We recently reported the success of the Royal Wolverhampton NHS Trust’s (RWT) Clinical Placement Expansion Programme (CPEP)¹. Since the publication, the CPEP has been expanded to include Dietetics, Paramedics, Diagnostic Radiography, Occupational Therapy, Podiatry and Speech and Language Therapy across RWT and Walsall Hospital Trust (WHT). Clinical supervision is central to practice for all healthcare professionals. The Health and Care professions council, of which all allied health professionals (AHPs) must be registered, states that all registrants must work in partnership with colleagues, sharing skills, knowledge and experience where appropriate². Thus, there should be a sense of shared responsibility for the supervision and education of our future workforce. Barriers to and challenges of effective supervision are critical for the healthcare workforce³. To ensure the expansion of the programme is successful, we must explore the barriers faced in the initial programme.

According to research⁴ there are several reasons identified to explain why a registered professional may decline supervision of a student including workplace stress, role strain, workload, fear of difficult student interactions, lack of space, lack of staff, and a lack of resources. Clinicians often perceive student supervision as an additional expectation and responsibility to their workload⁵, leading to a pervasive mindset that student placements are not a fundamental requirement of a clinician’s job role and instead an “optional extra”.  Clinicians who have input into the decision to supervise students were more likely not to take a student⁴, reinforcing the need for clear expectations of our clinical workforce when it comes to student supervision.  Students need to be seen as part of our teams and the normal running of our services, not an extra demand on our time and resources. Providing clinical supervision for students needs to be seen as routine rather than optional. However, at present, the only professional body with concrete expectations in terms of student supervision is the Royal College of Speech and Language Therapy (25 days per WTE)⁶.

The experience of student placements by WHT staff

At WHT the perception of student supervision as being an added job “demand” was intensified by the cessation of many placements during the COVID-19 pandemic. When the recommencement and proposed expansion were introduced in 2021, the pervasive mindset worsened as some areas had become used to not having a student presence. The effect of the pandemic is still having a major impact on our student offers at WHT, with social distancing measures in place in clinical areas. It has become more challenging to appropriately co-locate students within outpatient AHP services across the organisation. This, paired with a period of workforce shortage due to vacancies and COVID-19 absence, made our aspirations much more difficult to achieve.

Some clinicians had reservations about placement expansion, having had student performance issues in the past, where they felt unsupported by the higher education institute (HEI) in managing the situation. Thus, it was imperative to engage the local HEIs in our CPEP work to help avoid such experiences moving forward.

Despite the challenges faced, we have been able to fill CPEP secondments with passionate, enthusiastic, and driven WHT AHPs who have made tremendous progress in increasing the number of practice educators and placements offered across the board. This was achieved by working collaboratively with educators to manage historic mindsets and perceived barriers, providing a supportive coaching approach to planning placements, so that the experience can be positive for both the student and their educating clinician.

The experience of student placements by RWT staff

100% of RWT staff surveyed reported they would recommend other teams to try the alternative placement model they had used. Some felt unprepared as circumstances forced the change, whereas others felt very prepared as they had time to plan and create structure. At the time, there were limited resources available online for staff to access to familiarise themselves with their new delivery model, relying more on link tutors to assist who were not always available. This was brought up in the feedback we received. However, the Chartered Society of Physiotherapy (CSP) has since done lots of work to create placement profiles⁷ that staff can now access when required, to feel better prepared. Another difficulty staff reported was that marking criteria were designed towards a 1:1 placement model and thus, marking certain domains proved difficult. Subsequently, the CSP has produced a standardised assessment⁸ form that is being rolled out to all universities for use across all settings. Hopefully, more professional bodies will consider producing similar resources to support their clinicians.

Student supervision models

The importance of supervision of clinical students is well accepted⁹, and has been defined as “focusing on the progression of clinical practice through professional guidance and support”⁹. The three main functions of supervision have been described as administrative, educational, and supportive⁹. Despite the established importance of supervision, it is a term with multiple

definitions, and a variety of implementation approaches. Recommendations regarding the implementation of supervision are often devised in the absence of a high-quality evidence base and are generally found in grey literature rather than evidence-based reviews⁹.

Fair-share allocation model.

Hospital Trusts currently have no consistent expectation of the number of students per placement per quarter, hence the need for a fair share allocation model which ensures student placement supervision is fairly allocated across the entire clinical workforce. This type of model would ensure everyone was “taking their fair share” of placements. The suggested formula is 1 student (6 weeks of placement) per 1 WTE clinician per year.

The barriers to clinicians agreeing to student placement supervision can be mitigated via innovative supervision models.

The traditional 1:1 model is now seen as rigid and restrictive, giving the student the perspective of only one clinician, and is thought to be the main driver of the perception of students being a burden. The Dyad model which advocates a 2:1 approach (two students to one clinician) has the added benefit of increased placement capacity and permits peer learning between students, fostering a self-directed learning approach.

Split placement models can be utilised by services lacking in staff or which have limited operating hours. In such cases, the student placement is shared with another service, which can be a different profession to widen the students’ experience. A collaborative learning approach/learning environment is an extension of the 2:1 model, utilising the whole of the team, including administration, support, and technical staff.  The whole team takes responsibility for a group of students and the whole team is part of the learning environment.

Additionally, a student-led model of supervision can be utilised, this involves a group of students taking the lead in a patient’s care supervised by a clinician who has no clinical duties for the duration of the supervision (usually 24-hour blocks).  The supervisor is changed daily to ensure students get exposure to different perspectives. Extended day models incorporate longer shifts, usually 3 x 12-hour shifts, and are an effective use of time and resources in services which operate on a 24-hour basis.  Finally, the Technology Enabled Care Service (TECS) model can be used where services utilise telehealth.  Allowing students to join patient consultations virtually from any base.

It is clear clinical staff face challenges in meeting placement demands.  However, all registered staff have benefited from clinical placements in their career journey. It will be to our detriment if we do not rise to the challenge. For student placements to be successful collaborative efforts between clinicians, facilities, and higher education institutes are essential. Working innovatively, utilising a variety of placement models, and ensuring a fair share allocation of students between all clinical staff.

Can you rise to the challenge of taking a student for the first time?  Can you generate a discussion amongst your peers about the responsibility we all have for student education?

References

1. Eddison N, Leslie R, Green K, Edwards H. CPEP and beyond. The Institute of Health and Social Care Management. August 2022. Inst Heal Soc Care Manag. 2022.
2. Health and Care Professions Council. Your duties as a registrant: Standards of conduct, performance and ethics. 2021. https://www.hcpc-uk.org/globalassets/resources/standards/standards-of-conduct-performance-and-ethics.pdf%0Ahttps://www.hcpc-uk.org/globalassets/resources/standards/standards-of-conduct-performance-and-ethics.pdf%0Ahttps://www.hcpc-uk.org/assets/documents/. Accessed August 9, 2022.
3. Rothwell, Kehoe, Farook, Illing. Enablers and barriers to effective clinical supervision in the workplace: A rapid evidence review. BMJ Open. 2021;11(9):52929.
4. Varland, Cardell, Koski, McFadden. Factors Influencing Occupational Therapists’ Decision to Supervise Fieldwork Students. Occup Ther Heal Care. 2017;31(3):238-54.
5. Barton, Corban, Herrli-Warner, McClain, Riehle, Tinner. Role strain in occupational therapy fieldwork educators. Work. 2013;44(3):317-28.
6. The Royal College of Speech and Language Therapy. Practice-based Learning Guidance for SLTs and HEIs. https://www.rcslt.org/members/lifelong-learning/practice-based-learning/practice-based-learning-guidance/. Accessed August 9, 2022.
7. Physiotherapy. CSP launches ‘Placement Profile’ platform to showcase innovation and inspire others. https://www.csp.org.uk/news/2021-03-08-csp-launches-placement-profile-platform-showcase-innovation-inspire-others. Accessed August 11, 2022.
8. The Chartered Society of Physiotherapy. The Common Placement Assessment Form. https://www.csp.org.uk/frontline/article/common-placement-assessment-form. Accessed August 11, 2022.
9. Nancarrow, Wade, Moran, Coyle, Young, Boxall. Connecting practice: A practitioner centred model of supervision. Clin Gov. 2014;19(3):235-52.