During December 2019 reports emerged from Wuhan in China of a new respiratory infection. At the end of March 2022, globally, the virus now commonly known as COVID-19, has been responsible for more than 6 million deaths with more than 470 million confirmed cases (World Health Organization (WHO), 2022). Within the UK, the current death toll (deaths with COVID-19 noted on the death certificate), stands at more than 186 000, with more than 20 million confirmed cases (UK Health Security Agency/Gov.UK, 2022). In Wales, more than 7000 deaths and 860 000 known cases have been recorded (Public Health Wales (PHW), 2022).
The impact of COVID-19 across the UK has varied significantly region by region, and across social and occupational groups (Sa, 2020). Increasing age, pre-existing health conditions, obesity, particular ethnicities and sex have been noted risk factors in term of COVID-19 morbidity and mortality (Public Health England (PHE) 2020a; Navaratnam et al, 2021). The incidence and mortality rates of COVID-19 in Wales has been reported daily by PHW and at times also widely reported in the national media (BBC News, 2020). At one point, five areas in south Wales were reported to be in the UK's six most affected regions (Halliday, 2021).
Delivery of approved COVID-19 vaccines began in January 2021. Delivery of the vaccine to prioritised groups during phase 1 was as advised by the Joint Committee on Vaccination and Immunisation (JCVI) (2020). The distinctive nature of the vaccination programme and the learning opportunities that are an inherent feature of this service presented a unique public health/primary care placement experience for undergraduate nursing students. Given the unique nature of a mass vaccination centre (MVC) there was no available literature on the effectiveness of an MVC as a placement for student nurses.
This article describes a project exploring the use of the quality improvement methodology Plan, Do, Study, Act (PDSA) approach (NHS England/NHS Improvement, 2018) to an innovative placement experience for a group of undergraduate BN Adult Nursing students. These students worked under supervision within one of two MVC sites in a partner health board in south Wales as part of a structured practice learning experience and, in doing so, became trained vaccinators.
Plan
In December 2020, as part of an ongoing review of placements within one established partner organisation, the potential learning opportunities within an MVC were discussed. These were identified as learning opportunities in the areas of infection control, pharmacology, vaccines and their mode of action, medicines management, legal and professional issues, consent, advocacy, communication, team working, anaphylaxis, basic life support and information governance. The two MVC sites each aimed to vaccinate approximately 1000 people a day. Alongside deployed NHS staff, staff from the local council and the military services were also engaged in supporting the vaccination programme.
A key element within this planning phase was the students' ability to actively participate in the mass vaccination service. Outside of the current pandemic, vaccination services operate under a patient group direction (PGD), which stipulates the professional groups that can deliver medicines/vaccines that fall under the PGD (Jenkins, 2020). PGDs are the legal mechanism by which a prescription-only medicine (POM) can be supplied or administered for a patient for whom no individual prescription exists (Medicines and Healthcare products Regulatory Agency, 2017). However, given the logistical challenge of administering a vaccine to the UK population, a new legislative framework was developed called a national protocol (Welsh Government et al; 2020; PHE, 2022):
‘The national protocols allow specified classes of people, which need not be limited to registered health professionals, to administer COVID-19 vaccines.’
The proposed inclusion of students (non-registered health care workers) within the MVC service had the support of the health board's corporate nursing team. The organisation's COVID-19 Vaccine Governance Framework was amended to include the student group. A site visit in early January 2021 involving the partner organisation's professional lead for education, the lead practice education facilitator, the health board's emergency planning lead and the MVC clinical co-ordinator was held. The different groups within the planning cycle were unequivocal in their desire to see students on placement experiencing identified learning opportunities. In addition, the groups were clear that the MVC provided an opportunity for students to work according to the principles of the Nursing and Midwifery Council's (NMC) Code (2018a) to prioritise people, practice effectively, preserve safety and promote professionalism and trust.
The duration of the placement was agreed at 5 weeks (to include 1 week of induction). The planning phase was completed by an educational audit, with groups of year 2 and year 3 BN Adult Nursing students allocated according to established procedures to undertake the placement over a 10-week period commencing in January 2021.
Do
Students began the placement with a 1-week induction that included completing a range of specified e-learning packages, via the Health Education England (HEE) E-learning for Healthcare website (HEE, 2022) such as:
- COVID-19 vaccination
- Infection prevention and control
- Anaphylaxis.
There were also health board-specified packages. The induction programme included a day's face-to-face training within the MVC, training on core COVID-19 knowledge (PHE, 2020b) as well as orientation to the PHE (2020c) COVID-19 vaccinator competency assessment tool. It was also an opportunity to meet the team who would be supporting the student group throughout the placement.
During the placement, students worked under the supervision of the MVC's nominated clinical co-ordinator and with a registrant working alongside. In addition, a team of practice education facilitators had been deployed to the MVC on a sessional basis. This team was central in ensuring that students were being effectively supervised and were able to support registrants accordingly. In effect, a supervision ‘student support bubble’ was in place to support the students on a day-to-day basis. The immunisation training team and designated higher education institution (HEI) link tutor were also available to support the students.
In many cases, nurse registrants had undertaken training meeting the NMC's (2018b)Standards for student supervision and assessment and could fulfil the role of practice supervisor/practice assessor. However, due to the day-by-day variation in staff attending the centre, registrants provided feedback on daily progress rather than sign off. The sign-off element was provided by the practice education facilitator team, who acted as the students' designated educational contacts within the placement area. The practice education facilitators team were able to monitor and assess progress through observation of individual students, discussion with the student's MVC supervising staff and exploration of evidence gathered through completion of the core competency document.
Over the course of 10 weeks, 25 students rotated through their MVC placement, each for a 4-5 week period. Prior to starting the placement at either site, students were invited to complete a short pre-placement 10-question online form (Box 1). This form, based upon a modified Likert scale (Ho, 2017) was produced using Microsoft (MS) Forms, and deployed securely through the HEI's virtual learning environment. Students were invited to complete the same set of 10 question statements after their placement, thus enabling analysis. Each question statement was scored between 1 and 5 (Box 1). Twenty-one students completed both questionnaires.
Box 1.Pre- and post-placement questionnaire statements
All answers on a scale of 1–5, where: 1=Strongly disagree; 2=Disagree; 3=Neutral; 4=Agree; 5=Strongly agree
| 1. Primary care and public health relate to strategies designed to keep the population well. As part of my course I have experienced primary care/public health placements |
| 2. I have a very good understanding of how two named COVID-19 vaccines work |
| 3. I have a very good understanding of the legal framework (eg patient specific direction, patient group direction, national protocol) under which different vaccines are administered |
| 4. I have a very good understanding of staff roles and responsibilities within the five different stages a member of the public will pass through within the vaccination centre |
| 5. I feel confident in answering a range of basic questions and queries from members of the public related to the vaccination process |
| 6. I can demonstrate a range of core skills (eg responding to anaphylaxis, adverse events, disposal of sharps, cold chain) related to immunisation |
| 7. I feel confident in the administration of Intramuscular injections into the deltoid muscle |
| 8. I feel confident in raising concerns in an appropriate manner to relevant staff within the vaccination centre |
| 9. My practice/placement experiences to date have enabled me to work confidently with a wide range of members of the multidisciplinary team and other frontline staff |
| 10. A placement within a mass vaccination centre offers real potential for a positive learning experience |
All answers on a scale of 1–5, where: 1=Strongly disagree; 2=Disagree; 3=Neutral; 4=Agree; 5=Strongly agree
This collaborative quality service improvement project between a university and a partner organisation was a critical analysis of student feedback and not formal research. Prior to the placement, students were reminded that all feedback would be shared confidentially with the partner organisation providing the placement and used for quality assurance and quality improvement processes. In determining whether the level of any change in score post-placement was of statistical significance and not due to a random event, a paired (student's) t-test (Livingston, 2004) was used with the following null hypothesis and hypothesis identified:
- Null hypothesis: with reference to the learning explored by each question, a placement within an MVC will have no statistically significant (P>0.05) impact on learning
- Hypothesis: with reference to the learning explored by each question, a placement within a MVC will have a statistically significant (P<0.05) impact on learning.
Study
Data from the pre- and post-placement questions were collected using MS Forms, with a report being collated using MS Excel (Table 1). Excluding three responses, post-placement scores across all question statements were equal to or greater than their corresponding pre-placements scores.
Table 1. Pre- and post-placement results of questionnaire
| Student | Pre Q1 | Post Q1 | Pre Q2 | Post Q2 | Pre Q3 | Post Q3 | Pre Q4 | Post Q4 | Pre Q5 | Post Q5 | Pre Q6 | Post Q6 | Pre Q7 | Post Q7 | Pre Q8 | Post Q8 | Pre Q9 | Post Q9 | Pre Q10 | Post Q10 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| 2 | 3 | 5 | 2 | 5 | 2 | 5 | 3 | 5 | 2 | 5 | 2 | 5 | 3 | 5 | 2 | 5 | 3 | 5 | 3 | 5 |
| 3 | 5 | 5 | 4 | 5 | 4 | 5 | 5 | 5 | 4 | 5 | 4 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| 4 | 4 | 5 | 5 | 5 | 4 | 5 | 5 | 5 | 5 | 5 | 4 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| 6 | 5 | 5 | 5 | 5 | 4 | 5 | 5 | 5 | 5 | 5 | 4 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 4 | 5 |
| 7 | 4 | 5 | 3 | 5 | 2 | 5 | 2 | 5 | 3 | 5 | 2 | 5 | 2 | 5 | 3 | 5 | 3 | 5 | 5 | 5 |
| 8 | 5 | 5 | 5 | 5 | 4 | 5 | 4 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 3 | 5 | 4 | 5 |
| 9 | 4 | 5 | 3 | 4 | 3 | 4 | 2 | 4 | 3 | 4 | 3 | 4 | 3 | 4 | 4 | 4 | 3 | 5 | 4 | 5 |
| 10 | 3 | 5 | 4 | 5 | 3 | 5 | 3 | 5 | 4 | 5 | 4 | 5 | 4 | 5 | 4 | 5 | 4 | 5 | 4 | 5 |
| 11 | 5 | 5 | 3 | 5 | 3 | 5 | 4 | 5 | 2 | 5 | 2 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| 12 | 2 | 5 | 1 | 5 | 1 | 5 | 1 | 5 | 1 | 5 | 2 | 5 | 3 | 5 | 2 | 5 | 4 | 5 | 3 | 5 |
| 13 | 3 | 4 | 3 | 5 | 4 | 5 | 2 | 4 | 3 | 4 | 3 | 4 | 4 | 5 | 4 | 5 | 2 | 5 | 5 | 5 |
| 14 | 3 | 5 | 1 | 4 | 1 | 4 | 1 | 5 | 1 | 5 | 1 | 4 | 3 | 5 | 3 | 5 | 3 | 5 | 3 | 5 |
| 15 | 4 | 5 | 5 | 5 | 4 | 4 | 1 | 4 | 4 | 5 | 2 | 4 | 4 | 5 | 2 | 5 | 4 | 5 | 4 | 5 |
| 16 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| 17 | 4 | 4 | 3 | 4 | 1 | 4 | 1 | 4 | 1 | 4 | 1 | 4 | 3 | 5 | 4 | 5 | 5 | 5 | 5 | 5 |
| 18 | 4 | 3 | 4 | 5 | 3 | 4 | 3 | 3 | 3 | 4 | 4 | 4 | 4 | 5 | 4 | 4 | 4 | 4 | 3 | 2 |
| 19 | 5 | 5 | 3 | 5 | 3 | 5 | 1 | 1 | 4 | 5 | 5 | 3 | 5 | 5 | 5 | 5 | 5 | 4 | 5 | 3 |
| 20 | 2 | 5 | 1 | 5 | 2 | 4 | 1 | 4 | 1 | 5 | 1 | 3 | 3 | 5 | 3 | 5 | 3 | 5 | 3 | 4 |
| 21 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| Summary results | ||||||||||||||||||||
| Minimum | 2 | 3 | 1 | 4 | 1 | 4 | 1 | 1 | 1 | 4 | 1 | 3 | 2 | 4 | 2 | 4 | 2 | 4 | 3 | 2 |
| Maximum | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| Mean score | 4.0 | 4.8 | 3.6 | 4.9 | 3.2 | 4.7 | 3.0 | 4.5 | 3.4 | 4.8 | 3.3 | 4.5 | 4.1 | 5.0 | 4.0 | 4.9 | 4.1 | 4.9 | 4.3 | 4.7 |
| Standard deviation | 1.02 | 0.51 | 1.43 | 0.36 | 1.34 | 0.46 | 1.69 | 0.98 | 1.53 | 0.40 | 1.49 | 0.68 | 1.00 | 0.22 | 1.12 | 0.30 | 1.00 | 0.30 | 0.85 | 0.78 |
| t-test P value | 0.004 | 0.001 | 0.001 | 0.001 | 0.001 | 0.001 | 0.001 | 0.003 | 0.003 | 0.058 | ||||||||||
Statistical analysis using a paired student t-test explored differences in pre- and post-test mean scores, revealing statistically significant P values across 9 out of 10 questions. As seen in Table 1, P values ranged from P<0.001 to P=0.058 (to three decimal points), with the level of significance at P<0.05. Therefore, for these 9 questions, the difference in the mean score for the pre-to post-placement question statement was not a random or chance occurrence, but due to the learning experiences on placement.
For these 9 questions, the null hypothesis can be rejected and the hypothesis accepted.
Qualitative comments
Pre- and post-placement qualitative comments were also provided by the students. These were collated using a thematic approach and then categorised under the emerging themes (Table 2).
Table 2. Emerging themes from students post-placement comments
| Theme | Exemplar statement |
|---|---|
| Support | ‘The mass vaccination centre (MVC) provides a wide range of learning outcomes with positive support from all members of staff’ |
| Learning opportunities | ‘This placement has been amazing in all aspects, it has been the best placement for me so far and I feel I have learnt so much and feel so much [more] confident’ |
| Appreciation for the learning opportunity | ‘This placement has been incredible—I have learned new practical skills and gained lots of new knowledge. Thank you for this amazing opportunity’ |
| Variety of staff | ‘The variety of staff at the MVC enables you to learn new things on a daily basis’ |
The qualitative comments provided by the students were generally positive, with an emphasis on the support provided by the staff working within the MVC and the multiprofessional nature of the staff group providing a unique learning opportunity. The range of learning opportunities was a prominent theme with examples provided of the administration of medicines, knowledge of the Mental Capacity Act, and development of core skills such as communication and teamworking. Three students noted the busy nature of the MVC as a training centre.
Examining the results
The empirical data and qualitative comments provided by this group of students demonstrate clear evidence of a rich learning environment within an MVC with 9 out of 10 question statements seeing a statistically significant (P<0.05) difference across mean scores, pre- and post-placement. The reasons for such results are varied, with an effective preparation for placement, clear expectation of the students' role, being part of a supportive team, and receiving regular feedback all noted within the student feedback.
Two out of the 21 students recorded lower post-placement scores for question 10 than their corresponding pre-placement score. Such ‘within group’ variation in student expectations of the placement as a learning environment is not uncommon and demonstrates the individuality of students' learning needs (Hughes and Quinn, 2013; Dantas and Cunha, 2020). Statistically, these responses could be considered as outliers requiring judicious handling as their presence will skew empirical results; however, their inclusion can reveal important theory-building insights (Gibbert et al, 2020).
It is estimated that over the 10-week duration, the student group as a collective supported the vaccination of approximately 75 000 members of the public. The partner health board serves a population of approximately 600 000 (Welsh Government, 2021a). There are communities within the boundaries of the health board with numerous indicators of deprivation (Welsh Government, 2021b), chronic health conditions and an ageing profile. In relation to COVID-19 morbidity and mortality rates, these are known risk factors (Jordan et al, 2020; Sa, 2020) that contributed to the population the health board serves. Between March 2020 and March 2021, the area had the second highest number of deaths in the university health board in Wales (PHW, 2022). The student group lived within these local communities, were cognisant of the impact of COVID-19 and expressed a strong sense of purpose and excitement in being able to actively contribute to the mass vaccination programme and, in doing so, help protect their local communities. Two students commenting at the very start of the placement said:
‘Really excited to get started and help fight this pandemic in the vaccination centre.’
‘Thank you for this upcoming opportunity. I am very excited!’
In addition to a strong sense of purpose, a key emerging theme, and central to their learning experience, was the support of staff within the MVC. This theme was particularly important given the centrality of support and supervision to the learning environment (NMC, 2018b) and was a validation of the operational effectiveness of the project team's student support bubble. In addition to staff being approachable and supportive (Doyle et al, 2017; Sweet and Broadbent, 2017) a sense of ‘belonging’ is a recognised feature of an effective learning environment for students (Levett-Jones and Lathlean, 2008). Two students noted:
‘All the staff are very welcoming and keen to share their knowledge with myself. Staff are very helpful and they don't mind us asking questions.’
‘All members of the team and patients have been very supportive of our learning.’
Feedback from the students demonstrated two distinct facets, transactional and relational. These two features constitute core elements of the psychological contract within a employer-employee relationship (Coyle-Shapiro and Parzefall, 2008). Students described in very explicit terms the transactional element—the knowledge and skills they were learning. There was also a clear positive relational component within the placement, with students and staff commenting upon positive values and behaviours from each other, which augmented the learning experience. In formal feedback, one registrant who had worked with students stated:
‘Supporting students through this placement has been an absolute inspirational experience. Students have demonstrated commitment, enthusiasm to learn and extreme professionalism in being a part of history. They acknowledge the uniqueness of this learning experience and feel very privileged to have the opportunity to learn so many skills that otherwise they may not have had the opportunity to be exposed to.’
A range of core skills and learning opportunities
A range of evidence including the completion of the PHE competency document (PHE, 2020c) was collected by the students. It is notable that questions 2, 3 5 and 6 all relate to varying aspects of medicines management. Students' improvement in knowledge, understanding and clinical performance post-placement compared to pre-placement were all highly significant. MacDonald et al (2013) in exploring learning environments and medication dosage problem-solving, referred to ‘cognitive (knowing that and why) competence’ and ‘functional (know-how and skills) competence’. It is evident from these results that students developed such knowledge and understanding of such topics as the pharmacological mode of action of various vaccines, and developed competency in safely and effectively preparing and administering specific vaccines, under supervision. Therefore, for this group of students, an MVC placement provided a rich, structured and supported learning environment that facilitated their development of a range of medicines management core skills, a key elements of the NMC's (2010) essential skills cluster.
Limitations
This study had several notable weaknesses. First, the results at present constitute the experiences of 21 out of 25 students, across the two year groups, (year 2: n=20 and year 3 n=5). Further work will be undertaken to explore differences across these two groups. In addition, the students were also split across two sites, with the data including the experiences of 17 students in one MVC noted alongside 4 students from a second MVC. It is possible that experiences differed across year groups, across MVC sites or both. Further analysis of the data will explore these possibilities.
The use of a paired/student's t-test is logical for a paired pre-test, post-test design (McCrum-Gardner, 2008; Ho, 2017) and with small sample sizes (Livingston, 2004). Use of such a test is based upon several assumptions, one being an approximately normal distribution of results. This assumption held for some of the differences between pre- and post-placement results but not consistently for all. However, as this project was an analysis of feedback data as part of a quality improvement project and not a formal research project, the use of a student's t-test to establish the level of statistical significance within this baseline dataset is justified. Further analysis will involve triangulation of these results with an alternative non-parametric equivalent of the t-test. The self-reporting nature of the pre- and post-placement feedback forms is a further weakness, as the perceived increase in knowledge, understanding or competence is subjective. However, the triangulation of evidence—the positive feedback from training staff, supervisors and practice education facilitators provide evidence that the increase in performance reported by the students was in reality an objective self-assessment.
Act
The authors have made the following recommendations:
- Further statistical analysis of the data is required to explore variations across and within both student groups
- With appropriate support, supervision and governance frameworks, HEIs and partner organisations should provide placements for students in MVCs
- A discussion between relevant stakeholder groups should commence in order to explore the feasibility of students being actively engaged in vaccination programmes post national protocol
- The provision of a student support bubble could support students in a variety of settings where day-to-day staffing issues hinder a local cohesive support and supervision service for students
- Using a qualitative research methodology to explore the students' learning experience further will lead to an understanding of how this lived experience impacted upon the students' attitudes to vaccination and immunisation, how it influenced their own discussions (and outcomes) within their personal and social networks around vaccine uptake and reducing ‘antivax’ concerns. Realising this knowledge through the student voice can help inform current educational provision, aid potential recruitment to primary and community care services while potentially increasing vaccine uptake through effective and novel communication strategies to individuals worried about receiving a vaccine.
Conclusion
In December 2020, the mass vaccination programme commenced following the first of two vaccines being approved for use within the UK. One element of the logistical challenge in delivering this mass vaccination programme to the UK population is a suitably trained workforce. Across the UK, this workforce consists of both registered and non-registered health and care professionals as well as members of the public acting as volunteer vaccinators, all of whom have undergone appropriate training. Members of the public undertaking this role are to be applauded; however, the relative absence of students is preventing a unique multi-professional learning experience forming part of their professional development.
The ability to provide this placement was enabled through the innovative use of the national protocol by the partner organisation and an HEI. The national protocol will remain in place until the pandemic is considered over (PHE, 2022), at which point it is possible that COVID-19 vaccinations will become incorporated within the normal flu vaccination programme. This programme operates as part of a PGD with a specified range of registered staff able to administer vaccines and no ability to delegate and supervise activities. Healthcare students, regardless of their profession, are not able to actively engage in or support a vaccine programme delivered through a PGD. Enabling students to engage as they have done within the national protocol could help ensure students actively learn about public health and primary care strategies. This will help develop core skills related to medicines management as this student group demonstrated, and assist the primary care workforce in achieving higher vaccination rates. This avenue is worthy of further discussion between HEIs, partner organisations and policy makers as a change to the PGD framework would be required.
Given the clear strategic focus within the UK on promoting health and wellbeing, and the requirement of HEIs and partner organisations to ensure that the future nursing and healthcare workforce has the necessary knowledge, skills and experience to help deliver these strategies, maximising learning opportunities that focus on keeping people well is a priority. This project has demonstrated a range of rich learning opportunities within an MVC and logical and reasoned argument for student placements within an MVC. The data and empirical evidence offered is limited but conclusive in terms of the positive learning experience of an MVC placement for a group of nursing students. An MVC offers students a rich educational milieu with the potential for profound learning experiences at an important and formative stage on their journey to registration, during a global pandemic.
KEY POINTS
- The introduction of mass vaccination centres (MVCs) during the COVID-19 pandemic provided a unique public health/primary care placement experience for a group of undergraduate nursing students in Wales
- This article describes a project using the Plan, Do Study, Act quality improvement methodology approach to assessing the experience of student nurses in this placement
- The students took part in a 5-week placement with the support of registrants at the MVC and a team of practice education facilitators
- Twenty-one students completed a pre- and post-placement questionnaire and provided qualitative comments. Nine out of 10 question statements achieved a statistically significant difference across mean scores pre- and post-placement
- Student comments noted effective preparation, clear expectations, a supportive team and regular feedback
CPD reflective questions
- What do you consider are the key aspects of a positive student experience on a placement ?
- What are the different legal authorities that underpin the safe administration of medicines?
- How can students be further engaged in placement experiences that focus on keeping the population well?