Despite its status as the world's largest employer of highly skilled professionals, the NHS has struggled to align its workforce growth with the escalating demand for healthcare services (NHS England/NHS Improvement, 2019). The ageing population, presenting with increasing complex clinical needs and multi-morbidities (McKee et al, 2021), combined with unsustainable staffing vacancies and reduced staffing stability (Buchan et al, 2019), is creating profound pressures on the entire health sector.
These pressures have potentially significant adverse implications, threatening the quality of care provided, the health outcomes for individual patients and the quality of the learning experience offered to preregistration learners by each placement area (NHS Confederation, 2022).
Placements are not just for students' benefit
Effective clinical placements offer learners the chance to evolve their professional identity, while providing clinical areas with an opportunity to attract these individuals to their workforce. To maintain safe and effective staffing levels, many clinical areas depend on attracting and retaining preregistration learners in numbers at least equal to staff turnover as individuals leave following lifestyle changes.
Disrupting this delicate balance through unnecessary learner attrition can lead to serious and far-reaching implications for service provision (Buchan et al, 2019). To better understand this threat, the national RePair (Reducing Pre-Registration Attrition and Improving Retention) project was established in 2015 and has played a key role in the identification and sharing of best practice recommendations to reduce attrition. Its imminent closure happens at a time of significant workforce concerns.
With a notable decline in applications to healthcare courses, nurturing current learners and facilitating their transition into the workforce has become more crucial than ever (Hill, 2023). Many learners find navigating their clinical placements an overwhelming challenge at times, increasing the risk that they will prematurely leave their healthcare programmes and their chosen profession (Eick et al, 2012).
Understanding their experiences and fostering enhancement is crucial, and the National Education and Training Survey (NETS) plays an integral role in NHS England's quality assurance processes for clinical placements (NHS England, 2024). In 2022, 42% of the 6241 nursing students responding to NETS contemplated leaving their training programmes, reflecting an increase from 40% the previous year (Health Education England, 2022).
Learners need to feel supported and included
Although learner attrition is a complex dynamic problem impacted by both intrinsic and extrinsic factors (Hamshire et al, 2019), a key driver behind this response seems to be the insufficient human relations and support experienced during placements. Learners referenced less than satisfactory experiences on previous placements, their perception of stress relating to both academic and placement pressures, and their sense that, when they required support, it was either lacking or insufficient to meet their needs.
For those unlikely to recommend their placement experience, the culture within that clinical environment and their perception of not being included within the clinical team were key factors.
Nevertheless, significant strides can be made to boost learner retention individually by enhancing their sense of belonging within the clinical environment, team, and profession (Ashktorab et al, 2017). As a deeply personal and contextual psychological construct, a learner's sense of belonging evolves in response to the reciprocal relationships built upon shared experiences between the individual learner and the placement teams supporting them (Levett-Jones and Lathlean, 2008; Maher et al, 2013). Fostering this sense of belonging can often hinge on the strength of the professional and personal connections made (Davis et al, 2019; Middleton et al, 2021). Simple yet powerful gestures, such as learning and correctly using a learner's name, can significantly enhance their sense of inclusion, as opposed to impersonally referring to them as ‘the student’ (Ó Lúanaigh, 2015).
High-quality placements need input from the whole team
For each clinical team, the current structure of placement circuits and service demands can create many logistical challenges to fully integrating every learner they support. Learners are given a sense of being in constant transition (Hamshire et al, 2019), and the challenges they face can also reduce the quantity of shared experiences. However, those clinical teams who can fashion and prioritise high-quality learning experiences, aligned to each learner's educational needs, will help provide each learner that they support with a sense of feeling both valued and respected.
Proactive interventions can aid the development of mutual respect, fostering inclusivity and cohesion: they enable the learner to feel both clinically and socially included (Conner, 2015), as well as psychologically safe. Examples of such interventions include integrating each learner in the clinical team and empowering them to take up appropriate responsibilities. It is also important to find time to provide a genuine welcome, offer an induction and an effective orientation, and to create a student council or forum, enabling them to access and provide peer support.
However, the effectiveness of these interventions relies on their quality and delivery,. Poorly executed interventions risk being counterproductive, diminishing the learner's sense of value, heightening their sense of isolation and increasing their risk of attrition (Bøe and Debesay, 2021; Squire et al, 2024). Thus, for successful implementation within the current pressurised clinical climate, the responsibility for developing connections and fostering an inclusive environment must be shared across the entire clinical team.
Addressing the complex challenge of learner retention in health care requires a multifactorial approach centred on enhancing the sense of belonging and support for learners. By acknowledging and actively addressing the factors that contribute to feelings of exclusion, placement providers can create a more inclusive environment, aiding learner retention and their subsequent transition into the workforce.