Understanding Student Experience of Using Work-Integrated Learning to Develop Healthcare Redesign Capacity in a Hospital Setting: A Descriptive Qualitative Study

Abstract

Background: In 2021, an Australian Hospital Nursing Research Hub sponsored 13 healthcare staff to complete the Graduate Certificate (Clinical Redesign), to build capability in health service improvement though work-integrated learning (WIL). Healthcare professionals undertaking workplace-based WIL likely experience significant challenges including balancing professional and student roles and aligning work with academic requirement. These pressures were likely intensified during the Coronavirus disease 2019 (COVID-19) pandemic. This study aimed to explore and understand the experiences of hospital healthcare staff completing WIL redesign projects, including the impacts of COVID-19. Methods: A qualitative descriptive inquiry approach was used to explore individual student experiences. Thirteen staff, mostly nurses, who enrolled in the 2021 course were invited to participate. Online semi-structured interviews were conducted. Data were analyzed using a general inductive thematic analysis approach. Results: Four participants (36%) took part; all were female and working full-time. Five main themes were identified that centered around: COVID-19, Support, Motivation, Alignment and Relevance, and Success. Conclusions: Novel insights include the need to reconceptualize “success” to improve student experience, the critical role of organizational–university–student alignment in enabling WIL studies, and the unique pressures of completing WIL during crisis conditions that direct impact the health sector, such as COVID-19. Although not generalizable, these findings are likely to be important considerations more broadly to strengthen WIL design, support and student experiences, ultimately enhancing health service staff capability to lead quality improvement in the workplace.

1. Introduction

Work-integrated learning (WIL) is a term used to describe a range of approaches that enrich traditional academic learning by integrating theory with practice in the work setting, which are embedded in a purposefully designed curriculum [1,2]. WIL offers students opportunities to take the theoretical concepts learned throughout their academic studies and apply them in real-life scenarios [2,3]. This can occur during courses where students are placed in a work environment [4] or where qualified health professionals undertake a piece of assessment that directly relates to their workplace [5]. Many universities offer WIL as a strategic priority to equip students with professional capabilities, strengthening their employability and fostering professional identity development [6]. Increasingly, health services are engaging with these opportunities to build staff capacity for quality improvement. Courses with a professional WIL component can also benefit organizations, as students not only build context-relevant skills and knowledge but contribute to experimentation, innovation and improvement within the workplace [7].

Barnett [8] contended that learning experiences that are authentic, purposeful, and practice-based can also advance an individual’s personal development. Additional benefits of WIL for students, including enhancing their employability and personal development, continue to be reported [3,9,10]. Students who are active, motivated, and independent learners, such as postgraduate students, are considered to make the most of their WIL experiences [11]. A number of challenges with WIL have been noted including the alignment of learning activities with what can be assessed by a university [12]. Further, work focused models of learning in higher education can be diverse due to the contextual nature of a workplace [13].

The ways in which students perceive themselves as future professionals working in quality improvement through a process of reflection are important career-wide attributes [14]. Students should reflect not only on procedural and technical skills, but also on the challenges they face during WIL [15]. In healthcare, WIL has been shown to increase students’ capacity to identify and reflect on workplace issues, facilitate and evaluate changes in health service delivery [9,16]. Providing opportunities to reflect on the integration of theoretical and practical knowledge during WIL is known to stimulate learning [9]. Health services have also identified that WIL students can strengthen the capacity of departments, and that the benefits outweigh supervision time and see student contributions as valuable [4].

Effective education in healthcare redesign and healthcare quality improvement combines theoretical education with experiential project-based learning and on-the-ground coaching [17,18,19], specific to context. The postgraduate, Graduate Certificate (Clinical Redesign), now Graduate Certificate in Healthcare Redesign, course offered through the University of Tasmania is taught in a blended learning model, with a substantial WIL component. Students complete four units, two of which are project-based, requiring students to undertake a health service improvement project within their workplace, utilizing organizational systems and processes. While the Australian College of Nursing offer a range of Graduate Certificate courses, there are no courses that offer the opportunity to build healthcare redesign capacity. Although there are many benefits to WIL, combining study with employment can be challenging, particularly in healthcare where many complexities exist [2]. Furthermore, students undertaking workplace-based WIL must navigate the dual roles of both learner and professional, which at times may be in conflict [20].

While research has been undertaken about student WIL experiences in undergraduate study, less is known about postgraduate students’ experiences of WIL, particularly that undertaken within their own workplace. With the proportion of postgraduate health students participating in workplace-based WIL increasing globally [21], it is important to understand how these students experience WIL so they can be better supported to maximize their learning without undue burden. The study aimed to explore and understand the experiences of hospital healthcare staff undertaking work-integrated learning (WIL) redesign projects, including the effects of the COVID-19 pandemic. Specifically, the research objectives were to:

• Understand barriers, enablers, and experiences for achieving project and academic outcomes.
• Learn about the capacity for staff to lead redesign in their organization throughout the course, including the impact of the COVID-19 pandemic.

2. Materials and Methods

This study utilized a qualitative descriptive inquiry approach [22,23] to explore individual student experiences throughout the University of Tasmania’s WIL course, Graduate Certificate (Clinical Redesign). This design allowed deep exploration of experiences and perceptions in the local context during the COVID-19 pandemic. This study was approved by the Tasmanian Human Research Ethics Committee (Reference number H0027282). The research team included three female academics (PhD), one male academic (PhD), one female nurse lecturer, one female community engagement manager (PhD candidate) and one female director of the Nursing Research Hub.

2.1. Context

The Hospital is a multi-site, public tertiary hospital providing a comprehensive range of healthcare services in Victoria, Australia. In 2021, the Hospital Nursing Research Hub sponsored 13 healthcare staff who were predominantly nurses, to complete the postgraduate award course, Graduate Certificate (Clinical Redesign), to improve health service improvement. As part of the course, each staff member identified a workplace project to complete with sponsorship from their local line management and further academic support within the Nursing Research Hub.

In March 2020, the World Health Organization declared COVID-19 a global pandemic [24], further straining the Australian healthcare system. The capacity of health services to meet the needs of those infected with COVID-19 whilst maintaining care for patients with other health conditions proved to be a major challenge in the acute care setting [25]. Collectively, these factors would make it more challenging for students to complete their studies. The hospital faced significant challenges during and in the aftermath of the COVID-19 pandemic with large numbers of staff experiencing COVID-19 infections and many staff being furloughed [26].

2.2. Participants

Information power guided the sampling frame for this study. Contemporary guidance emphasizes that credible findings can be produced from small samples when the study aim is narrowly focused, the sample is highly specific, there is strong interviewer–participant dialog, and the analysis is case-oriented with sufficiently rich data [27,28,29]. All students (n = 13) from the Australian Hospital, who enrolled in the Graduate Certificate (Clinical Redesign) in 2021 were initially eligible. We excluded any students who had withdrawn from the Graduate Certificate due to health reasons (n = 2). The participant group invited to participate via email (n = 11) comprised a range of healthcare professionals (including nurses, allied health practitioners, and quality improvement staff) who were working in clinical and non-clinical roles during the COVID-19 pandemic.

2.3. Data Collection

One-on-one, semi-structured interviews were conducted via an online provider (Zoom Workplace (Zoom Video Communications 2023) or Microsoft Teams (Microsoft Corporation 2023) by authors SW and PG who had not taught participants in the Graduate Certificate Course. Consent was obtained in writing and confirmed verbally prior to each interview and all interviews were conducted by a member of the research team who was unknown to the participant. The interview schedule comprised broad questions around five main areas, including why they enrolled, barriers and enablers faced, what they valued, experiences and gains. All interviews were audio recorded and transcribed professionally. All transcripts were sent to participants for checking and any further feedback; however, no changes to transcripts were made.

2.4. Data Analysis

Data were analyzed using a general inductive thematic analysis approach [23]. This systematic method enables themes to be generated from the data, rather than being constrained by predetermined structures typical of deductive analyses, which can limit or obscure theme development [30]. In addition, a descriptive thematic approach rather than theory-building was adopted as this is appropriate for a small sample size [21,22,31]. This approach allowed the research team to identify themes related to participants’ barriers, enablers and experiences during their WIL projects.

Four members of the research team (SW, PG, SP, JB) conducted direct coding and used an inductive process to develop themes across five steps: data cleaning, familiarization with transcripts, coding, theme development, validation and theme refinement [30]. Credibility and confirmability assurance [30] included a sense checking process completed manually in Microsoft Excel (Microsoft Corporation)—by the four coders (SW, PG, SP, JB) during the first four steps and by all authors during the final step, which includes two service providers (JB, KL)—appropriate to the small size of the dataset.

3. Results

Of the eleven healthcare professionals who were eligible to participate, four (36%) participants consented to being included in this study. All participants were female, working in full-time, clinical and non-clinical roles during 2021 with an average age of 46 years (range 42–49). Due to the number of participants and to keep anonymity, specific details about roles are not provided.

Analysis of the interview transcripts yielded five main themes that describe barriers, enablers and experiences to achieve project and academic outcomes. The themes were based on students’ experiences during the course and centered around COVID-19 (barrier), Support (barrier and enabler), Motivation (enabler and barrier), Alignment and Relevance (enabler), and Success (experience). A full description of each theme is below.

3.1. Theme 1: COVID-19 Created a Lot of Barriers for WIL Students

A key barrier for students was studying during the COVID-19 pandemic. This theme focused primarily on the way that COVID-19 impacted the student journey and the unexpected events that influenced student projects (“I’ve got, you know I’ve got a family about three young kids at home and husband at work…I think I could have got more out of the course if I wasn’t chasing my tail the whole time.” (P3)). Participants spoke about the need to prioritize their personal responsibilities, including home schooling of children, working and managing their own health, as well as trying to maintain meaningful engagement for their redesign projects (“… it was definitely a challenge to be, you know, working, studying, trying to deal with COVID at work and… home schooling children…” (P2)).

COVID-19 created a lot of pressure in the health system, and necessary changes in communication approaches within the organization made it more difficult for some participants to engage with colleagues and deliver on planned project activities (“… it then became a trying to juggle it around full-time work because our priorities changed.” (P4)). Project stakeholder capacity was often limited, and projects were not seen as a priority (“It was post COVID and I think I just wasn’t a high priority.” (P1)).

3.2. Theme 2: Organizational and University Support Were Key Enablers to Progress WIL Projects

Support from the health service was the most important enabler to progress WIL projects (“I was very lucky to have project that was well supported by the organization, and even throughout the… COVID outbreaks, … They still prioritized it…” (P2)). Whereas lack of support from the organization impacted the progression of some WIL projects. Challenges engaging stakeholders (“I think I just had to accept at times that I was not going to get input … people or the stakeholders I wanted to get input from…” (P2)) were discussed as barriers. However, it was acknowledged that clinicians were under enormous time pressures (“you’ve got clinicians that we needed to engage with as our subject matter experts and people leading pieces of work that were just, you know, basically decimated…” (P4)). Peer support was acknowledged as helpful to progress their project (“…there was a group of us, and we felt like we were… I had a bit of a sort of a team together… that we could, you know, bounce ideas off each other. That was good.” (P2)).

The flexibility from university around assessment deadlines and deferral of studies were identified as supportive (“…I was just getting so overwhelmed… so that was really supportive and they were happy to do that.” (P3)) and (“… some of my colleagues, … just couldn’t meet deadlines because they were working clinically and short-staffed… that [flexibility] was good. That was an enabler.” (P2)). However, one student identified that too much flexibility had the opposite effect as there was no urgency to progress (“It was almost in a way too supportive … So it was almost too, yeah, too much to leverage I think.” (P4)). This is an important insight for the university to consider when deciding the level of flexibility to ensure it is an enabler, not a hindrance for completion.

Support from the university alone was not enough to help students complete the tasks required for the course. Participants highlighted that health service support in conjunction with university support was vital for success. Lack of support from health service managers, stakeholders and departments was identified as a barrier for progressing project work and participants found this confronting. A supportive culture for WIL was reported to be highly valuable for participants (“An enabler for me… it was well supported by the hospital and it was part of my day-to-day work” (P2)).

3.3. Theme 3: Committing to WIL Requires Both Personal and Professional Motivation

Participants were motivated to build skills and knowledge for making change in their workplace on both a professional level (“…the whole option to be able to integrate that with what I was already doing that was really that was probably the biggest selling point for me.” (P4)) and personal level (“…she realized that I was frustrated with my clinical environment and thought that I’d be suited to learning more about quality improvement.” (P1)). Motivation was a key enabler to enter the course and to then engage with the content and requirements of the course.

The course was recommended by health service colleagues and participants were motivated to make change using a course that aligned with their current role. Motivation related to professional development and a drive to improve patient experience in the healthcare system (“I wanted to sort of understand better how I could improve the patient experience, make changes within that role.” (P3)). Two participants also identified that lack of motivation, or ‘hitting a roadblock’, was a barrier to finishing their studies (“It was COVID related initially and then it was a motivation issue later… like I just wasn’t in…” (P4)) and (“…I sort of hit a roadblock really…” (P1)).

3.4. Theme 4: WIL Is Impactful When Aligned with Students’ Professional Values and Relevant to the Workplace

The three ‘partners’ in WIL are health service organizations, students and universities. This theme relates to participant perceptions about organizational and university alignment and how that affected their WIL project. Alignment and relevance were recognized at a professional and personal level (“…For the nurse that is interested in making some sort of change and making things better for the patient and the nurse that can see how things might be different. It is the perfect course.” (P1)). Although linked with the ‘Motivation’ theme, this theme goes further, suggesting that students consider the WIL learning experience more meaningful when it is aligned with students’ professional values and has perceived benefit for their work and patients (“…great opportunity because there was just such alignment with what I was doing anyway to sort of stand up at, you know, a project and ingrained a new process with problems along the way, I thought that’d be helpful.” (P4)).

Relevance was also discussed in terms of the WIL projects meeting study and work needs (“That was one of the reasons why I was attracted to it, because I was like It’s it can be work, I can do that’s relevant to both work and the Uni…” (P2)). There was acknowledgement that without WIL, it would have been challenging to find the time to complete their studies (“…it sounded really interesting and really relevant to the work that I do…. If it wasn’t WIL, it would have been harder to find the time” (P2)).

3.5. Theme 5: Identifying and Acknowledging the Various Ways Students Define Success Can Improve Their Student Experience

‘Success’ is a term used by universities to denote the completion of a course or project. For an organization, this may be different. However, the concept of success varies between students (“Success… It’s not that everyone I invited turned up to the meeting, …. make sure they were still informed about what was happening, and I may not have got any replies from it, … hopefully they’ve read it.” (P2)). There was discussion about positive aspects of the WIL experience, which included engagement with stakeholders, support within the organization at a senior level (“… if you can get at an executive level, I think that then you’re gonna You probably have more success.” (P2)) and learning new skills (“Our process mapping and how to how to conduct a or put together a project. It was all brand new to me and I loved it. It was perfect for me….” (P1)).

Others discussed aspects of their experience where they felt progress did not go well, and as a consequence, they did not feel like the project was successful (“I found that probably pretty hard and towards the end I felt that I just had to throw it together because I…Couldn’t get any real data anyway.” (P1)) and (“I was quite overwhelmed with the workload from day dot… was throughout the whole course. I always felt like I was chasing my tail.” (P3)).

One participant struggled to complete the course but really enjoyed it (“Hopefully I might get another opportunity and try again. I still want to be able to use what I have learned in the course. I really enjoyed it…So you know, you just gotta keep trying.” (P1)), which perhaps should be more openly acknowledged to students as a success. Another spoke of the importance of acknowledgement as validation that they were successful, and particularly when this acknowledgement came from a senior colleague (“I did feel like nobody cared.…, when I did sort of present it still back to Nursing Executive, … they were appreciative of just the work I did manage to do…” (P2)).

4. Discussion

This study explored the experiences of frontline staff from a hospital who were students in the WIL Graduate Certificate (Clinical Redesign) course during the COVID-19 pandemic. The five themes developed from interviews reflected the barriers, enablers and experiences of participants, and the factors that influenced their capacity or decision to complete or withdraw from the work-integrated learning (WIL) course.

The findings suggest that a student’s ability to progress or withdraw from the course was shaped by contextual and structural demands including the intensified pressures of COVID-19, plus the resources and supports available across the university and workplace. While personal and professional motivation initiated engagement, it could not sustain students’ involvement without consistent organizational support, aligned expectations, and meaningful workplace affordances. Students, universities, and healthcare organizations also held different ideas of success, highlighting that WIL operates not only as an academic exercise but as a site of professional growth, identity development, and workplace change. This study demonstrates that successful WIL participation depends on more than individual effort: it requires coordinated, inclusive, and well-resourced systems that buffer high demands, enable authentic engagement, and align stakeholder expectations to support sustainable learner progression.

Organizational and university support was crucial for students to endure the challenges of studying while juggling life (work, study, family) and the added pressure of COVID-19. This is consistent with the pedagogy of work-integrated learning [32] and inclusive pedagogy [33], which suggest that inclusive WIL requires systems that actively consider financial, cultural, structural, and relational barriers and assist students to continue despite competing pressures. WIL has been shown to have many benefits for students [8,9,10,20]. However, completing tertiary studies while grappling with the complex nature of healthcare is known to put even more pressure on those working in frontline roles [9,33]. Understanding what can be done to enable students to persist through these challenges can strengthen the commitment to, and consistency of, WIL course completion. Participants in this study were clear that support from both the health service and university was key to helping them progress. Support from the organization is an enabling factor and empowering for students when received from different levels across the health service. In contrast, lack of support or difficulty in working collaboratively at an organizational level impacts progression of projects in WIL contexts. It is important for university and health services to be inclusive and ensure that support of students to progress WIL is established across all stakeholders involved in the process [4,34].

The impact of COVID-19 on the health system is well reported [25,26,35]. This study shows that COVID-19 contributed greatly to the professional and personal pressure on students, consistent with other studies that demonstrate the impact of the pandemic on workplace learning [36,37,38]. Specifically, the pandemic created workload pressure, staff shortages, and shifting organizational priorities, conditions consistent with broader literature showing that COVID-19 significantly disrupted workplace learning environments [39]. However, in our data, these pandemic related pressures did not emerge as the predominant or direct cause of WIL noncompletion. Instead, they amplified preexisting structural issues within WIL design and support systems such as limited organizational capacity, uneven sponsor support, and challenges in aligning study with frontline work demands.

Professional and personal motivation were enablers for students to commit to the course, which aligns with previous studies that show motivation in higher education is crucial for academic performance [39,40,41,42]. However, this study infers that personal and professional motivation was not enough to maintain the level of drive required to complete WIL projects. This pattern is consistent with Self Determination Theory (SDT), which argues that motivation is most durable when the learning environment supports the basic psychological needs of autonomy, competence, and relatedness; without these, even initially strong motivation becomes vulnerable under stressors such as workload, competing demands, or structural barriers [43]. Workplace learning theory, particularly Billett’s [32] conception of co-participation, emphasizes that learners’ engagement is shaped jointly by their personal agency and the opportunities, support, and guidance afforded by the workplace; where these affordances are inconsistent or constrained, learner motivation alone cannot ensure progression. This aligns with our findings that organizational support, supervisor availability, and alignment between project expectations and workplace realities were decisive factors in whether students could translate their initial motivation into sustained engagement.

Success was understood differently across stakeholders: for the university, it centered on course completion; for the healthcare organization, it was linked to delivering a project that generated system level improvement. Students, however, described success in more personal and professional terms—such as developing professionally, receiving mentoring, gaining insight into practice, contributing to patient experience, building theoretical understanding, and persevering through competing demands. These varied definitions highlight that success in WIL is multidimensional and shaped by students’ professional identity development and personal drivers. Aligning institutional and organizational expectations with what students themselves perceive as meaningful is therefore critical for supporting engagement and sustaining motivation within WIL, suggesting that reconceptualizing the concept of success could be an important component of student experience and completion of WIL.

The main limitation of this study is the small study cohort. However, in purely qualitative research where the depth of information matters and information power is used to guide the sampling frame, small numbers do not compromise study integrity. Given such a specific cohort, the concept of information power [27] supports the rigor of this study. While four participants in this study constituted adequate information power for our narrowly defined aim and descriptive analysis, we note that studies seeking meaning saturation at a higher level of abstraction or spanning more heterogeneous professional groups typically require larger samples; future work could extend our findings by sampling additional roles/sites. Further, the findings are not generalizable outside the COVID-19 pandemic-single hospital context. The research team reflected on the likely effect of COVID-19 contributing to lower participant recruitment. While COVID-19 amplified preexisting issues and challenges for staff, it also directly increased staff workload, reducing their capacity to participate in the study alongside their project responsibilities.

5. Conclusions

As found in similar research with undergraduate students, this study highlights that motivation, alignment of learning with work responsibilities, and relevant learning are also essential enablers for postgraduate students undertaking WIL in healthcare redesign, particularly when balancing work and family responsibilities. Novel insights include the need to reconceptualize “success” to improve student experience, the critical role of organizational–university–student alignment as an enabler for WIL studies, and the unique pressures of completing WIL during crisis conditions that directly impact the health sector, such as COVID-19. Although the findings in this study are contextually bound and not generalizable, they offer important insights that are likely to strengthen postgraduate WIL design, support and student experience more broadly. The study underscores the shared responsibility of universities and health services in supporting students to achieve meaningful outcomes that ultimately contribute to health system improvement.