The COVID-19 pandemic has had a profound effect on all aspects of society and presented previously unencountered difficulties for those in higher education and, in particular, those enrolled in clinically based degrees including nursing. Universities had to move swiftly from face-to-face teaching to online learning as countries went into lockdown to reduce transmission of SARS-Cov-2 (Seah et al, 2021). Across the globe, many student nurses were unable to undertake their planned clinical placements and had to adjust to self-directed learning and an increase in simulated learning. Several papers have highlighted the issues facing student nurses, which impacted not only their learning opportunities but also their psychological wellbeing (Michel et al, 2021; Ulenaers et al, 2021). One qualitative study from Belgium reported nursing students' practical worries relating to fewer learning opportunities as well as many requiring greater psychosocial support and the need for establishing regular contact with their clinical placement supervisor (Ulenaers et al, 2021). These findings were replicated in a survey of 540 student nurses across the USA who expressed the need for greater in-person clinical placements and strong academic and clinical partnerships (Michel et al, 2021).
Background
Given the issues with clinical placements, higher education institutions, along with their clinical partners, were required to develop innovative ways of ensuring students had the required hours and adequate exposure to clinical practice beyond traditional clinical placements. In the UK, there have been two extended periods of lockdown and those students who were clinically vulnerable or were unable to attend clinical placements required alternative placements.
As a suitable alternative to clinical placements, the authors' higher education institution trialled a research placement for two second-year BSc adult nursing students, and this is the account from one placement. The student gave permission for quotes to be used for this article and is a co-author.
The academic team devised specific questions that students were to consider for their research electives and provided a template for their written work with the aim of writing a weekly report to reflect their learning. In particular, the two students had to identify how their learning related to the UK Nursing and Midwifery Council (NMC) code of conduct. The Code (NMC, 2018) represents the professional standards that nurses, midwives and nursing associates must uphold in order to be registered to practise in the UK.
The specific questions were:
- What was the nature of the activity and/or practice-related feedback and/or event or experience?
- What did you learn from the activity and/or feedback and/or event or experience in your practice?
- How did you change or improve your practice as a result?
- How is this relevant to the NMC code of conduct?
Findings from reflection
The second-year student (KR) was assigned to a senior academic who was active in research as well as having a clinical role running a specialised clinic one day a week. The research placement took place over a 3-week period in 2021 and consisted of weekly meetings to review aims and objectives and plan the week's work and review the work completed. The student devised aims and objectives and developed a clear learning plan around research, with objectives that included increasing her understanding of how to write an academic paper for the healthcare/nursing field, increasing her understanding of advanced clinical practice nursing and understanding of how evidence is used and applied to improve practice. Together with the academic, specific tasks were delegated relating to undertaking literature searches and writing some sections for an academic paper as well as working on a draft of a paper based on one of the assignments.
KR also completed reflective evidence (500 to 750 words each week) that provided an overview of the research placement experience and key learnings with updated objectives or issues that were raised that she could further explore. Each week, KR submitted a detailed overview of the placement and outlined key learnings in relation to each of the questions. The academic (GL) provided oral and written feedback and by the end of the placement, the student had written a draft of the background for a paper, and completed a draft of an editorial based on one of her assignments.
Regarding clinically related experience, the student also attended the weekly nurse-led rapid access atrial fibrillation clinics run by GL so she could observe advanced clinical practice nursing. KR joined the rapid access virtual consultations to learn about atrial fibrillation, risk factors, assessing stroke risk and bleeding risk and shared decision-making between practitioner and patient as well as seeing multidisciplinary working with the pharmacist and cardiology team. The student was able to monitor effective communication and clinical decision making with patients as well as scrutinise the therapeutic relationship (albeit it virtually) between the advanced nurse practitioner and the patient.
The research placement demonstrated the valuable role of these placements and enhanced the student's understanding of research, the importance of working in a multidisciplinary team, the processes of record-keeping and documentation (an essential skill for clinical researchers) and the integration of research into practice – in this case, relating to the assessment and management of atrial fibrillation in the nurse-led clinics. For example, in response to the question ‘What did you learn from activity and/or feedback and/or event or experience in your practice?’ the student was able to articulate the importance of shared decision-making:
‘The nurse needed to make decisions about patients with complex needs due to polypharmacy and comorbidities. She used the risk-assessment tools to assess the patients' risk of stroke and bleeding to inform her decisions. She used the scores to explain to the patients their risks and involve them in the decision-making process about whether they [should be] started on an anti-coagulant. She adapted her language as necessary to ensure the patients understood the information being given to them.’
The student was able to articulate how her practice would improve as a result of the research placement:
‘Learning from the example of shared decision-making, I will seek to use risk-assessment tools as a means of assessing a patient and also communicating with them … I will approach a patient as an individual and adapt my communication to suit their needs.’
In relation to their professional development and the Code (NMC, 2018), the student was able to identify specific areas of the code of conduct that she had either observed or used in her research placement. For example, in prioritising people and promoting professionalism and trust, the student was able to observe how the patient was treated as an individual (section 1.3; 1.4), and had their concerns listened to (section 2.1-2.4). KR was also able to observe how the practitioner practised effectively by advising and prescribing medicines within the limits of their competence and in line with the scope of the advanced practice guidance and regulations (section 18.1, 18.3).
Some specific examples from the NMC Code that the student observed or used in the elective research placement were:
- Treat people as individuals and uphold their dignity (section 1.3 and 1.4)
- Listen to people and respond to their preferences and concerns (section 2.1-2.4)
- Make sure that people's physical, social and psychological needs are assessed and responded to (section 3.1 and 3.3)
- Act in the best interests of people at all times (section 4.1 and 4.2)
- Always practise in line with the best available evidence (section 6.1 and 6.2)
- Communicate clearly (section 7.1 and 7.2, 7.4 and 7.5)
As well as teaching and clinics, the shift to virtual meetings also took place with conferences. The research placement coincided with a virtual conference, the EuroHeartCare 2021 conference run by the Association of Cardiovascular Nurses and Applied Professionals. KR viewed 20 hours of presentations and was able to summarise the key themes from the sessions, which included implementation of virtual services due to COVID-19, the importance of lifestyle in relation to cardiovascular disease and the importance of person-centred care. From the EuroHeartCare 2021 sessions, KR was able to demonstrate where she could use this information in her clinical practice. She wrote about certain aspects she could use in practice:
‘Thinking about co-design and audience when delivering patient education, creating new tools or services, advice for lifestyle changes to prevent/manage cardiovascular disease and skills to support people through these behaviour changes and knowledge of risks and risk-assessment tools to identify people at risk and discuss these with them.’
The research placement was successful and can be considered as a suitable alternative where clinical placements are limited or not suitable. This is in line with the position taken by the NMC in January 2021, recognising that, as the pandemic placed a huge burden on clinical practice, an alternative to student clinical placements was necessary:
‘We have therefore reinstated the emergency standard which allows first year nursing and midwifery students to focus on academic and online learning rather than participating in clinical placements while the system is under pressure due to the pandemic and as a result, supervision of these students is not possible in line with our standards’
The placement gave students a chance to contribute to manuscripts for journal publication where they can learn about the process of writing for a healthcare audience, including identifying the appropriate journal for publication, its aims and scope, and the requirements for authors. By being actively involved, students begin to appreciate the importance of determining the aims and objectives of a research paper, the target audience, and the publication process. It gives them the opportunity to develop their scientific writing style and learn how to use evidence to structure an argument and critically allows them to really understand how research is translated into clinical practice. It can help the student not only to understand what good practice is, but also to recognise why they are doing things, not simply how to do them.
Overall, the format of the research placement provides a great opportunity for students to appreciate the skills needed for research and the importance of reflection and analysis. In this elective, the student was able to see how practical ‘hands on’ scientific evidence influences clinical practice, and the vital role of healthcare researchers in improving patient services. By encouraging the student to question and probe, they were able to see the benefit to patient care and how it has the potential to improve patient care and safety.
As the student stated:
‘In the way that researchers reflect on practice, nurses must take their findings and reflect on them within their own practice. This in turn translates into rationalising a decision in care with evidence and communicating it to patients, their families, or other health professionals.’
The research elective has great potential and allows students tangible opportunities to seek out evidence for themselves and use it to inform their clinical practice. In this case, the student also commented:
‘I will participate in studies to support research when asked.’
Conclusion
Research placements offer a viable alternative to increase placement capacity and placement opportunities, and a lens to observe other roles such as advanced practice, and opportunities to develop professional employability skills for different career pathways and opportunities such as clinical academic roles. Given the continued impact of COVID-19, it may be time for universities and clinical partners to become more creative while also ensuring future nurses are confident in reading, interpreting and applying research to clinical practice.
KEY POINTS
- COVID-19 and the measures taken to try to reduce transmission of the virus responsible have affected clinical education and clinical placements
- Universities had to move to online learning to reduce transmission
- There is a need to offer alternatives to clinical placements and one option is research electives
- It is possible for student nurses to learn on research electives and relate these to the Nursing and Midwifery Council's code of conduct
CPD reflective questions
- How would you organise a research elective in your workplace?
- Can the NMC code of conduct be applied to research electives?
- Could you develop objectives for student nurses undertaking research electives?
- Are there any practical considerations needed for students on research electives?