Higher education institutions (HEIs) have established a varied and extensive programme aligned with the guidelines of the Nursing and Midwifery Council (NMC) to enhance the knowledge and comprehension of nursing students, effectively readying them for clinical placements and future careers in the healthcare sector. The introduction of Project 2000 marked a change in the curriculum, placing greater importance on learning in clinical settings, by increasing the hours spent in placements to better prepare students to fulfil the requirements of the NHS (Fulbrook et al, 2000). The BSc Nursing programme distinguishes itself from other courses offered by HEIs, because it is associated with higher instances of adverse psychological impacts such as stress, attributed to the somewhat rigid curriculum, substantial academic workload encompassing theoretical and practical assessments, and the mandatory 2300 clinical placement hours necessary for registration with the nursing regulatory body (Hwang and Kim, 2022; NMC, 2023;2024). Despite the emotional and academic hurdles, there is a notable absence of essential content delivered to nursing students in HEIs to prepare them adequately psychologically for the clinical environment, despite the heightened risks of physical and psychological issues leading to burnout among student nurses (Hwang and Kim, 2022). The National Audit Office (2024), considering NHS England's Long Term Workforce Plan, highlighted increases in nurses, with a surge in training opportunities, allowing for 170 000 more registered nurses by 2036-2037. Although an increase in staff numbers is of course welcomed, their preparedness for practice remains unchanged.
Although existing literature has delved into the effects of the initial clinical placement on mental wellbeing of nursing students over time (Swift et al, 2020), there is a dearth of knowledge regarding their psychological preparedness for clinical placements at the outset, with particularly limited research focusing on child field student nurses (CFSNs) (Robba, et al, 2022). Notably, CFSNs tend to be among the youngest applicants, which is associated with higher attrition rates due to the ongoing development of identity, emotional immaturity, and challenges related to resilience. Consequently, this study aims to understand the psychological preparedness of CFSN's for their first-year clinical placements.
Background
Participants in this study were current second-year CFSNs who reflected on their experience of psychological preparedness for clinical placements. ‘Psychological preparedness’ refers to the specific measures implemented to furnish individuals with direction and assistance alongside pertinent information, aiming to alleviate anxiety (Carroll et al, 2022).
Li and Hasson (2020) delved into the concept of the ‘protection factor’, highlighting the significance of resilience and how a nursing student's capacity to overcome adversity contributes to the preservation of optimal psychological wellbeing, crucial for the retention and advancement of student nurses. Nevertheless, the relatively young age of CFSNs on programme entry frequently results in limited social and emotional competence, leading to heightened stress and other psychological drawbacks (Çınar Özbay et al, 2023).
Students in higher education encounter numerous well-known stressors such as financial concerns, separation from social circles, and the burden of continual evaluations (Betz, 2021). Nevertheless, nursing students encounter additional stressors, many of which stem from fulfilling NMC-mandated practice hours in diverse, occasionally demanding, and geographically distant clinical settings, confronting the realities of their healthcare careers from the outset (Ab Latif and Mat Nor, 2019). Hence, it is not surprising that there is a higher prevalence of psychiatric comorbidities, such as stress, anxiety, low self-esteem and depression among nursing students compared with students on other tertiary education programmes (Reverte-Villarroya, 2021).
The BSc Nursing programme is structured around a blend of theoretical lectures, as well as hands-on simulated practice. Despite variations in programmes, most CFSNs commence their initial clinical placement after only a few months of study at an HEI (Marriott et al, 2024).
The first clinical placement for a CFSN is pivotal and, although many find it fulfilling and stimulating, it can also be physically strenuous and psychologically demanding (Marriot et al, 2024). Clinical placements constitute fundamental components of the programme, enabling CFSNs to apply their knowledge directly to practice. Key competencies are acquired and evaluated during clinical placements, with practice assessors/practice supervisors overseeing and evaluating learning through progression meetings that formally assess student nurses' development. However, research highlights that negative clinical placement experiences are a contributory factor to individuals leaving the programme without completion (Yorke and Longden, 2008; Leducq et al, 2012).
For CFSNs, care involves not only catering to the child through age-appropriate service delivery, but also embracing the patient's parents/carers and siblings holistically (Royal College of Paediatrics and Child Health, 2018). Emphasising family-centred care is a fundamental principle in the field of child nursing, adding pressure to foster a collaborative relationship (Çınar Özbay et al, 2023).
The transitional period for novice CFSNs in their initial year is a crucial phase that HEIs must approach cautiously.
Second-year CFSNs were recruited to participate in virtual one-on-one semi-structured interviews to reflect on their first-year clinical placements (two 6-week placements). The findings of these interviews are presented in this analysis to substantiate and advocate for potential enhancements to the nursing curriculum.
Aim
The aim of this study was to understand the psychological preparedness of CFSN's for their first-year clinical placements.
Methodology
Sampling strategy and recruitment
Inclusion criteria for this study were that participants must be enrolled in the BSc Children's Nursing programme at the selected HEI, and participants must have completed a minimum of 675 practice hours in Year 1. The adoption of purposeful sampling entailed the selection of ‘information-rich’ participants who were deemed suitable for the project (Vasileiou, 2018). Using the online learning platform of a chosen UK-based HEI, a ‘cohort announcement’ was disseminated on the children's nursing cohort page.
Eight individuals meeting the inclusion criteria expressed interest in participating in the study and gave informed consent to take part. In Braun and Clarke's (2019) extensive work questioning data saturation, studies by Namey et al (2006) and Coenen et al (2012) were reviewed, with the overall consensus recommending a sample size of eight interviews to adequately reach data saturation. Following confirmation of their eligibility and consent to participate, the students were invited to a meeting on Microsoft Teams, which was recorded, and engaged in semi-structured individual interviews to facilitate a participant-focused exploration of their thoughts and emotions.
The semi-structured interviews were based around four predetermined questions developed around the study aims:
Ethical considerations
All procedures were performed in compliance with relevant laws and institutional guidelines. Appropriate institutional approval was obtained for this study.
Data analysis
Thematic analysis (TA) was employed for the interpretation of data gathered from semi-structured interviews. Transcriptions were done verbatim using Microsoft Teams inbuilt transcription tools, then cross-checked by the interviewer with the recorded interviews, followed by the application of Braun and Clarke's (2006) six-phase guide to thematic analysis.
Data were coded through the categorisation of descriptions provided by each CFSN during interviews, facilitating meaningful organisation. The use of ‘open coding’ was implemented due to the absence of predetermined codes. Themes emerged through exploratory comments, with categories such ‘knowledge gaps’, ‘logistical considerations’, and ‘interactions with others’ identified. These themes progressed conceptually, moving from surface-level content towards abstract ideas. Grouping themes as per each participant's input proved advantageous in understanding commonalities across individual responses.
Results
Themes
Themes generated from the data analysis were:
Subthemes similar to the generated themes were also devised. In the verbatim quotes that follow, participants are given identifying numbers (P1, P2 etc); pauses in speech are indicated with ‘…’ whereas omitted sections are marked by ‘(…)’.
Theme one: Keeping your eyes and mind open.
P1, P2, P3 and P4 mentioned the need to keep an open mind and be prepared to see situations that they may not have encountered before:
‘(…) Often your first time in hospital … you've never seen bad stuff before … you may have not experienced that emotion before.’
‘(…) A lot of what we see on placement isn't necessarily things we would see or have experienced before.’
‘Be ready to see and learn lots.’
‘(…) the environment is unpredictable (…) knowing that it can go from 0 to 100 very quickly.’
Subtheme: Expecting the unexpected
Participants expressed the difficulty they experienced in preparing emotionally and physically for the unknown:
‘(…) Thinking about challenges you may face and what situations might affect you.’
‘Making sure you understand things you're going to see … the environment is unpredictable.’
‘Emotions that we might experience and how we deal with them in the moment or afterwards on reflection.’
Similarly, another participant said:
‘(…) being warned about the sort of things you may experience (…) being given tools to manage difficult and complicated situations.’
Theme two: Children caring for children
Two participants highlighted the influence of age on their psychological preparedness.
‘Little 19-year-old me versus a parent of, like, 30 years old/older … a very weird thing to have someone older than you looking to you for support … feels like it should be the other way around (…) I would be the person parents would look to for comfort … they would be crying on my shoulder.’
Subtheme: Knowledge known, practicalities pending
Seven of the eight participants disclosed not feeling psychologically prepared for their first-year clinical placements.
‘Probably not (…) I had never even been to a hospital before (…) all the stuff we do in skills is really great, but then you go in [referring to the ward] and it's, like, … thrown in the deep end.’
‘I felt clinically prepared … like I knew about the patients (…) I don't think you can be prepared for living out the reality.’
The one participant who did feel psychologically prepared had previous experience working in a healthcare setting:
‘I think I did, to be fair, but I think that's because I have previously worked in health care.’
Theme three: Locating the emotion off-switch
Many of the participants commented on the difficulty in keeping the ‘placement in placement’.
‘(…) I went home and they [referring to an acutely unwell patient] were all I could think about … they're a human being that you're caring for … but you need to see them as a patient.’
‘You're going to walk out [referring to the hospital] and still think of that child … it's human nature to care.’
Subtheme: How am I meant to deal with that?
Participants described individual scenarios that challenged their emotions.
‘Seeing the results of violence (…) they [the hospital team] would shut down the ward to stop people [referring to those involved in the incident] coming in (…) horrific safeguarding situations … kids being abused (…) how am I meant to deal with that?’
‘Patients deteriorate quickly … the idea of it is very different to it happening …it happens so quickly.’
‘Parents' distress … having parents screaming at you that their child is dying … they are looking for someone to blame … we take on the guilt … something I hadn't even thought of before (…) knowing what to say … you can't say “I know how you feel” because you don't.’
‘In oncology/haematology … I saw a lot of scary things; [followed by behavioural challenges on their second placement including] children throwing chairs across the room … kicked me (…) it was a scary situation because we were in a very small room.’
‘Looking after someone who is dying … that could be spoken about more.’
Discussion
Keeping your eyes and mind open
Participants could express their perspectives, not necessarily providing a precise definition of psychological preparedness, but describing series of attributes that could facilitate one's state of being psychologically prepared. They emphasised the importance of maintaining an ‘open mind’ and stressed the significance of being prepared to witness things that are not commonly observed and experience emotions that are not commonly felt. For two out of eight participants, it marked their initial encounter with a hospital setting, and for many, the unpredictable nature of the environment induced feelings of overwhelming uncertainty.
This corroborates the findings of Marriot et al (2024) who similarly observed that first-year nursing students tend to feel ‘distressed and overwhelmed’ and experience a sense of ‘inferiority’ during clinical practice. While grappling with the challenge of defining ‘psychological preparedness’, seven out of eight participants admitted to lacking psychological preparedness for their first-year clinical placements, with the eighth participant attributing their heightened awareness to prior clinical exposure. This lack of readiness stemmed from various factors, including possessing the necessary clinical knowledge and encountering difficulties in applying it.
In HEIs, there is an allocation of dedicated simulated practice time, during which CFSNs can acquire and practise their skills in a ‘safe’ setting; the NMC allows up to 600 hours out of the required 2300 hours for registration to be undertaken in such environments (NMC, 2023;2024). Despite this practice time, allocation research highlights persistent deficiencies in psychological preparation for the clinical reality. It is the anxiety experienced by CFSNs during clinical practice that heightens the likelihood of prematurely withdrawing from the programme (Webster et al, 2016; Vuolo, 2018). Greater emphasis must be placed on creating realistic scenarios to further cultivate these proficiencies.
Children caring for children
The CFSNs involved in this research are all part of Generation Z (although recruited on voluntary basis, participants fell in this category). When examining the sentiments and viewpoints of the participants in relation to generational attributes, it is crucial to acknowledge that not all individuals within this cohort will hold identical values. For example, two our of eight participants explicitly linked age with experience, whereas six out of eight participants adopted a more general stance when expressing uncertainties. The impact of age became more pronounced when recounting interactions with patient's parents, with one participant recounting how a parent had sought solace from them, a dynamic that felt unnatural for an 18-year-old. By viewing adolescence as a transitional phase into adulthood, during which self-identity has yet to fully solidify, it is understandable that professional challenges surface in such situations (Çınar Özbay et al, 2023). This observation resonates with earlier research by Oh (1974), who elucidated how parents of ill children sought acceptance and validation from CFSNs, qualities that CFSNs themselves are also striving to attain.
It is imperative to take into account the social challenges faced by CFSNs when they leave home to pursue higher education at university. Although research studies have extensively examined the adolescent demographic in professional workforce, the expectations of Generation Z exhibit notable distinctions from their predecessors (Lillekroken et al, 2024). Generation Z individuals require ongoing guidance and a sense of security, alongside traits such as transparency and ethical behaviour, which may not always be guaranteed (Serafin et al, 2020; Keith et al, 2021).
Locating the emotion off-switch
Consideration of emotional intelligence has become increasingly prominent in HEIs, it being particularly noted that student nurses are among those who require enhanced emotional skills (McCloughen et al, 2020). The healthcare field presents numerous emotional challenges, such as dealing with illnesses, suffering, family/carer distress and death, all of which contribute to a higher risk of experiencing ‘burnout syndrome’ (McCloughen et al, 2020). Emotional intelligence is considered an important aspect of nursing practice, however, it is not something that can be easily taught. A recent literature review by Hamad and Gurbutt (2023) described how more emphasis needs to be placed on improving the consistency of emotional intelligence constructs and components taught in HEI preregistration nurse curricula. Cheng et al (2023) also highlighted a positive correlation between higher emotional intelligence and better problem-solving and coping skills, in addition to overall better mental health in nursing students.
The CFSNs interviewed discussed the challenges of managing their emotions during clinical placements, expressing difficulty in containing their feelings within the hospital setting. Many mentioned that they often found themselves consumed by thoughts of patients and that certain situations lingered in their minds. This struggle to detach from emotions resonates with the earlier highlighted lack of preparedness, as participants shared their surprise at the overwhelming experiences they encountered and the emotional immaturity that hindered their ability to process and express their feelings. The CFSNs' inability to disengage from their emotions, particularly in critical situations involving palliative patients, safeguarding issues, and distressed parents, was a recurring theme.
Summary
Interviews revealed that CFSNs experienced a sense of unpreparedness for challenging situations, relying predominantly on experiential learning rather than education and training. They discussed the impact of this learning style, asserting that a student's feeling of emotional exhaustion leads to being labelled as ‘a liability’, which increases the sense of pressure felt by the CFSNs. When participants were asked about potential strategies for enhancing the psychological preparedness of CFSNs for clinical practice, this prompted a response on the need for HEIs to incorporate dedicated sessions focusing on resilience and mental health/wellbeing. It highlights deficiencies within the existing curriculum that necessitate addressing psychological preparedness of CFSNs.
The findings unequivocally point towards the need for HEIs to enhance their efforts in preparing and safeguarding the psychological preparedness of CFSNs.
As the researcher is a cohort lead within the HEI in which the participants are studying, rapport has been developed with the participants and so potential bias has been considered. As stated in the participant information sheet, there will be no impact on the participants' place/progression on the programme to avoid any feelings of coercion. Much like the National Student Survey (2023), participants will be informed and reassured that this project allows for ‘freedom of expression’ and help to inform future cohorts of CFSNs and HEIs.
Conclusions and recommendations
Findings indicate that psychological preparedness for clinical placement is multifactorial, encompassing both practical and emotional preparation for the diverse experiences and challenges that clinical settings present. It was recognised by CFSNs that complete preparedness is not always attainable.
The impact of the young age at which CFSNs enter nursing significantly influences their psychological preparedness. The emergence of ‘Generation Z’ CFSNs brings forth individuals with limited life experiences, hence an increased need for guidance, mentorship and stability, which may not always be consistently provided in healthcare environments despite the best efforts of the practice assessors/practice supervisors. Consequently, CFSNs encounter difficulties in certain situations, such as when patients' parents seek support and comfort from them, while they themselves are still learning to navigate their emotions and circumstances. This raises questions among CFSNs regarding the expectations around coping with traumatic events and distressing emotions as part of their role.
The interviews revealed a common sentiment among CFSNs that the psychological preparedness offered by HEIs need enhancement. Improvements must be made within HEIs to ensure that student nurses are psychologically prepared for clinical realties. This should have three aspects:
Greater emphasis must be placed on creating enhanced ‘real-to-life’ scenarios within HEIs prior to clinical placement. This would develop CFSNs' competence in understanding the day-to-day practicalities of working within a healthcare setting, in addition to developing students' confidence.