-and-spoke and/or placement types. A study by Millar et al (2017) was distinct, in that it provided insight into both the benefits of hub-and-spoke placements and the elements of these placements that enhanced student learning. Unlike most studies, Craig et al (2014) evaluated the impact that hub-and-spoke placements had on more applied clinical skills, such as communication and interdisciplinary working.
Two studies provided accounts of how hub-and-spoke placements were implemented. Millar (2014) reported on a hub-and-spoke implementation project at a UK university, discussing the steps taken in scoping the model and implementing it. This study explained how the first phase of the project scoped elements of the hub-and-spoke approach that were present in existing placement models, within the different nursing fields taught at the university. For example, learning disability nursing had previously been integrated into a ‘base and associate’ approach to practice learning, while midwifery already included elements of the hub-and-spoke model by providing students with the experience following ‘a pregnancy to birth journey’.
After establishing the current placement practices and implementations, Millar (2014) described how general aims and outcomes, but also nursing field-specific aims for the practice placements were developed. In contrast to more traditional placement models, the hub-and-spoke approach required a change in recording practices related to placement experiences by students and within the relevant hubs and spokes. This involved changes in how placements were planned, and also included the creation of a database of community services available and the geographical locations, as well as the production of a one-page information leaflet to inform all students, staff and stakeholders about the hub-and-spoke model. An interdisciplinary action group led in implementing this project and communicating to all staff (Millar, 2014).
Heath et al (2021) also described their experiences of engaging with and selecting primary care networks (PCNs) to be part of the hub-and-spoke placement rather than individual GP practices. Partner universities facilitated these placements and worked together with PCNs to have students engage in the hub-and-spoke placements. The authors also noted a number of ‘stumbling blocks’, including issues related to payment for placements, along with inadequate time to develop the programme fully and a lack of funding, meaning that in the longer term the programme's future remained uncertain. Heath et al (2021) further reported briefly on the experiences of those involved in the model – students, universities and supervisors – and suggested that each saw benefits from participating in the model. Furthermore, this study suggested that this model could be used as a means to develop leadership in the primary care workforce. In particular, and in relation to student experience, Heath et al (2021) concluded that students benefited from participating in different patterns of work, methods of delivering care and exploration of the variety of work that the general practice nurse workforce has to offer.
Four further studies offered a general evaluation of hub-and-spoke placement models. Humphries et al (2020) explored perceptions and satisfaction related to such a model implemented at a UK university. Among 30 nursing students, the model was generally evaluated positively, with the approach found to be a valuable informative experience that encouraged autonomous practice. The model was also endorsed by the organisations involved; the staff felt valued and they welcomed the opportunity to share and promote the valuable work occurring in their services.
Although the model was generally perceived positively, there were some challenges. For example, both practice assessors and students thought that using an online practice assessment tool was beneficial to keep track of the learning activities. However, a number of students were challenged by the self-directed elements of this practice learning approach and perceived it as stressful because they had to reflect on their learning using the online tool, as well as being proactive in managing learning opportunities. Overall, the study concluded that a hub-and-spoke approach provided a valuable experience and generated an increase in placement capacity.
Similarly, Thomas and Westwood's (2016) study found that the hub-and-spoke model was beneficial and contributed to the development of a number of clinical skills, alongside other positives, such as enhanced student understanding of the whole patient journey, a great variety of learning experiences and the development of transferable skills such as communication and adaptability (Humphries et al, 2020; Heath et al, 2021; Millar, 2014; Millar et al, 2017). Students reported a sense of belongingness in their placements, and many reported an overall positive learning experience. However, some challenges were apparent, including issues related to ‘personality difficulties’ and organisational problems, particularly in terms of spoke placements. For example, the purpose of spoke placements was not always apparent and, in some instances, there was a lack of appropriate student learning opportunities facilitated by spoke mentors.
White and King (2015) reported on their experience of implementing and evaluating a hub-and-spoke model with 25 nursing students. They concluded that this approach had several benefits, including offering a richer learning experience; a heightened sense of belonging; enhanced understanding of the patient journey; greater insight into the roles and responsibilities of an interdisciplinary team; and increased awareness of possible career choices. The students were able to work more confidently with different clinicians and teams. It was also noted that this model increased placement capacity.
A study by Arnott (2010) presented a brief summary of the results of a pilot study, with a number of themes emerging from the data suggesting hub-and-spoke placements linked well with the NMC's modernising agenda and the [then] standards for pre-registration nursing (NMC, 2004).
Three further studies also explored the benefits and drawbacks of a hub-and-spoke approach, comparing the differences between placement environments and placement models. McCallum et al (2016) sought to explore whether the type of hub-and-spoke model influenced the perceptions of students and mentors. The study evaluated the experiences of nursing students' (n=216) and their mentors' (n=29) with regard to specialist versus traditional general areas as their hub practice learning environment. The quantitative results from this mixed-methods survey suggested that, overall, students found both the general and specialist placements valuable, with feedback generally positive from those who had completed both general and specialist placements. Findings from the qualitative element of this survey suggested that, although almost all students felt adequately supported in the specialist placements as much as in their hub, a small number nonetheless would have liked more time with their mentor. Similarly, while most students and mentors indicated that the specialist placements offered ample learning opportunities, some participants felt that their learning opportunities had been limited. Students and mentors also reported a sense of belonging related to this model, namely that the familiarity of environment, staff and client group helped their confidence and sense of belonging when they returned to their hub. The two final themes that emerged related to person-centredness and preparedness, with most participants indicating that the hub-and-spoke model exposed them to the realities of nursing; however, two students and some mentors reported that some of the learning environments were not prepared for the hub-and-spoke model.
Roxburgh et al (2012) explored the impact of three types of hub-and-spoke models. They reported a generally positive picture, however they found that there were some tensions relating to the breadth versus depth of learning provided. Several more specific benefits were found across each of the models. First, there was a continuum of student-led learning, which supports the process with opportunities for individual students to be positively innovative and creative in their learning approaches. Second, placement capacity was increased.
In a later study, Roxburgh (2014) sought to explore undergraduate nurses' perceptions of the hub-and-spoke and the rotational model of placement allocation. The results suggested that participants felt the experiences of year 1 had raised their confidence in their ability to cope with the practice learning and educational demands of nursing, with students generally seeing themselves as better prepared for their second year as a result of participating in the hub-and-spoke model.
Conducted over two phases, findings from the focus group illustrated that students who had experienced hub-and-spoke placements had a greater sense of belongingness than those who had placements within a rotational approach. Feedback on the hub-and-spoke model found students reporting higher levels of anxiety because they had to reinvent themselves with the ‘spoking experience’ due to shorter placement durations; however, the hub-and-spoke model had prepared them better, and had increased their confidence and resilience for when working in the rotational model that took place in hospital. Furthermore, students reported developing confidence and resilience and having more confidence in their achievements following placement via the hub-and-spoke model, which was confirmed by regular and consistent feedback from their mentors. Finally, although some students benefited from transitioning from a hub-and-spoke placement model, for some, by their second year the benefits had dissipated.
One final theme that emerged in Roxburgh's (2014) study after the students had completed their rotational placement related to their preferred model. Most reported a preference for a hybrid model, that is, a hub-and-spoke approach in years 1 and 3 and a model akin to a rotational model in year 2.
The above studies found small differences between hub-and-spoke and more traditional placements. Millar et al's (2017) study provided insight into the benefits of hub-and-spoke placements, while identifying key elements of these placements that enhance student learning. Rather than focusing on the benefits of the model, the study explored the characteristics of the hub-and-spoke model that support students' learning by enabling them to develop a deep understanding of a person-centred approach to care. Of the nursing students who completed a survey (n=24) and participated in focus groups (n=27) all participants felt that their experiences enabled them to form a better understanding of issues relating to the patients' communities. Additionally, all participants felt that the hub-and-spoke placement complemented the knowledge they gained in university and that, in contrast to the rotational model of practice learning, connecting the hubs to the spokes meant that movements between placement areas were reduced and were then driven by student learning objectives, rather than by regulations or limitations in mentor capacity.
Impact of hub-and-spoke placement on clinical practice and learning
In the only study that was not based in the UK, Craig et al (2014) explored the benefits of a hub-and-spoke model in an Australian, interdisciplinary setting. This study reported some short-term positive outcomes, including improvements in students' attitudes, and elements of co-operation and interdisciplinary ‘collaboration’. Students were clearer on their professional roles and were able to engage in interdisciplinary conversations that potentially improved patient care prior to their placement. Similarly, Thomas and Westwood (2016) found that the hub-and-spoke model enhanced students' understanding of the ‘whole patient journey’, offering a breadth of experience and the development of transferable skills, such as improved communication and adaptability.
Discussion
The aim of this systematic scoping review was to summarise and synthesise the literature related to hub-and-spoke placements used to train undergraduate nurses and increase placement capacity. A secondary aim was to evaluate the strengths and drawbacks of hub-and-spoke placement models. The above results suggest that hub-and-spoke models were generally evaluated favourably, with students and mentors reporting a range of benefits, including fostering resilience and independence in regard to placements, as well as a sense of belonging while on placement. A number of studies identified that hub-and-spoke models allowed higher education institutions, together with placement providers (ie NHS trusts including community-based services), to increase their placement capacity (Roxburgh et al, 2012; White and King, 2015; Humphries et al, 2020).
Studies that compared hub-and-spoke placements against more traditional placements suggest that elements of the hub-and-spoke model had advantages over the more traditional, ie rotational placements models. Participants reported a greater sense of belonging in hub-and-spoke placements compared with rotational models and also reported that such placements complemented what they had learnt in university. Authors also concluded that the use of the hub-and-spoke placement model reduced movement between placement areas and were driven by student learning objectives, rather than by regulations or limitations in mentor capacity.
A number of limitations were, however, noted. Some studies reported difficulties in implementing a hub-and-spoke approach. Most studies also reported that some students had difficulty with this approach, predominately in the spokes placements and with the more self-directed nature of this model. Some studies noted organisational problems in spoke organisations and that, in some cases, students did not feel that there were enough appropriate learning opportunities. As a whole, the literature also suggested that a one-size-fits-all approach may not be appropriate, with the need for hub-and-spoke placements to be designed to meet student needs, which might vary according to field of practice.
The UK Parliament is currently progressing new legislation – the Health and Care Bill 2021 – which brings together recommendations from the NHS Long Term Plan (NHS England/NHS Improvement, 2019) and the Government's white paper Integration and Innovation: Working Together to Improve Health and Social Care for All (Department of Health and Social Care, 2021). The bill is in part a response to the changes necessitated in the delivery of health care due to the COVID-19 pandemic, as well as a response to the increasing complexity of patient care arising from an increasing level of comorbidities. Underpinning the bill is therefore the need for greater collaboration to enable an integrated approach to care.
In the UK, student nurse placements are predominantly within secondary care, ie acute NHS trusts, with occasional rotation to community-based placements. A rotational allocation model focuses therefore on a specific point in time in a patient journey, often arising from either planned or unplanned admission to hospital. An integrated approach to care requires nurses to understand and witness a full patient journey, and how services need to collaborate to ensure the best outcome for patients. A hub-and-spoke approach to placement allocation aligns with an integrated care approach and has the potential to better prepare nurses of the future for the complexities of healthcare delivery, nurses being at the centre of co-ordination and collaboration across services.
Nevertheless, more research is needed to develop a body of knowledge around the implementations and variations in the hub-and-spoke model. This is particularly relevant, in view of the number of pre-registration nursing programmes currently being offered and funded through the apprenticeship route in the UK. Students who choose to take the apprenticeship route will need to negotiate with their current healthcare employer to secure a position as a registered nurse degree apprentice and to be released to study at a university part time and to work in a range of practice placements (NHS website, 2023). Considering this development, it can be argued that there is a shift in the hub-and-spoke model to a form of employer ‘controlled’ practice placements – this is likely to bring further challenges, but also opportunities for students' learning experience and becoming ready for practice.
In summary, further research is needed to evaluate hub-and-spoke placements in the different nursing fields and around the types of collaboration of placement providers and higher education institutions. This systematic scoping review has several limitations, which includes that the search was carried out in English only and the search terms were selective not to include other forms of placement models, which in comparison could also increase capacity (for a list of potential models, see Markowski et al, 2021). Indeed, there is a need overall for further research because most of the studies reviewed were small, and many were of low quality.
Future research should explore the impact of hub-and-spoke models, beyond their perceptions of the model itself and look toward how hub-and-spoke places impact clinical skills' development, for example. Further research is also needed into what makes hub-and-spoke placements successful and to cater for the needs of all students: that is, the literature suggests that although the feedback on hub-and-spoke model was generally positive, some students struggled with these placements. Nevertheless, the existing literature suggests that hub-and-spoke placements are a promising model that could offer a range of benefits over more traditional placements.
KEY POINTS
- In hub-and-spoke models, both students and mentors reported a range of benefits, including fostering resilience, increased confidence, independence and a sense of belonging
- The hub-and-spoke placement model reduced movement between placement areas and was driven by student learning objectives, rather than by regulations or limitations in mentor capacity
- There are some challenges to overcome when implementing a hub-and-spoke approach, especially concerning the self-directed learning nature and learning opportunities within spoke placements
- A one-size-fits-all approach may not be appropriate and more research is needed, since hub-and-spoke placements need to be designed to meet students' learning needs based in their field of practice
CPD reflective questions
- If you were to adopt a hub-and-spoke approach to practice placements in your trust in partnership with the higher education institution (HEI), which field(s) of nursing and training routes (eg apprenticeship) might enable a smooth initial introduction of the model?
- What advantages/disadvantages might exist for students/educators working with a hub-and-spoke approach to placements in your trust/HEI over the rotational/traditional model?
- What factors enable or inhibit a smooth transition from the rotational/traditional model to a hub-and-spoke approach and support for students' self-directed learning?
- What existing resources does your trust have to implement the hub-and-spoke approach, and to support students' self-directed learning?