Insights from the pandemic: an autoethnography of nursing clinical placement teams

Abstract

Background

Designated placement staff, including academics, professional clinical support teams and stakeholder clinical teams, are responsible for organising students' clinical placements. Disciplines have reported sustained innovations in the way placement staff work following the pandemic. There are few published reports from nursing placement staff. Aim: Understand how challenges during the pandemic, may have led to disrupting the status quo for nursing placement staff.

Design

Nine academic, professional and industry nursing placement staff reflected on their daily work practices and team culture post the pandemic disruptions. The reflections were analysed using a descriptive thematic approach.

Results

Staff described “a double-edged sword” balancing fatigue from the dynamic situation increasing their workloads with wanting to seize opportunities to challenge the status quo. Three themes were identified.

Conclusion

Clinical placement staff shared reflections are useful for identifying workplace initiatives that may enhance nursing and other disciplinary placement staff team culture and ways of working.

Keywords:

• clinical learning
• clinical placement
• clinical practicum
• pre- registration students
• nursing
• work integrated learning

Impact statement

An autoethnography of nursing clinical placement staff contributes four novel workplace initiatives to enhance nursing clinical placement staff teamwork and team culture. These four initiatives reinforce that challenges present opportunities for sustained change if staff develop the necessary skills to embrace workplace challenges.

Plain Language summary

Most of us experienced disruptions to our lives during the recent COVID-19 pandemic. In nursing, students must complete a clinical placement consisting of mandated hours in hospital and healthcare settings under supervision of a registered nurse. Clinical placement teams of nurse academics, registered nurses and professional staff organise and the clinical placements. The planning and coordination of clinical placements was greatly affected during the Covid pandemic. Placements were cancelled or postponed, impacting students, education providers and nursing placement staff. There has been much shared about student and education provider experiences but very little has been heard from nursing placement staff. The pandemic led to sustained improvements in our daily life; more flexibility with work at home arrangements, and a sustained connection with each other through conferencing technologies. This paper reports the reflections of a group of nine Australian nursing clinical placement staff, showing how they overcame the challenges facing them to change their daily workplace practices and culture. Individuals shared their experience of ‘a double-edged sword,’ constantly balancing fatigue from the additional workload pressures, the burden of anxious students and wanting to seize opportunities to challenge the status quo. They were able to innovate management and coordination of daily work practices, develop and enrich new and existing relationships with industry, and adopt compassionate approaches to communicating with nursing students.

Introduction and background

Work-integrated learning (WIL) programmes are an essential component of some courses offering students supervised time to transfer classroom knowledge into real-world practice. The real-world practice experiences, in nursing programmes, and referred to in this paper are called clinical placements. These placements endured interruption and disruption during the recent Covid pandemic. Staff, both academic and professional within university clinical placement teams, and clinical placement teams within hospitals and health services, are tasked with sourcing, organising and managing the clinical placement. Rapidly changing organisational directives and lockdowns, aimed at curbing the spread of the virus and ensuring public safety (Dean et al., 2022), resulted in placement cancellations and postponements (Queensland Health, 2023). To overcome the disruptions, clinical placement staff reported spending increased time problem solving. Remote or virtual placement initiatives saw business, information and technology and medical students’ complete placements online and quickly became favoured for allowing students to progress through their studies (Kay et al., 2020).

In nursing, whilst virtual learning has long been used to remotely prepare nursing students for their placements, Australia and New Zealand nursing councils have confirmed nursing clinical placements need to remain in real-world healthcare settings (Australian Nursing and Midwifery Accreditation Council [ANMAC], 2022). The Covid pandemic however, necessitated healthcare systems worldwide to look at new models of care delivery, including virtual or remote models of delivery and this presented significant disruption to the typical clinical placement opportunities available to nursing students (Dean et al., 2022). Along with the disruptions, increased attention to improving student and staff health and wellbeing (Köse & Murat, 2022), and a focus on teamwork, cohesion and culture (Jingxia et al., 2022) also emerged.

Group culture builds over time as member interactions and experiences lead to shared knowledge, attitudes, beliefs and values (Creswell, 2007). There is much written about nursing workplace culture in healthcare settings showing direct links between; positive culture and improved patient safety quality of care outcomes (Braithwaite et al., 2017). Poortaghi et al. (2021) found that nurse managers who were flexible, resilient, adaptable to change and able to provide staff psychological support, enhanced workplace culture. Nursing academics reportedly thrive, in organisations and teams that value work-life balance, autonomy, professional development and mentoring (Singh et al., 2020) and when they have confidence in the curriculum and the teaching team (Boamah et al., 2023).

Design

The primary aim of this study was to explore nursing clinical placement teams experiences of working through the recent pandemic, to deepen understanding of teamwork structures and culture. A secondary aim was to explore how the team managed challenges and barriers to coordinating student placement.

Prompts provided to guide participants reflective contributions were:

1. What was your experience of working through the pandemic?

2. How was this different to the way you used to work?

3. Has this practice continued/not continued post the pandemic?

4. Would you have made these changes without the disruption of COVID-19?

Nine staff from three separate institutions involved in nursing clinical placements were involved in this study. All nine staff contributed as researchers and participants. The institutions were two universities and a large tertiary hospital. Staff were a mix of professional staff (5), academic nurses (3) and one tertiary hospital education manager.

Earlier some of the researchers had published on innovations in nursing clinical placements during COVID-19 (Dean et al., 2022) and were interested to expand the discussion. A conversation with their respective clinical placement teams highlighted an interest in working collaboratively to explore their collective experiences.

Methods

Ethnography seeks to shed light on how groups work together, especially groups such as this one, where little is known about their everyday social practices and lived experiences (Creswell & Poth, 2018). Specifically, collaborative auto-ethnography was used in this study as it is an ethnographic approach, conducted in groups, to understand the collective experience, through the sharing of stories that may contribute to co-constructing team culture and ways of working (Hernandez et al., 2017). The participants as researchers were interested in examining their collaborative narratives to illuminate tension points that may have led to changes in teamwork and work practices, and the nature of any sustained changes.

Participants and recruitment

Recruitment occurred via an email invitation that included the discussion prompts. Human research ethics approval was obtained (HREC 24067) and consent was implied when participants chose to share their written reflections or spoken narratives.

Data collection

Data were collected between October and December 2022. Participants either emailed written reflections or met online via a digital collaborative platform to share and record their narratives that were then transcribed from digital recordings. It was decided to offer both methods of data collection, after some participants indicated a preference to narrate their experiences. Each participant cross-checked transcriptions for confirmation prior to data analysis.

Data analysis

Creswell and Poth’s (2018) three steps to analysing ethnographic data were employed. First, the group is described – see previous sections on participants and study context. Identifying the themes is the second step. Braun and Clarke’s (2006) six-step approach guided the theming process as outlined in Table 1. Creswell and Poth’s (2018) final step is a collection of statements or rules providing insight into the group culture. All participants agreed upon the group rules, presented in the discussion.

Table 1. Data analysis steps.

Step 1 Familiarisation – an inductive analysis was adopted that saw CR and FW read the transcripts several times.

Step 2 Generation of codes – CR and FW completed independent coding of the transcriptions line by line.

Step 3 Grouping of codes – Analysis was aimed at revealing semantic (face value, descriptive) and latent (hidden) meanings.

Step 4 Reviewing – FW and CR met on several occasions to discuss and review the theming

Step 5 Deciding on significance of themes – SD was consulted to reach consensus.

Step 6 Reporting – Participant authors submitted approval to be named authors and identifier codes were assigned to data units using individual’s initials in the data reporting

Results

Four participants requested a group online session, the remaining five submitted written reflections. Of the nine participants, five are university professional staff, three are nurse academics and one is a clinical placement education manager at a large tertiary hospital. The thematic analysis revealed three themes offering a descriptive exploration of team and individual experiences of working through COVID-19: balancing the challenges, embracing new opportunities and lasting change. Data supporting the following text is presented in Table 2.

Table 2. Themes, analysis and supporting data.

Theme	Analysis	Codes
Balancing the challenges	Challenges needed to be managed creatively. Data analysis revealed that with introspection the teams developed improved team culture through learning to be resilient, flexible and adaptable. Team experiences balancing policy and organisational requirements illuminated an unknown misunderstanding between stakeholders during the border closures.	We learned to become really creative in sourcing innovative placements (P5) and … thinking outside the box, looking at alternative placement opportunities which previously hadn’t been considered, and working with practice partners we were able to implement these new opportunities (P4). P1 shared … I developed my resilience, gained a greater insight into placement management and the workings of the university, and strengthened my relationships with my internal team and placement providers. P8 reflected; … the uncertainty of COVID 19 has taught me to tolerate uncertainty – I don’t stress so much about things changing … and having to get all students placed without any changes. It’s been better for my mental health! and P2 agreed … there was an increased need for flexibility and patience and a shared sense of overcoming adversity; it just felt like this team were going above and beyond (P9).  … a hospital in my region cancelled all of our placements (more than 60 students) … we didn’t know why … it came out that they thought we were sending students from [one region] to another … because we are based so far away from the hospital. This was a real insight for us. It seemed this facility never understood that we only sent local students. All placements were reinstated when we provided student postcodes, verifying they lived locally (P3).
Embracing new opportunities	P5 manages interstate and remote clinical placements. Here she shared how seizing opportunities to air shared challenges and utilising technology in new ways, improved working relationships and advanced work processes. P6 reflections revealed the teams’ increased reliance on placement software systems and the need to introduce technology (coding) for ease of rapid data analysis. P4 shared a similar narrative about supporting students on placement with the increasing use of video conferencing technology such as Zoom. CGT valued technology for providing the opportunity to work from home and shared this has become the norm still today;	we all appreciated the challenging work we had to do and that brought us closer. We would also end up in online meetings with people we had never met before … Before, I would pick up the phone and get nowhere. … now we get to know each other, can answer questions better … the key players are online at the same time. … nursing managers and the likes to problem solve, sharing our ideas and experiences. This was great and allowed us to build new relationships with our partners that we still maintain today (P5). There were a lot of extra reporting requirements during this time. We had to work quickly to change the software. This led to improved collection of data and internal and external reporting. That might not have happened without COVID. You could say the disruption of COVID has moved us along quite a bit improving software and processes. Now we are identifying more changes to make our processes even better (P6).  … the support and the chance to interact with other clinical teachers and unit assessors and the clinical academic team. These offerings have been  … embraced by the clinical facilitators and given its success, will be continued post COVID19 restrictions (P4). Further, P9 shared an observation that Clinical placement Officers seemed more autonomous in their decision-making, and I see this still today. I can now work from home and still do since the pandemic has eased a bit. This suits me well with my family and little boy. They used to say professional staff can’t do their work at home. I never understood why. I think I do just the same job, maybe even a little bit more productive at home (P8).
Lasting Change	Shift in students approaches to placement.	we also think students were more accepting of new/different types of placements and locations … before COVID-19 we had to remind students that our WIL policy says they may have to travel at their own expense … then we have students telling us they would travel anywhere to do a placement. They seemed to be thinking more about placement as a learning experience and they appeared more open to new experiences. Some of this attitude is still around today (P8 and P3).

Note: This table supports the findings section.

Balancing the challenges

This theme revealed teamwork challenges, oftentimes a result of political decision making, required in the moment problem solving; Rapidly changing government restrictions, sudden lockdowns, vaccination mandates, and mask requirements all impacted the function of the team … rapid responses to constant changes were essential (P1). Government policies rapidly changed sometimes more than once per day. Immediate border closures hard (state) and soft (regional) prevented students accessing placements, requiring agile processes to ensure student progression with minimal interruption. As P2 and P1 reflected; NSW and QLD had different policies, and the border division caused issues … students who traditionally … crossed the state border could no longer do so.

To manage the constant changes, participants found they needed to draw on shared team and individual creative solutions. Team introspection assisted in an improved team culture through individuals learning to be resilient, flexible and adaptable.

For everyone involved in clinical placements, in the university or within the health services, it became necessary during the pandemic, to balance the challenges of policy, organisational requirements and the student’s wants and needs. This often led to staff needing to prioritise compassion over adhering to rules. Students had to consider contingencies such as isolation and travel difficulties, vaccination, PPE requirements, physical and psychological safety, conflicting family and study demands, curriculum requirements and financial constraints. In order to navigate through the pandemic experience, nursing students required additional support (Ulenaers et al., 2021). Because of this, P1 considered the pandemic a double-edged sword. On one side, we needed to have strict processes and systems, which included deadlines, strict student attendance expectations, and fast-paced turnaround of documentation and communication. On the other edge, compassion, understanding, support, and ethical considerations also needed to be considered in decision-making and when working as part of a team, with partners, and with students. Finding the right balance was difficult, but the lessons learned from this experience continue to inform current practices (P1). Balancing policy and organisational requirements deepened communications and understanding between stakeholders (see Table 2 for supporting data). COVID-19 was a time of constant change, adaptation, and the need to manage challenges. Team narratives clearly revealed this and led to a second theme.

Embracing new opportunities

Analysis of team reflections revealed that disruption can provide teams the impetus to look for new opportunities, partnerships, and ways of working. As a clinical placement team manager, P1 observed growth in collaborations and partnerships through teams being open to opportunity; many hours were spent talking to placement providers, discussing opportunities, and negotiating new placement opportunities. I also had to liaise with the academic team to negotiate flexibility to allow students to attend placement during teaching periods. placement … it was a whole team approach that required clear communication (P1). P3 contributed further technological improvements to teamwork processes through the use collaborative digital platforms; Teams [Microsoft Teams] has become a real benefit to me. It’s so easy for storing documents, chatting directly with people when there are questions or problems. It’s also helped with relationships … working with these people virtually, it’s brought us closer together. If a meeting is needed it can quickly be organised in Teams [Microsoft teams] (P3).

One opportunity that all participants embraced was advancing communication; communication, networking and working as collegial teams were really fostered during COVID-19, … and without COVID-19 may have taken much longer to establish – if at all. (P4). P5 shared how partner communications have improved overall; Our relationships with facilities whilst good are now even stronger because of the commonality [during this time] we communicated and shared a comradery that wasn’t there before. P5 further explained the advances in communications; … it has forced us to use the technology. Silly really the technology was already there (P5) … we continue to have more online meetings today (P5). P1’s reflections confirmed P5’s experience; new communication strategies and pathways were developed and continue today (P1). P5 also reflected on new progressing communication initiatives; … we started developing templates before COVID-19 but it wasn’t a priority, it takes time to develop them. COVID-19 made us work really hard to finish these off. Now we have templates for communication, templates for placement information, for confirming placement details, for student pre-clinical requirements, just for everything. It saves us a lot of time (P5).

From an industry partner perspective communication was key to optimising student placement management and presented as another double-edged sword. Some aspects of partner communications improved; in partnership with the healthcare providers, we looked at placements and opportunities to improve and streamline clinical assessment processes. Now we use only electronic documents, saving time and providing more consistency and reliability in tracking student log of hours and assessment data (P6) and others remained challenging. P7 emphasised the importance of dissemination of correct and timely communications; communication between the education providers and health services was particularly important with the need to disseminate information quickly as the response to the pandemic evolved (P7). Lessons were learned as inconsistent messaging or communication between parties caused confusion and increased workloads due to the fallout of this confusion (P1). These stories indicate nursing clinical placement staff embraced the opportunity to discover new ways of working many of which were related to technology.

Lasting change

This theme evidences the true impact of the pandemic disruptions on the nursing clinical placement teams. Analysis of team reflections highlighted the destabilising of routine thinking and practices. This resulted in lasting change in the coordination and thinking about clinical placements in nursing. COVID presented an opportunity for a comprehensive review of the way placement was organised and allowed us to look for potential improvements, efficiencies and effective distribution of roles and responsibilities. New roles and redistribution of responsibilities have been implemented to streamline processes and reduce the burden on single individuals (P1).

Through improved partnership and collaboration between stakeholders some previous barriers were addressed, presented here and in Table 2. Students who miss clinical hours must make them up in subsequent clinical placements, to meet the overall total of hours required for a student to graduate. Routine thinking around booking make up hours for a full week were challenged; … facilities were more open to taking students just for their makeup hours only, like one or two days. Before COVID-19 facilities would only offer makeup in weekly blocks (P8). According to P1, the challenges of COVID opened up the discussion to explore new ways of delivering placement to meet all university’s placement capacity needs. More collaboration requiring procedures to complete make-up hours continues still.

The routine practice of delivering facility orientations required a re-think, partly because of social distancing restrictions and partly because it was imperative to get students into the working environments as quickly as possible. P8 and P3 shared; … prior [to COVID-19] we had started asking facilities to put their orientation online. We really pushed for this during COVID to save time and have students on the wards as soon as possible. I’ve noticed more facilities are taking this up. It makes sense (P8).

Despite the workload pressures and challenges caused by COVID-19, the disruption to coordinating clinical placements resulted in improved workflow, improved communication, flexibility and adaptability. A lot more work but a lot of positives have come out of this experience like changes in practice that we have all talked about here. As a team we have kept on using and improving these changes today (P5). COVID enabled moving away from “how it had always been done”. P1 wrote, COVID created the need and allowed for the opportunity for different stakeholders to gain further insights into how the larger placement system works, looking at placement from a different perspective. The lessons learned will stay with me and I will continue to develop my practice. P2 acknowledged the camaraderie clinical placement staff drew upon to do their work; I believe we all worked together to achieve the best possible outcome for students.

Discussion

In this project nursing clinical placement staff shared reflections and narratives during a time of many disruptions to daily practices. Researchers were particularly interested to see in what ways staff had managed or overcome the challenges and whether the experience enabled innovative and lasting improvements, presented next as group rules, in the management of clinical placements and team-work culture.

Participants in this study referred to working in a double-edged sword situation, needing to balance rapidly and constantly changing unyielding restrictions and needing to be flexible with key stakeholders to manage the restrictions. The first group rule then is: fostering staff to develop skills for embracing challenges leads to positive changes in their daily work. Being creative, solving problems quickly and approaching students compassionately were helpful skills identified here. Recent literature reviews suggest creativity is encouraged in nursing education (Ma et al., 2018) and is an expected quality for those managing the challenges of supporting students during clinical placements (Ryan & McAllister, 2020). Cheraghi et al. (2021) suggest that supportive managers who foster creativity and divergent thinking can enhance nurses’ creative decision making and postive and impactful workplace changes.

Participants’ shared stories informed a second rule – Workplaces that value staff autonomy can enhance team cohesion and reduce burden of work. The example participants shared, saw individual placement staff allocated protected time to complete difficult and time-consuming task of developing effective large scale communications. Poor organisational communication has been identified as a major stressor for nursing students (Luo et al., 2023), confirmed by participants in this study. The pandemic disruptions have placed official communication channels under scrutiny, challenging existing models and theories to illuminate new ways forward (Lodzki & Kopecka-Piech, 2022). This study has shown the benefits from prioritising time-consuming communication tasks such as creating templates; communications with all stakeholders were improved and the burden of work reduced. Research evidences that autonomous nurses enhance quality of patient care and deflect the impact of negative workplace cultures such as moral distress (Gottlieb et al., 2021).

Similarly, a third rule builds on the idea of agency and autonomy – Encouraging whole of team and individual introspection leads to implementation of positive and lasting workplace changes. Work-integrated learning (WIL) staff from business and information technology (Connor et al., 2021) and nursing managers (Poortaghi et al., 2021) have been observed as flexible and resilient to change (Poortaghi et al., 2021), yet few studies have reported on introspection and outcomes of teams sharing in the moment thinking. Introspection refers to examining thoughts and feelings. In our study, the reference is related to sharing of thoughts (see participant’s narratives in Table 2 about reinstating large numbers of student placements through providing students postcodes and teams building resilience). Teams in this study also adopted the think aloud technique, often applied in nursing education to understand and assess students’ clinical reasoning (Verkuyl et al., 2018) to assist in their problem solving and to share new learnings such as embracing uncertainty.

A fourth and final group rule is – Embracing technology improves stakeholder relations and data management. This rule remains as a driver of study participants’ teamwork culture, given that clinical placements are heavily dependent on stakeholder relations (Wilson et al., 2022). The benefits of technology for allowing virtual stakeholder meetings for enhanced relationships and improved problem solving through key personnel attendance were claimed. For some participants, technology made hybrid working arrangements possible, improving work-life balance and productivity (see Table 2). This is an important finding contradicting concerns that remote working would reduce student support and prevent clinical placement staff from working collaboratively and productively (Kay et al., 2020).

In this study online conferencing technology allowed for collaboration and negotiation around orientating student nurses to the placement learning environments. Prior to the pandemic, face-to-face sessions were commonly used for the orientations. Students experienced the orientations as lengthy and boring and were considered as a delay to engaging in direct patient cares (Ryan et al., 2023). Moving orientations online meant students were better prepared for placement through early introductions to key staff and organisational placement requirements. Other studies report technological enhanced innovations such as the successful use of telemedicine to facilitate clinical placements in specialised and niche nursing roles, inside and outside of the traditional hospital environment (Dean et al., 2022).

Embracing technology enhanced nursing placement staff data management processes. Teams studied here experienced an increased expectation to report on students’ placement hours missed, number of interrupted placements by region and student readiness for placement (such as completed vaccination and mask fit testing status). Creating and using electronic forms and adapting placement software programmes to enable data management became necessary innovations to manage these requests; a sustained practice improving workflow and saving time.

A surprising outcome of using technology in this way was the ability for participants to improve processes around students missed clinical placement hours. With exact reporting, placement officers were able to negotiate only exact make up hours, overturning normal practice of students undertaking a full working week (40 hours) of placement, irrespective of hours required to complete (which may have been 8 hours or less). This allowed education providers to graduate students on time and open up placement opportunities (Dean et al., 2022). This initiative continues to enhance nursing placement team communication, improving the availability of placement opportunities.

These four rules illuminate nursing placement staff team culture. Important examples shared here, show how challenging routine thinking can lead to positive change in workplace culture.

Limitations

Generalisability cannot be claimed in this study, due to the small amount of participants and the chosen methodology and methods. Observational methods, of placement officers were not included for time’s sake. As not all team members participated, meaning perceptions of the negative effects of the lasting changes reported here may be missed. Further exploration using a different study design, might deepen understanding of the impact of constant change on nursing clinical placement staff and individual placement officers. A recent systematic review highlighted the need for exploration and research into the effective management of nursing clinical placements during large-scale disasters such as the Covid pandemic (Luo et al., 2023).

As researchers and participants, we acknowledged our positions of power within the team however this remains a limitation in this study as no investigation of the impact of power on our narratives and on each other was undertaken. Yet with few studies exploring the experiences of nursing clinical placement teams, the findings from this study are important for showing ways forward for other nursing clinical placement teams and for nursing teams generally.

Conclusion

A collaborative autoethnography approach was used to gain a more nuanced and comprehensive understanding of nursing clinical placement staff experiences during a pandemic. The collection of narratives offer a rich and detailed understanding of the complex interplay and patterns between nursing clinical placement staff and their stakeholders. Learning how to use available and emerging technologies, understanding and appreciating the importance of empathy, compassion and autonomous work, as well as being creative, flexible, and adaptable are qualities that could assist nursing placement staff. Four group rules, informed by participants’ narratives are offered to enhance the way nursing clinical placement staff approach their work, leading to improved team culture. Whilst the pandemic was the impetus for this study, we believe the findings indicate a way forward for more much needed research into the management of the nuances of nursing clinical placements.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.