Pre-entry student clinical placement demand: can it be met?

Clinical placements are a core component of pre-entry qualifications in allied health professions,¹ enabling students to gain essential skills and experience in the delivery of health care. The demand for clinical placements has increased due to growth in university health programs and cohort numbers.² Commitments to clinical education at a national and state government level, innovation in clinical placement provision and support and recognition for clinical educators are reported as contributing to the capacity of healthcare services to meet the challenge posed by this increasing demand.^3,4 Guidelines for a coherent and collaborative approach to clinical education have been recommended, with the need for the tertiary education and healthcare sectors to work in partnership as a central tenet.^3,5,6

The capacity of health services for student placement provision has been the topic of considerable professional and academic debate,^7,8 commonly stimulated by changes to university programs or health service systems.^3,9,10 Discussions on the responsibility for resourcing student placement provision have focussed on the perceived impact of student placements on health service educator work practices and workplace productivity.^11–13 Challenges from changing patient care demands, models of care, staff workload expectations, increasing university programs and quality supervision expectations have led to implementation of a range of placement capacity building approaches within a university or health service environment.^3,5,6,7,14 These approaches have included changing the models of placement education and/or ratio of students to educators,^4,14–16 organisation of student-led clinics or student supported services,¹⁷ increasing the use of non-traditional placement sites,⁴ increasing the use of simulation in preplacement courses or during placements¹⁸ and providing clinical placement coordinators in health services or university faculties.^7,11 Central to all these strategies has been the need to support the workload of health professional staff associated with the provision of clinical placements within the overall aim of graduating capable and work-ready allied health professionals. It is not uncommon to see partnerships between universities and healthcare facilities arising and playing a central role in ensuring the above strategies are managed effectively.^6,9,11 What is also common is the ad hoc or reactive nature of the strategies, often isolated to one profession and/or within one facility.^12,15 Typically, there has been a lack of coordination across allied health professions or jurisdictions to meet increases in placement demand from a growing university program sector.³

In the mid-to-late 2000s, rapid growth in the number of allied health courses offered by Queensland universities produced a significant increase in actual and projected demand for clinical placements. This resulted in tension between service provision and clinical education, ultimately leading to industrial issues in some public healthcare facilities as clinicians expressed concern about the amount of goodwill and work required to manage clinical placements.^15,19 At the same time, an adverse clinical event in a Queensland public health facility, attributed, in part, to inadequate clinical education and training, saw the establishment of a Queensland Government Ministerial Taskforce on Clinical Education and Training (see http://www.health.qld.gov.au/ahwac/html/cet.asp, accessed 4 May 2014). As a result, the Queensland government heightened support for, and investment in, clinical education and training as a risk management strategy, and the opportunity to address these issues within an enterprise bargaining framework emerged.

In 2007, provision was made within an industrial agreement to provide for a Clinical Education Workload Management Initiative (the Initiative). The industrial agreement was the Health Practitioners (Queensland Health) Certified Agreement (No. 1), first negotiated in 2007 and renegotiated in 2011 as the Health Practitioners (Queensland Health) Certified Agreement (No. 2) (HPEB2) CA/2011/106 (see http:www.qirc.qld.gov.au/agreement_award/certified_agreements/public_sector.htm, accessed 16 May 2014; the Agreement). The Agreement covers a workforce that includes allied health, scientist, oral health and public health practitioners within the Queensland public sector health service. The resulting consultative, collaborative, multiprofessional, jurisdiction-wide Initiative enshrined in the Agreement enabled significant investment aimed at increasing the capacity of health services to manage and accommodate student placements. This paper describes outcomes of a quality review of the Initiative’s financial support to allied health professions to build placement capacity and manage the workload associated with clinical placements.

Funding phased in over the life of the Agreement was equivalent to the cost of 164 full-time equivalent (FTE) health professionals at the mid-level pay point within the entry level classification structure. The intent of the Initiative was to support clinicians with the workload of providing clinical placements for pre-entry students and the provision of support for new graduates. Actual financial allocations to each of the allied health professions was based on a combination of employee numbers, current and anticipated student placement numbers, planned new graduate support strategies and the outcomes of negotiations with the relevant unions. Each profession was given the opportunity to design and implement a model of Initiative funding utilisation that best suited their needs for placement supply and demand. Governance of their allocated funding is profession specific and is managed within a state-wide framework coordinated by profession specific leadership groups and the Allied Health Professions’ Office of Queensland. Professions were required to develop key performance indicators against which they could report and review the usefulness and effectiveness of their approach to implementation using Initiative funding. Although Initiative funding encompassed support to new graduates as well as pre-entry student education, this paper concentrates on the impact of the Initiative on pre-entry student clinical education.

Professions used the funding to establish dedicated clinical educator and/or clinical education coordinator positions or to back fill front-line clinicians, enabling the release of required professional expertise for clinical placements within Hospital and Health Services (16 geographically delineated Hospital and Health Services exist across Queensland). Most of these positions were established at a senior health professional level in recognition of the skills and expertise required for the roles. All professions ultimately aimed to enhance the capacity of local services to undertake clinical education and training regardless of their chosen staff establishment model. The Initiative-funded positions work to: (1) manage the risk associated with novice learners in healthcare; (2) build the confidence, skill, knowledge and capability of allied health professionals in clinical education; and (3) provide coordination of logistical elements for placements in consultation with university programs. The professions use Initiative funding to build partnerships with universities, focusing on strategies to support student preparedness for placements, placement allocation and student support.

In 2011, an evaluation framework for the Initiative was commissioned to support its ongoing review. Elements of this framework informed a quality review of the work of the Initiative relating to support for pre-entry clinical placements. Of interest to the quality review actions reported on in this paper is funding provided to five allied health professions, namely medical radiation, nutrition and dietetics, occupational therapy, physiotherapy and speech pathology (i.e. funding for 87 FTE). These five professions were chosen because they were allocated funding early in the life of the Initiative, enabling the authors’ use of the clinical placement data evaluation indicator, identified in the evaluation framework, over a longer period of time (2010–13). The quality review actions undertaken and advised as part of the evaluation framework were: (1) an appraisal of clinical placement activity data; (2) collation of allied health workforce statistics; (3) collation of the number of allied health university students and programs geographically located in Queensland; and (4) a review of responses within customised surveys gathering the perceptions of key stakeholders on the contribution of the Initiative to the workload management of clinical placements for pre-entry students. The key stakeholders were the allied health workforce, Initiative-funded FTE clinical educators, state-wide profession-specific clinical education program managers, profession directors and allied health directors.

Ethics approval for conducting and reporting on quality review outcomes was obtained from the Human Research Ethics Committee of Queensland Health. On-line surveys were created and sent via email to the allied health workforce and Initiative-funded clinical educators in the State’s 16 Hospital and Health Services. A combination of forced choice, multiple choice with multiple answers and comment-optional questions was included. A survey with open-comment questions was sent to state-wide profession-specific clinical education program managers, profession directors and allied health directors via email. Each survey, taking approximately 15 min to complete, was piloted to refine the items before distribution.²⁰ A copy of the surveys can be obtained from the authors.

Allied health workforce data publicly available (Queensland Health yearly staff profile; see http://www.health.qld.gov.au/performance/docs/qh-staffing.pdf, accessed 2 May 2014) was combined with internally available staff data from health services across the state. Allied health clinical placement activity data were sourced from routine data collected and published (clinical placement activity data; see http://www.health.qld.gov.au/ahwac/html/cet.asp, accessed 4 May 2014). Clinical placement activity data reporting occurs twice each year, in January and July. The clinical placement activity data includes the number of placement days offered to university allied health programs and the actual number of placement days provided to the universities, by profession and Hospital and Health Service. Data are collected via the lead allied health staff in the 16 Hospital and Health Services, collated and verified by the professions before being distributed to stakeholders and published on the Internet. Clinical placement activity data collected from 2010 onwards can be reliably compared and reported on for the five professions.

In 2013, Queensland’s public health facilities’ 16 allied health professions, a workforce of approximately 5500 FTE staff (Queensland Health yearly staff profile; http://www.health.qld.gov.au/performance/docs/qh-staffing.pdf, accessed 2 July 2014), offered a total of 150 755 placement days to universities (clinical placement activity data; http://www.health.qld.gov.au/ahwac/html/cet.asp, accessed 4 May 2014). Placement day offers for the five professions (~3266 FTE) increased 23% from 83 093 days in 2010 to 102 563 days in 2013. Student placement days offered by these five professions represent 68% of total allied health professional offers. This information is detailed in Table 1. Within these professions, the allocation to placements is the responsibility of the university program staff and therefore placement offers are considered to be an important indicator of supply of placements as a result of placement building actions undertaken by staff within the Initiative. It needs to be noted that the drop in nutrition and dietetics placement offers in 2013 is a direct result of decreased community and public health nutrition placement offers. This occurred when, as a result of significant organisational restructure, the public health and community nutrition workforce decreased by 73% from 2012 to 2013.

Table 1.  Clinical placement days offered by the Queensland public health system to pre-entry students from Queensland and interstate universities from 2010 to 2013 for the five allied health professions in scope for the quality review
Note, one student day is equal to a minimum of 7 h

Figure 1 shows several factors impacting on placement supply and demand significant to the Initiative. To enable comparison, the factors are reported as the percentage change over the review period (2010–13). The upward trend in clinical placement activity based on placement offers and the upward trend in the number of programs and commencing students enrolled is evident. These upward trends are in contrast with the downward trend of staff FTE numbers across the five professions. The allied health FTE staffing figures represent the number of potential staff available to supervise students on placement.

Fig. 1.  Three-year trend for key factors impacting on placement demand and supply, comparing data for 2011–13 with data from 2010. (♦), placement days offered by the Queensland public health system to pre-entry students from Queensland and interstate universities; (■), number of programs physically located within the state of Queensland; (●), projected student numbers in final year based on commencing student numbers; (▲), staff full-time equivalents for the 16 Hospital and Health Services in Queensland.

A total of 536 survey responses was received from the allied health workforce. Of these, 244 responses were received from staff who provide pre-entry clinical placements in the five professions in scope for this paper. Survey responses pertaining to their perceptions of the impact of the Initiative on workload management were reviewed by two of the authors (LJM and JH). Responses were collated into a spreadsheet format and two authors (CF and LM) analysed the responses, noting key patterns.^20,21 Initial patterns from the data were organised into 11 meaningful codes through discussion.²² Data extracts were linked to each code by the authors and the coded data sorted into potential themes. These themes were then reviewed by all authors and refined into six: (1) regular and timely support; (2) preparing supervisor for placements; (3) placement logistics support; (4) workload management of student orientation, education and supervision for safe practice; (5) support for difficult student learning situations; and (6) clinical education resource development and dissemination.

Responses in the survey regarding the reasons why staff reported they offered more placement days from 2011 to 2013 were also appraised. These responses were prompted by multiple choice with multiple answer question options against 12 categories. These 12 categories were potential reasons proposed in the commissioned evaluation framework as to why staff would consider increasing placement offers. In the data analysis conducted by two of the authors (CF and LM) the frequency of responses against the 12 possible response categories were collated. The top six response categories chosen by staff as reasons why they offered more pre-entry placements were: (1) realisation of increased pre-entry student numbers; (2) support from Initiative-funded positions; (3) the priority given to pre-entry clinical education as core business for all allied health professionals within their health service; (4) links between department and/or team and universities; (5) coordination of pre-entry clinical education from Initiative-funded positions; and (6) training regarding clinical education for pre-entry students.

Profession directors and allied health director stakeholders reported that the Initiative had noticeably increased the provision of and support for clinical placements, enabling a more sustainable approach to pre-entry student education across professions and health services. The role of Initiative-funded positions in enhancing collaboration with university partners was seen as a major achievement. Directors also reported the positive impact the Initiative-funded roles had on providing logistical support and coordination of placements. The managers strongly supported any current and future interprofessional collaborations occurring as a feature of the positions, to reduce duplication of effort and to enhance the quality of cross-professional support to the workload management of clinical placements.

In 2012, Queensland Health underwent a significant restructure and reform process. This had an impact on allied health staff recruitment and retention, and it was perceived that it would also impact on the capacity of this workforce to provide clinical education placements to pre-entry students. At the same time, universities in Queensland were increasing their number of allied health programs and their cohort numbers, thereby creating a current and growing future demand for clinical placements from Queensland Health. Despite restructuring and decreased workforce numbers, the clinical placements offered from allied health staff for the five professions (medical radiation, nutrition and dietetics, occupational therapy, physiotherapy and speech pathology) either increased or were sustained during the review period. It is also evident that staff did not disinvest effort and support to student placements in a time of increased demand from growing program and student numbers.

Review outcomes indicated that the support from the Initiative staff had a positive impact on the capacity of health services to provide clinical placements through their assistance with the workload associated with placements. However, when appraising placement offers, it is noted that in some professions (nutrition and dietetics, medical radiation and occupational therapy) the upward trend appears to have plateaued from 2012 to 2013, leading to the question of at what point does a profession or health service reach the peak of its capacity? It is possible that ongoing workplace restructure has had an impact on student placement offers. The next areas for investigation would be to explore factors impacting placement offers and the development of strategies to sustain any ‘peak’ in offers.

The present quality review has also raised several future financial considerations for managers. It is evident that the financial and cultural commitment of a health service to the management of the clinical education of the future workforce is a driver for placement capacity building initiatives. Questions of sustainability of resource investment and outcomes arise, especially in an environment of ongoing change and fiscal tightening. Linked to these are questions related to whether the provision of dedicated clinical educator roles within health services is cost-effective. The review outcomes demonstrate that dedicated clinical educator positions do assist the workplace with perceived or actual workload associated with clinical placements. They are valued for the support they provide to supervisors and the efficiencies created in the management of placement logistics. Significantly, the state-wide profession-specific governance and leadership within the Initiative strengthen the capacity for collaboration with universities around management of placement supply. Considering the latter, there is a growing argument for strengthened partnerships, possibly through joint funding with universities for these positions.

The provision for clinical education staff in an industrial agreement is definitely unique and acknowledges the education contribution of the workforce in a more explicit fashion while providing financial support to placement capacity building strategies. Queensland Health remains committed to the clinical education of its future workforce.²³ Continued investment in Initiative-funded FTE is at the discretion of the now independent Queensland Hospital and Health Services. Considering the pressure on health budgets, whether these Hospital and Health Services continue the current level of financial investment in the Initiative-funded FTE remains to be seen.

The present review falls short of a cost–benefit or outcome analysis measuring the cost-effectiveness of providing a dedicated resource for clinical placement provision. It has also not investigated whether this resource does, in fact, free up allied health professionals’ time to provide more direct clinical care to healthcare consumers. The complexity of such research is beyond the scope of this quality review activity, but is acknowledged by the authors as research that would serve to better support management decisions on the ongoing viability of the Initiative within the jurisdiction.

The outcomes of the review support the premise that when value is placed on clinical education, and there is recognition and dedicated support to the workload of providing clinical placements, placement capacity building is realised.²⁴ The Initiative, reportedly valued by staff and managers, provided a dedicated clinical education resource with the explicit aim of building placement capacity through supporting the associated workload. There is a perception that the Initiative has contributed to the ability of professions and health services to meet the increasing demand for placements. The jurisdiction-wide approach has enabled greater consistency in the support provided to the defined clinical education roles and for the ongoing review of outcomes of the Initiative. Central management and coordination of the Initiative resources by individual professions has enabled timely profession-led responses to increases in demand for placements. The Initiative has also been successful in engaging internal and external stakeholders across the jurisdiction, and forging valuable collaborations between the health and education sectors. This coordinated and collaborative response is seen as vital to the ongoing sustainability of pre-entry student placement provision in public health services.

None declared.