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Abstract
There is an expanding workforce gap in the NHS. Alongside national programmes to train, recruit and retain staff, efforts are needed on a local level. Clinical placements can make up to a third of healthcare student’s time while at university thus placement experience is an important factor to reducing attrition rates at universities and increase conversion rates from student to qualified professional. This quality improvement project aimed to increase reported rates of students’ satisfaction to 100% for each item of the student experience survey by March 2024 within Berkshire Healthcare National Health Service (NHS) Foundation Trust.
To gain a deeper understanding of the experience and problems within healthcare student clinical placements interviews of students and staff were conducted alongside a literature review, which revealed six key themes around student placement experience: belonging and acceptance, familiarity and continuity, confidence and competence, preparation and preparedness, supervision and support, feeling overwhelmed/stress/impact on social and emotional health. These themes were translated into a student experience survey to achieve baseline and subsequent measurements.
Changes were introduced to improve student satisfaction with clinical placements based on the baseline data of student satisfaction reported in the first student experience survey. Changes included introducing student inductions, better access to IT, student induction packs and newsletters. While the quantitative measurements of the items on the student experience survey remained positive, the nature of the qualitative feedback reflected the impact of the changes. Additionally, the improved communication and collaboration across teams because of the process highlighted the need for clear streamlined administrative processes. Regular review of student feedback has enabled timely feedback processes to placements and visible follow-up for students, highlighting the investment in them as the future workforce.
- Healthcare quality improvement
- Communication
- Continuing education, continuing professional development
- Continuous quality improvement
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Healthcare quality improvement
- Communication
- Continuing education, continuing professional development
- Continuous quality improvement
WHAT IS ALREADY KNOWN ON THIS TOPIC
The NHS Long Term Plan, Health Education England’s placement expansion strategy and the Reducing Pre-registration Attrition and Improving Retention Programme, all aim to address the significant staff shortages in the NHS. The workforce gap in the NHS is over 100 000 full-time equivalents, with 1 in four nursing students on average leaving or suspending their studies in England.
WHAT THIS STUDY ADDS
The project defines six key themes of healthcare student experience and details how these can be used to create a measurement plan to evaluate student experience. The project shows how changes can enhance healthcare students experience and highlights the need for internal communication and processes to be examined in order to make successful change.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This project provides a robust insight around healthcare student experiences. This understanding is transferable to other providers of healthcare student clinical placements and can be used to inform their own improvement work. The project provides change ideas that can be replicated to support a better student experience and encourage a collaborative effort to improve healthcare student placements.
Problem description
Berkshire Healthcare NHS Foundation Trust is a community and mental health trust providing a wide range of services to people of all ages. Despite employing over 4500 staff, recruiting and retaining healthcare professionals into Berkshire Healthcare is a challenge. One area of investigation was into the recruitment of staff who had previously had a clinical placement within Berkshire Healthcare. Investigation revealed that approximately only 30% of student nurses and student allied health professionals (AHPs) were taking up employment within the organisation post-registration (after qualifying as a healthcare professional).
Berkshire Healthcare provides clinical placement for student nurses and AHPs from 18 universities. In addition to the low recruitment of students postregistration, several students had raised their dissatisfaction with their clinical placements to the relevant learning environment lead (LEL). LELs are responsible for supporting preregistration nursing students, AHP students and apprentices. LELs support the development of all staff, supervising and assessing students in clinical practice within Berkshire Healthcare.
The initial concerns raised by students centred around poor communication across services, including short-notice placement arrangements and changes. Students also reported that at times they did not feel valued by placement areas and that opportunities for varying placement areas, to gain a breadth of experience, were limited.
Furthermore, in line with national policy Berkshire Healthcare began working towards expanding the offer of clinical placements in 2020 to support the workforce gap (table 1).
Placement expansion figures across Berkshire Healthcare National Health Service (NHS) Foundation Berkshire Healthcare
The improving student experience project was proposed by the head of clinical education within Berkshire Healthcare as part of the 2021 clinical education strategy and was funded by Health Education England (HEE). The project aimed to contribute to the implementation of two strategic aims; preregistration placement expansion and improvement in the rate of student to staff conversion.
The wider context
The NHS Long Term Plan, HEE’s placement expansion strategy and the Reducing Pre-registration Attrition and Improving Retention Programme,1–3 all aim to address the significant staff shortages in the NHS.
The workforce gap in the NHS is over 100 000 full-time equivalents,4 with 1 in 4 nursing students on average leaving or suspending their studies in England, rising to 1 in 3 nursing students in the Southeast.5 6 Clinical placements can make up to one-third of healthcare student’s time while at university, thus placement experience is an important factor in reducing attrition rates at universities and increasing conversion rates from student to qualified professional. Furthermore, student experience while on clinical placement greatly contributes to decisions of where graduates may choose to work and as such is a key consideration for recruitment and future workforce plans.
Aim
The aim of this project was to increase reported rates of students’ satisfaction to 100% for each item of the student experience survey by March 2024. The survey was specifically designed to measure what mattered to students based on the in-depth interviews and review of the literature. 100% was chosen as an ambitious and achievable aim after receiving the completed baseline questionnaires.
Method
To gain a deeper understanding of the experience and problems within healthcare student clinical placements within Berkshire Healthcare, the project team conducted several interviews with students and other key stakeholders including staff from well-being services, recruitment and retention, research and development, clinical education and placement leads. Participant information leaflets were given to all interviewees providing context and purpose of the interviews and data storage and usage. Interviews were not recorded but contemporaneous notes were taken and informed consent was obtained verbally from participants for responses to be used anonymously.
A review of the literature was also conducted to provide wider context and investigate whether solutions had been tried elsewhere. The literature review did not yield papers with solutions to improve the student experience, however, it did provide a wealth of papers describing the challenges of healthcare students.
Thematic analysis was conducted on interview notes and literature papers using Braun and Clarke’s six phase reflexive thematic analysis method.7 This resulted in six main themes or areas of importance for healthcare students’ experiences. A full list of subthemes can be found in online supplemental information.
Supplemental material
A student experience survey was created by designing statements to assess student’s experience around the six main themes resulting from the analysis. These were measured using either a 5-point Likert scale, ranging from strongly disagree to strongly agree, or yes/no option response.
The six main themes and resulting statements are detailed below.
Theme #1: Belonging and acceptance centred around feeling integrated either as part of the student cohort or the placement team.
Student experience survey statements:
Placement area was welcoming and I felt a sense of belonging and acceptance within the team.
I experienced recognition and respect for my contributions by other professionals.
During your placement, did you have any contact from the LEL or recruitment team regarding job opportunities within the Trust? (yes/no).
Theme #2: Familiarity and continuity highlighted the need to orientate students to places, staff, processes, procedures and paperwork, particularly those who have not previously worked in or had placements in Berkshire Healthcare.
Student experience survey statements:
Student induction helped me to prepare for my placement in Berkshire Healthcare.
I knew what to expect from the placement.
Theme #3: Confidence and competence focused on the need to acknowledge students’ own self-doubt as a normal part of learning, the importance of feedback and support from others and exposure to ‘real-world’ nursing such as shift work and balancing risk.
Student experience survey statements:
If I was not sure of something, I felt permitted and confident to ask questions and clarify my doubts.
I had tailored learning opportunities to practice relevant skills under supervision to enable the achievement of my learning outcomes.
During my final placement, I was supported to develop confidence and competence which helped me to transition successfully into the role of the registered professional
Theme #4: Preparation and preparedness were reported in the context of the student’s readiness, such as clear learning outcomes, needs and objectives of placements. And the placement areas’ need to be ready for students arriving, such as being ready to welcome students starting.
Student experience survey statements:
My learning objectives were clearly understood by the practice assessors/educators.
Role and responsibilities of the practice assessor was clearly understood by practice supervisors and assessors.
Specific questions around Information Technology (IT) access were added as part of this theme with response options of; it was ready when I arrive, 1 week, 2–3 weeks, I did not have IT access throughout my placement or not applicable.
If you needed any IT equipment such as a laptop for your placement, how long did you wait to receive this?
How long did you have to wait for your IT access (RiO, email, etc)?
Theme #5: Supervision and support emphasised the need for time to be given to understand students’ individual learning needs and motivations to build Berkshire Healthcare and to identify if any reasonable adjustments are needed from the start of placement.
Student experience survey statements:
There was a clear chain of command to raise concerns about patient care.
I knew whom to speak to if I had any problems achieving my learning outcomes.
Theme#6: Feeling overwhelmed/stress/impact on social and emotional health included students’ need to juggle multiple competing demands on physical capabilities, personal resources, income and time. The experience of the COVID-19 pandemic also brought with it an additional layer of feeling guilty through worry about protecting loved ones from exposure to COVID-19 and potential course delays or failure to complete placement hours.
Student experience survey statements:
While on placement, I was given the same health and safety advise and equipment for protection (eg, Personal Protective Equipment) as the staff.
I knew who my named contact within learning and development/practice education team was and how to contact them if I needed pastoral support (yes/no).
To give students the opportunity to provide narrative around their answers the following free text questions were also included within the student experience survey.
Please comment on the highlights of your placement within Berkshire Healthcare.
Please provide details of possible improvements to your placement experience within Berkshire Healthcare.
The student experience survey was sent by email to students to complete via a link and detailed that responses were anonymous and information provided would be used for the purpose of service improvement and subsequent reporting.
Initially, the survey was sent to all students on a paid placement in March 2021. (Paid placements were part of the government’s response to the pandemic where nursing students in their final 6 months of studies were paid for their placements in clinical practice.) This was followed by the survey being resent every week, with an individualised reminder weekly for 3 weeks. However, this yielded a very low response rate and therefore a wider second phase was required.
The second phase included all students (apprentices, paramedics, AHPs and all preregistration students) on placement to take part, with the survey sent out in April 2021 and then followed by an individualised reminder weekly for 3 weeks. This helped increase the response rate to 34% (67/198) and give an overall balanced picture of the students’ experience.
Although the response rate for the baseline survey was lower than hoped for, the results of the first student experience survey identified strengths and areas for improvement by those who responded (tables 2 and 3).
Results of the student experience survey
Results of the student experience survey, questions about IT access
Results of baseline measure
Student responses to the initial survey sent out in March and April 2021 formed the baseline measure for the project. Students highlighted excellence in some of the non-technical areas of placements; 99% reported experiencing recognition and respect by other professionals, and all students felt permitted and confident to ask questions. It was also encouraging to see 84% (56 of 67) of respondents would recommend Berkshire Healthcare as a place for excellent placement experience to other students.
Analysis of response patterns showed some of the items may be linked in terms of student experience. For example, there were similar responses of ‘disagree’ or ‘strongly disagree’ to the items ‘student induction helped me prepare for placement’ and ‘I understood what to expect from my placement’. However, respondents who rated the induction item positively rated the item about confidence and competence negatively.
IT access was the biggest area identified for improvement. There was also a marked difference between universities and those who had the longer 2–3 weeks wait for access. Poor access to IT had a strong association with negative responses to other items, and likewise, quick access to IT was strongly associated with positive responses to other items.
Only 49% of respondents ‘agreed’ or ‘strongly agreed’ with the items regarding the LEL or the recruitment teams. This was lowest for the AHP students only (5/16) and highest for the paid placement nursing students (19/31).
All respondents completed free text questions at the end of the survey about highlights and improvements from their placement experiences.
Respondents’ placement highlights centred around students feeling supported and valued by their placement teams and the willingness of staff to support students to learn. Students also highly valued being able to work with different team members across disciplines and the input from practice educators.
‘The team were all so friendly and willing to aid my learning, enabling me to get the most out of the experience.’
Feedback and quality time with staff were themes for both highlights and improvements.
‘Lots of opportunity to challenge myself and learn, fantastic feedback (both informal and formal) throughout and a chance to gain hands-on experience.’
‘I have had good experiences within my placements but always felt nervous in the first few days. Having a clear structure of proficiencies required and quality time with a supervisor would be beneficial.’
Suggestions for improvements centred around poor experiences with staff in clinical placement areas, IT access and equipment availability for the start of the placements. Students also requested student induction or induction packs and better organisation and preparation from placement areas to identify learning opportunities.
‘….there must be clear structure. Clear guidelines, SUPPORTIVE environment, some staff were rude, one staff didn’t even have the decency to learn my name and I was there TWO months.’
‘Being given a Student Pack would have helped with my induction to my placement area. Additionally, student pack should include a list of learning opportunities within the trust and contact details.’
Change ideas
Change ideas were then formed by the project team from the baseline data. All changes were introduced in August 2021 after presenting the initial findings to the Berkshire Healthcare’s strategic group.
Access to IT
As IT access was one of the biggest problem areas we wanted to make sure we tackled this as a priority. The main challenge to IT access was the process surrounding this; reliance on students’ ability to organise training before placement began, and multiple steps relying on several services to ensure the process worked.
The changes made were in two parts:
Part 1
Historically, there had been poor communication between the LELs, Rio team (Rio is Berkshire Healthcare’s electronic patient record system) and students, this has been a focus for improvement to have a better working relationship. Fortnightly virtual drop-in sessions have been introduced for students with the Rio team and LEL administrators to troubleshoot and clarify what needs to be done.
Getting these drop-in sessions in place was challenging and required time and support from the senior team, as the problem was not recognised or known about by all involved. Having the baseline data from the student experience survey was very helpful in demonstrating the need for this change.
Part 2
Another IT issue was the increasing number of students who needed a Berkshire Healthcare laptop for their placement. The process for this was not well defined, therefore, LEL and library staff (where the laptops are stored) worked together to make a clear and efficient process for notification and collection.
A new spreadsheet was created to give a system-wide view of all placement areas that require laptops for students, this is completed as laptops are given/returned. Monthly meetings between LEL and library staff have supported these changes to discuss any problems and turn on all the laptops to ensure any updates are completed prior to the student’s collection.
Monthly inductions
Monthly induction sessions were introduced for students to feel a sense of belonging, be welcomed into Berkshire Healthcare, and get to know the LELs to talk to about any personal issues, reasonable adjustments or IT issues from the start. (Monthly refers to once per month and induction is the process by which students are welcomed and given key information).
The inductions began with LELs emailing all students who were on placement at the time to invite them to an online induction to Berkshire Healthcare. The induction session included presentations on a range of topics:
How to prepare for placement.
Well-being and student support.
Professionalism and practicalities in practice such as wearing an ID badge, social media and appropriate shoes.
What the LEL team offers, for example, training, pastoral support, interview preparation for employment.
Library services.
Incident reporting using incident reporting forms.
Equality diversity and inclusion.
Recruitment and retention.
Royal college of nursing union membership.
NHS professionals working while studying.
Induction ran this way for six occurrences (6 months) before rethinking the organisation as there was a lot of co-ordination and resource put in for low or sometimes no attendance. Induction was then streamlined to align with when students come into placement at approximately three time points in the year.
Induction is now an embedded part of the student programme and runs as an allocated day for students. The online sessions run for 3 hours in the morning while the afternoon is allocated for E-learning completion or pastoral time with the LELs. Sessions are recorded for students who cannot attend, and placement areas are aware students should attend and be given practice hours for attending.
In the most recent review of the induction process, the sessions have been separated for AHP and nursing students to better meet the needs of the different groups, such as information about whom the key contacts are within the Berkshire Healthcare and organisation of the placements.
Induction packs
The student feedback highlighted that there was high variation across placement areas regarding student induction packs. Therefore, a scoping exercise was conducted with all placements about their induction packs and what was in place for students. This showed a lot of variety, from placements with a room and computer for students alongside an induction pack and student ambassadors to other areas that did not have anything in place.
A generic induction pack was created, based on the most comprehensive packs, and sent out to all the individual placement leads, practice assessors and clinical educators within Berkshire Healthcare. Placement leads edited the packs for the specific placement area and then returned once completed. Now all placement areas have an induction pack to offer students when they arrive that includes:
Introductions and welcomes of the team.
Information about the specific placement—what type of clinical area.
What to expect from us.
What we expect from you (the student).
Orientation—parking, start time/shift times.
Contact information for practice assessor.
Tips and important information—lone working, safeguarding.
Learning opportunities.
Learning resources—library, links to education newsletters, trust clinical skills E-learning.
Berkshire Healthcare policies.
An example of a timetable for a student in that placement.
Reflection models.
Newsletters
To create a culture of positive communication with placement areas the LELs began sending quarterly newsletters to all placements with area-specific feedback from students, the results of the latest student experience survey and any changes happening.
There have been several iterations of the newsletter, the main change is that only the positive qualitative feedback is now included. The reason for this was to make this communication a celebration of the placement areas and to ensure more timely communication of negative feedback or issues identified. Responses of the student experience survey are monitored weekly by the LEL team who then raise negative feedback or issues identified directly with the specific placement.
The frequency of the newsletters has been reduced from quarterly to 6 monthly to capture a broader group of placement areas and a larger analysis of student experience surveys. This is in line with Berkshire Healthcare formal reporting.
Recruitment contact
The baseline survey showed that a significant number of students were not being contacted by the recruitment team about working for Berkshire Healthcare post-qualification. This has been taken forward by the recruitment team as a separate project to improve student retention and close workforce gaps.
Changes to the measurement process
The LEL team is continuing to test the best way to get a better response rate from students and have made changes to reporting the results to ensure that this is meaningful. One of the challenges to both gathering and reporting on the student experience survey is the variation in length of student placements for different courses.
As part of reviewing the student survey, advice was sought from Berkshire Healthcare’s research team and alongside student feedback about the survey itself, a small number of improvements were made to the survey for subsequent measurements in 2022 to ensure it was accessible and suitable for all learners.
From January 2022, the student experience survey is now sent out by email to all preregistration students and apprentices 2 weeks before the end of their placement, followed by a reminder email 1 week later. Initially, this was a resource-intensive process, however, it is now managed by the LEL team administrator through a master spreadsheet of student placements and has become a routine task.
Additionally, engagement work with placement areas was carried out promoting the survey and requesting this be discussed during students’ final meetings to ensure that the placement area gets their results/feedback. A QR code was created for students to scan to access the survey, which is displayed in placement areas.
Formal reporting of the student experience survey was originally three times a year, however, this was found to be too frequent analysis and reporting and was changed to 6 monthly reporting from March 2023.
Results
Since the baseline measurement, there have been three further rounds of the student experience survey (tables 2 and 3). There was initial delay between the baseline (first round) and second round while the project was presented to Berkshire Healthcare’s executive team for their buy-in and to finalise processes for the change ideas.
The quantitative results of the survey (tables 2 and 3) have remained largely positive. The greatest evidence of the impact of the changes made is seen within the placement highlights responses.
‘The placement preparation of the local induction day was very insightful and beneficial.’
‘It was a good experience with a lot of learning opportunities and supportive teams.’
Improvement responses have changed in nature and reflect the challenges of the wider NHS picture. Many students commented on the effect of staff shortages, however, many more students responded that there were no improvements they could think of.
‘Due to lack of staff, it sometimes causes a delay in seeing a mentor as they were always busy.’
Invisible impacts
The biggest impacts of the project are the invisible or non-measured changes experienced and reported by students and staff. These are the improved relationships, communication and processes between the teams in Berkshire Healthcare around student placements. Without building better relationships and having open communication with other teams, the administrative process changes that have been vital would not have been possible.
The monthly inductions required a clear and well communicated administrative process to ensure students were aware they needed to attend sessions and that placement teams knew this was an expectation of students as part of their placements. Additionally reviewing the frequency of induction sessions alongside a better administrative understanding of placement start dates for all students, allowed for attendance to be maximised and reduced potential wasted time and resources.
Improving student’s access to IT equipment and access to Berkshire Healthcare email and electronic health record continues to be a work in progress. However, better communication and a tight administrative process with library staff is supporting students to better access the equipment they need. Drop-in sessions with LEL and Rio staff have created a space for communication between teams and with students around IT issues.
Although change around induction packs was initially resource intensive, it has enabled a standardised offer for students that can be made bespoke for specific placements. It has reduced the unwarranted variation across placement areas and gives assurance that key information is now available to students wherever they are on placement.
The invisible impacts of relationships, communication and processes between teams and with students reflect the findings of previous literature where these results are found to support successful and sustainable clinical placements.8
Future changes
The survey continues to be reviewed and sent out to gather student feedback at the end of their placements. Recent feedback from paramedic students highlighted that for their observational placements of 2 weeks not all items of the survey are relevant to them.
Work began in January 2023 to standardise the AHP and nursing student processes around students.
A pamphlet about the student experience survey with the QR code will be made available in placement areas.
A similar survey for student mentors, practice assessors and placement leads is currently being considered.
The biggest change planned is to introduce automatic reporting of the student experience survey result through Tableau (a visual analytics platform). This will reduce the time and resource needed to analyse the data and ensure that up-to-date results are available as needed.
Reflection and learning
Through the student experience project, it has become clear what makes a good student onboarding experience. The literature review and initial student interviews provided a strong starting place to pick out themes and focuses both from a wider and local perspective.
The project has reached further than just the localised placement areas and has enabled a better understanding of the value of the LEL role for students. Reporting of the project has provided the senior leadership team with a better knowledge and understanding of current issues and highlights the positive support provided by staff to students.
The anonymity of the survey allows students to give candid feedback and through the actions of the LEL team allows students to feel confident that their feedback will be acted on.
The project has enhanced reporting structures through clear data which feeds into audits, feedback and CQC information. For example, negative feedback via the survey was received about a specific hospital. From the survey, it was evident that similar comments were received from all different learners which enabled a wider view of the placements. When explored, higher levels of staff sickness and staffing issues alongside an increase in the number of students allocated were found. Therefore, a broader approach was taken to support the different teams, including targeted teaching and pastoral support, which has been helpful to manage the number of students on placement during difficult times to reduce burn-out of staff and improve student experience.
The success of the project has been due to making students the main priority and showing they are valued and sort-after clinicians after qualification. Many more students are reporting in their conversations with LELs that they want to work in Berkshire Healthcare after seeing investment in them and their concerns followed up.
A key part of the project was making the information known and visible, through a variety of methods, including presenting in different forums and at senior meetings, sharing directly with colleagues. As well as holding good practice events for clinical educators across Thames Valley to share the student experience project and other projects within the field of clinical education. This has served to inform people, encourage teams to work together more, and enable mentors and practice supervisors and assessors to feel their hard work supporting students is valued and making a difference.
Teams and placement areas have been able to learn from each other through the shared events and newsletters and staff have also been asking for their students’ feedback as part of their revalidation and continuing professional development.
Challenges have been around staff resources, particularly administrative tasks to make the changes and collecting and analysing data, staff turnover in the LEL team impacted on the available time spent on the project.
Conclusion
The authors of this paper hope that by sharing this work it may provide ideas and inspiration to other providers of healthcare students’ clinical placements as to how they might understand and improve students’ experience. The provision of the literature and interview themes in full in online supplemental materials and student experience survey questions may support an existing understanding of problems and give a basis from which to begin. The changes described may serve as a checklist of what is in place or not in place in other locations and form the start of discussions around what changes can be made and if they are relevant in the local context.
Overall, the student experience survey has been a great achievement that has aided significant service improvement in how to analyse, action and evaluate student feedback. Organisation and communication changes streamlined processes to work effectively. Finally, the project has increased collaboration between teams and created a sense of achievement in having students. As a result, motivation to have students in placement has increased, maximising the potential for future recruitment.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants but this work was approved by Berkshire Healthcare NHS Foundation Trust as a quality improvement project. Advice regarding ethical approval was sought from the Trust’s research and development team and deemed not necessary as the project did not directly involve patients, randomisation or the change of treatment/care/services to patients and results are not intended to be generalisable. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank all the staff and students who contributed to this project, without their ongoing motivation and hard work the project would not have been possible. The time given and willingness to share experiences have been invaluable in helping to understand and make changes to improve healthcare student experiences.
A special thank goes to the Head of Education, Pearly Thomas, at Berkshire Healthcare for her invaluable guidance and support throughout the project process and the Clinical Education team, especially the Learning Environment Leads.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors ER led the project and wrote up of the project for journal submission and is the guarantor author. HT supported with the academic write-up and data analysis for journal submission.
Funding This study was funded by Health Foundation (0571246253).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.