International Journal of Nursing Education Scholarship 2014; 11(1): 137–144
Research Article Kathleen Andresen* and Pamela Levin
Enhancing Quantity and Quality of Clinical Experiences in a Baccalaureate Nursing Program Abstract: Nursing programs encounter barriers to clinical education, which may include limited clinical capacity for nursing students. Congestion of clinical placements compounded by multiple external influences prompted a need to develop an alternative approach for meeting program standards pertaining to clinical education. A curriculum improvement project was implemented within a school of nursing with the primary goal of expanding clinical learning opportunities while maintaining program quality. The unique aspect of this project was a comprehensive evaluative design, including qualitative responses from students, faculty, and clinical site stakeholders, as well as standardized student test scores. Augmenting the tools and processes for evaluation of clinical learning required collaboration from the faculty. Project outcomes include expanded clinical capacity, increased variety of clinical learning experiences, and improved quality of the clinical experiences. Collaborative partnerships yielded valuable lessons, which have implications for other nursing programs challenged with clinical placements. Keywords: clinical education, baccalaureate nursing education, expanding clinical capacity, collaborative partnerships DOI 10.1515/ijnes-2013-0053
In the past decade, there has been an increased emphasis on educating nurses in quality and varied experiences to prepare them for complex work environments. One influence driving nursing education is the Institute of Medicine’s Future of Nursing report (IOM, 2010). Additional influences include national initiatives (Robert *Corresponding author: Kathleen Andresen, Department of Nursing, St. Ambrose University, 1320 W. Lombard, Davenport, IA 52804, USA, E-mail: [email protected] Pamela Levin, College of Nursing, Rush University, Chicago, IL, USA, E-mail: [email protected]
Wood Johnson Foundation, 2012), as well as state and regional coalitions (STATE Action Coalition, 2012) that have formed to address recommendations to improve quality and safety within nursing care delivery. In addition to incorporating these recommendations, schools of nursing are challenged to meet the increased nursing workforce demands and are seeking methods to overcome these challenges. This paper outlines specific challenges experienced by a baccalaureate nursing program in the Midwestern United States and identifies a method for ensuring the quality of the clinical experience during a time of rapid increase in enrollment, thus also enhancing the quantity of clinical experiences within that program. The faculty in this nursing program are committed to addressing the challenge presented in the Future of Nursing report (IOM, 2010) of increasing the number of BSN-prepared nurses in STATE, as evidenced by the university mandate to increase the pre-licensure student enrollment rate by 20% by 2017. The nursing program has struggled to obtain clinical learning opportunities due to competition from nearby schools of nursing and an already rapid growth of the nursing program. The problem of a limited number and variety of quality clinical experiences prompted a need for infrastructure development to build capacity and to assure standards specified by nursing education accreditation agencies were met. The purpose of this paper is to describe a project designed to address this need (Promoting Expansion of Nursing Clinical Education & Learning [PENCIL]) and the process the nursing program at SCHOOL initiated to expand clinical capacity, enhance the variety of clinical experiences, and improve clinical education quality. The logic model (W.K. Kellogg Foundation, 2004) was the theory that guided the development of the PENCIL project from initially determining the context of the problem, as well as project mission, scope, and components, through to the program processes (e.g., activities, outputs) needed to achieve specific measurable and sustainable outcomes for this program. Based in change theory, the term “logic model” is used interchangeably
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
138
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
with “program theory” within the evaluation field (Kellogg, 2004; McLaughlin & Jordan, 2010). The model is designed to guide both planning and evaluation of a program’s structure and outcomes through a process that reveals an understanding of gaps between project vision and program resources. Program structure includes the necessary resources to support the actions needed to produce the program services; these services in turn result in changes in people served and in organizations – the short- and long-term outcomes. The logic model is promoted within the evaluation field to further understanding of program structure on intended outcomes and is applied in this SCHOOL’s setting toward understanding the context of clinical capacity augmentation.
Review of literature Quality education of nurses requires incorporating clinical learning experiences that increase the critical thinking skills necessary to provide patient care in complex health systems (American Association of Colleges of Nursing [AACN], 2006). High-quality clinical placements are required if students are to achieve the necessary experience and levels of competence (Murray & Williamson, 2009). The quality of the clinical learning environment is an important factor in determining the quality of students’ clinical experience in baccalaureate nursing curricula (Edwards, Smith, Courtney, Finlayson, & Chapman, 2004). However, a lack of clinical practice settings continues to be a critical constraint to expanding admissions to prelicensure programs nationwide, with 30% of baccalaureate schools of nursing identifying lack of clinical practice settings as the primary barrier for expanding enrollment (Kaufman, 2010). In a 2007 survey, baccalaureate nursing programs identified “insufficient clinical sites” as the second most limiting factor to accepting a greater number of applications, right behind faculty shortage (AACN, 2008). Clinical placement poses a challenge for schools of nursing due to competition among schools, limited inpatient care opportunities, and lack of clinical nurse educators (AACN, 2006, 2008; National League for Nursing [NLN], 2010; Tanner, 2002). Limited clinical education is an international issue, as nursing education programs worldwide are seeking strategies to increase the capacity of their program enrollment with extremely limited resources; there is no single
method for implementing clinical site expansion (Harrison, 2004; Hutchings, Williamson, & Humphreys, 2005; Murray & Williamson, 2009). Examples of how clinical education deficits are being addressed through a variety of alternative learning experiences include, but are not limited to (Delunus & Rooda, 2009; Joynt & Kimball, 2008): – Simulated patient experiences that augment traditional patterns of training nurses in a clinical setting and use of high-fidelity simulation (Jeffries, 2009); – Collaborative relationships with clinical facilities that focus on facility relationships versus a specific unit (Delunus & Rooda, 2009; Ellenbecker, O’Brien, & Byrne, 2002; Hoffart, 2006; Williams et al., 2002); Service-learning activities, as nurses’ working in an inter-professional team is an essential piece of nursing education today (IOM, 2010), and the benefits of, as well as opportunities for, integrating service learning in the clinical curriculum have been demonstrated (Amerson, 2010; Seifer & Vaughn, 2002). Service learning is an approach where students’ learning is enhanced through active participation in structured learning opportunities that address needs identified in collaboration with agency/community members; there is equal benefit to the students and the agency/community (Campus Compact, 1999–2014). To assure a quality experience, faculty need to (1) plan structured opportunities that align with outcomes to be achieved, (2) design opportunities for students to critically reflect, and (3) assess and evaluate with students and agency/community whether intended outcomes were met (Campus Compact, 1999– 2014). AACN (2012) supports formal partnerships between schools of nursing and clinical facilities; these partners collaboratively identify and capitalize on specific benefits that are attractive and useful to both partners and should result in enhanced clinical experiences for students. With a partnership or collaborative approach, faculty member capacity was doubled in the clinical setting; students were satisfied with their clinical experience; and the affiliation between the hospital and the school of nursing was strengthened (Delunus & Rooda, 2009; Hunsberger, Baumann, Lappan, Carter, & Goddard, 2000). Most of the collaborative approaches included developing effective working relationships between healthcare practitioners and the schools of nursing. Barriers cited in the literature for these efforts stemmed from clinician reluctance to precept nursing students (Elliott,
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
2002), which may relate to lack of satisfaction with faculty communication and uncertainty regarding student preparation for the clinical experience (Matsumura, Callister, Palmer, Harmer, & Larsen, 2004). However, these two factors have been remedied in other schools of nursing by establishing strategic partnerships (Henderson, Heel, & Twentyman, 2007) and including routine evaluations of the clinical learning environment and stakeholder’s perceptions of the clinical learning experience (Clare et al., 2003). Providing staff nurses with daily objectives for student learning and including skills development and positive feedback to staff are methods for enhancing clinical stakeholder partnerships (Matsumura et al., 2004). Additionally, strategies to solidify ongoing staff nurse support are crucial in motivating and recognizing nurses for their efforts. Some expressions of appreciation included inviting staff nurses to participate in lectures by guest professionals or extending academic privileges to nurse mentors, such as guest privileges to the university library. Awards, luncheons, and simple gifts, such as a college pin indicating preceptorship/mentorship status, are other ways that have demonstrated efficacy in recognizing and retaining staff nurses as preceptors (Matsumura et al., 2004). In summary, numerous obstacles exist for meeting the increasing demand of clinical experiences in nursing education. Improvement of clinical education deficits and methods for overcoming logistical barriers to implement possible solutions did not exist at SCHOOL, the nursing program of focus for this paper. Although several options were identified in the literature, when guided by the logic model through focusing on the problem in light of resources and desired results, the nursing department decided to narrow the project focus to service learning, simulation, and collaborative learning environments.
Project on promoting expansion of nursing clinical instruction and learning (pencil) Project scope and process The mission of the PENCIL project was to increase the number of available clinical learning opportunities for
139
students within the nursing program at SCHOOL. The mission has been supported by developing strategic alliances with community partners, as well as exploring additional methods for alternative learning experiences. The unique challenge of the project was to meet increased student enrollment demands without raising cost or compromising nursing education quality through such approaches as more efficient utilization of existing organizational and community resources as well as inclusion of alternative clinical learning opportunities. The scope of the project was guided by the logic model by focusing on the intended results in light of existing program resources; project scope included establishing a system for evaluating the quality of clinical learning experiences, incorporating alternative learning experiences, and expanding the capacity of the nursing department’s ability to meet an increased enrollment of 80 students per year. These changes occurred over an incremental period of time in three phases, from infrastructure development (April 2010–February 2011), through initial implementation and process evaluation (March 2011–December 2011), and to outcome evaluation and sustainability (January 2012 and continuing). As in the logic model, the process and outcome evaluations were designed to provide indication of whether intended actions or services were provided, as well as intended outcomes reached; project objectives guided these evaluations and are detailed in Table 1. This project was reviewed and approved by the human subjects review board at SCHOOL.
Setting There are currently six nursing programs in the area where SCHOOL is located, a bi-state Midwest rural and suburban community of 300,000 citizens. All nursing programs are competing for the same limited resources, which include two hospital systems, one of which houses its own baccalaureate nursing program. Individual instructors are responsible for all aspects of clinical scheduling, contractual agreements, and evaluating the clinical experience. Competition among clinical faculty for student experiences was problematic, due to limited clinical facilities. Clinical education consumes significant faculty and financial resources, due to the stipulations set by accrediting agencies and state boards of nursing specifying student-to-instructor ratio (Elliott, 2002). Because there were multiple individuals managing these
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
140
Table 1
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
PENCIL project objectives: process and outcome
Process
Outcome
– Establish and appoint members to nursing clinical committee – Faculty approve inclusion of alternative learning experiences in all courses, as defined by the clinical committee – 90% of faculty participate in faculty development sessions which focus on strategies for development and integration of alternative learning experiences in clinical courses – Pilot clinical satisfaction evaluation tools for students, faculty, and clinical sites in 10% of clinical courses – Pilot a quality review process incorporating student, faculty, and clinical site satisfaction evaluation tools in 10% of clinical courses – Explore development of a Web-based scheduling system with area health-care providers and nursing education programs – 90% of students, faculty, and clinical sites report the SCHOOL clinical experience meets expectations – 90% of clinical courses include alternative learning experiences
– Number of clinical sites hosting SCHOOL students will increase 20% over baseline – Students achieving an exit HESI test score of at least 850 will remain consistent or improve over baseline – Students achieving a passing NCLEX test score will remain consistent or improve over baseline – Nursing program graduates that would likely recommend SCHOOL nursing program to others will increase 10% over baseline
tasks, the overall quality of the student experience had not been evaluated consistently within SCHOOL. The SCHOOL nursing program had grown significantly in both student enrollment and faculty since it was established in 2000. Within 10 years, the full-time nursing faculty grew from 3 to 16 and one-third of the current full-time faculty have less than 5 years’ teaching experience. Additionally, several seasoned faculty members are eligible for retirement within the next 10 years. Somewhat unique to SCHOOL, the nursing program had no established committees, with decisions made by the entire faculty as opposed to smaller work groups bringing forth recommendations.
Table 2
Tools Instruments used to measure the outcomes for PENCIL include the Health Education Systems, Inc. (HESI) Examination and the National Council of Licensing Examination (NCLEX). In addition, three existing tools used in the nursing department were revised as an aspect of the project: BSN Alumni Questionnaire, Faculty Agency Evaluation tool, and the Student Clinical Course Evaluation tool. An additional fourth tool to measure clinical site perceptions, Nursing Agency Clinical Experience Evaluation, was developed as part of the project, with closed- and open-ended items (Table 2). Items are measured on a 4-point, Likert-type scale. The tool was reviewed for item clarity and face validity.
Agency clinical experience evaluation tool items
1. Information provided to you prior to the clinical experience at your facility prepared you for working with SCHOOL nursing students. 2. Expectations pertaining to the level of clinical skills students were prepared to perform were clearly communicated to you prior to this clinical experience. 3. SCHOOL Nursing students were prepared for their clinical experience at this facility. 4. SCHOOL Nursing students demonstrated adherence to facility policies pertaining to safety, HIPAA, and other client rights. 5. SCHOOL Nursing students demonstrated professional behaviors, including appropriate attire, grooming, timeliness, and communication skills. 6. Communication between SCHOOL faculty and your facility representatives was timely and clear for the duration of the clinical experience. 7. The experiences available at this facility provide ample opportunities for nursing students at this level of their nursing education. 8. You are willing to provide a clinical experience for SCHOOL nursing students in the future at this facility. 9. Please share additional comments, especially pertaining to individual students.
Project evaluation results The following summarizes the project efforts to date. These project evaluation results relate to meeting process objectives and beginning efforts in meeting the longerterm outcome objectives as detailed in Table 1.
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
One of the initial project efforts was establishing a five-member clinical committee; members were selected for their particular interest in clinical education and varied specialty clinical expertise. Members’ commitment to the process was indicated by their consistent attendance (90%), and the fact that their project activities were met within the anticipated timeframe. It is important to note that, prior to 2009, the work of the nursing department was completed by the faculty as a whole, as there were no individual committees. Therefore, a request to work on tasks outside of the whole faculty group was viewed as a threat by some faculty because it represented a shift in organizational culture. Methods to overcome the anticipated resistance to the clinical committee’s work were addressed through monthly updates for faculty pertaining to committee work that emphasized that the committee functions as a work group that makes recommendations to faculty for consensus. By the second phase of the project timeline, faculty voted to move this committee from an ad hoc status to permanent committee, which establishes long-term support for the committee work and provides a venue to build sustainability for future project work. At this time, four instructors have revised course syllabi to include alternative learning activities, including those in collaborative learning environments, simulation, and service-learning experiences, consistent with course objectives. An example includes collaborating with a local health facility to utilize nursing students for employee influenza administration and includes student reflection, client satisfaction, and number of clients vaccinated as metrics of outcome evaluation. Faculty implementing these experiences in their courses verbalized their commitment to providing active learning opportunities for students. The selection of additional courses in which to pilot alternative learning will coincide with demand for increased course capacity and instructor readiness for adopting a change. While the faculty at large has agreed to incorporate alternative learning experiences in their courses, difficulties with implementation are anticipated. An integral part of garnering support for this project included monthly opportunities for faculty development and discussion regarding the PENCIL activities, which took place at faculty meetings. All of the faculty have attended 90% of the faculty sessions on development and integration of alternative learning experiences in clinical courses. Inclusion of clinical satisfaction evaluation tools for students, faculty, and clinical sites in the pilot phase exceeded expectations, as 74% of clinical courses included these tools. While most clinical faculty expressed willingness to have these evaluation tools
141
included in their course evaluations for students, the distribution of electronic surveys to clinical site personnel was problematic. Contributing factors included some faculty reluctance to release site contact information to other faculty and the lack of a centralized tracking system for clinical sites, including contacts. This reluctance to share information was anticipated, based upon the historical nature of the department in which individual faculty seek and maintain their own clinical lists. Based upon strategies to address similar faculty resistance found in the literature (Clare et al., 2003; Hoffart, 2006), additional efforts to reassure faculty such as providing immediate results regarding survey responses as well as full transparency pertaining to barriers for completing a comprehensive clinical program evaluation produced additional site contact information. Unanticipated barriers for clinical site survey distribution included lack of a central location for tracking clinical sites currently utilized per course. This barrier served as an incentive to explore methods for accurately tracking all clinical information, including facility demographics, course utilized, contact information, and contract status (a requirement of the STATE Board of Nursing) in a cost-sensitive manner, as contacting with a proprietary student tracking systems was not feasible. Faculty actively pursued an opportunity to collaborate with graduate-level computer technology students on campus to develop a clinical tracking database which meets all the aforementioned needs. While the database was not complete until after the surveys were deployed, a system utilizing work study students for data entry is in place to ensure accurate tracking of all clinical components as the project moves forward. The clinical committee has established a system for annual distribution and review of evaluation results in courses. This system includes clinical committee oversight for annual review of clinical evaluation results, internal benchmarking with baseline results, and providing formal recommendations to faculty for clinical activity augmentation based upon these findings. Prior to establishing this process, a comprehensive system of review was not in place for clinical activities; rather, individual instructors utilized student evaluations to make changes within their own courses based on unilateral perceptions instead of multiple stakeholder feedback. Baseline evaluations conducted in May 2011 using the clinical evaluation tools indicate that clinical experience met expectations of students, faculty, and clinical sites. Student cohorts varied by grade level as how satisfied they were with clinical experiences meeting expectations; however, overall they reported high level of
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
142
Table 3
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
Satisfaction with clinical experience from students, clinical site personnel, and clinical nurse faculty
Respondents
Agreement May 2011 (n)
Agreement May 2012
Type of students and experiencea Sophomores: operating room Sophomores: medication administration in rehabilitation Juniors: acute care medical-surgical Juniors: WIC Seniors: WIC Seniors: visiting nurses, home care, and hospice
88% (n ¼ 33)
– – – – 86% (n ¼ 22) 79% (n ¼ 42)
Clinical Site Personnel From all sites used
97% (n ¼ 70)
100% (n ¼ 30)
100% (n ¼ 12)
90% (n ¼ 10)
Clinical Nurse Faculty Clinical instructors from all sites used
92% (n 87% (n 82% (n 79% (n
¼ ¼ ¼ ¼
43) 43) 35) 35)
Notes: aStudent Clinical Course Evaluation tool item: This clinical environment met my expectations as a student for nursing education in this course. b Nursing Agency Clinical Experience Evaluation tool item: You are willing to provide a clinical experience for SCHOOL nursing students in the future at this facility. cFaculty Agency Evaluation tool item: This clinical environment met my expectations as an instructor for nursing education in this course.
satisfaction, ranging from 79% to 92% (see Table 3). Narrative student comments suggested dissatisfaction with negative staff attitudes toward students, as well as overcrowded clinical settings. Due to course changes at the sophomore level, comparable data for 2012 were not available. At the junior level, a change in faculty utilization of the evaluation tool resulted in non-comparable results. One significant change in clinical placement involved moving the Women, Infants and Children (WIC) experience to the senior level as a result of 2011 data. While respondent numbers were lower due to agency capacity for this experience, the overall improvement in satisfaction with this site suggests that this change has been favorable for students. Clinical faculty and clinical site personnel also reported being highly satisfied with the clinical experience (See Table 3). Despite high levels of reported satisfaction on the questionnaire, clinical site personnel’s narrative comments contained several remarks pertaining to lack of communication with scheduling students and coordinating student activities for the clinical day. Additional comments from clinical site personnel were positive and emphasized that most nurses want to have nursing students at their facility. Clinical site personnel noted several faculty members by name as being efficient with scheduling and communicating. While a potential barrier with this process is inability to follow up with specific comments (because the surveys were distributed anonymously), the clinical committee supports continuing the current approach because the purpose is to gather aggregate data as opposed to specific concerns. A process for students and clinical site personnel to submit specific
concerns to faculty will be explored further within the clinical committee. Competition for clinical sites in the area surrounding SCHOOL remains, and efforts toward increasing experiences in collaborative environments resulted in two new clinical site contracts, as well as establishing 14 new clinical sites within existing contracts. An additional nine sites were acquired during the 2011–2012 school year, while sustaining use of formerly established clinical sites. This expansion resulted from an effective practical application by faculty of concepts from the literature in expanding learning opportunities. For example, a screening process for newly acquired sites has been useful in establishing communication with a faculty member and designated agency personnel. Learning objectives are provided to agencies prior to student arrival. Ongoing faculty communication with agency personnel throughout the clinical experience, as well as post-experience evaluations, has been implemented. Finally, a clinical partner appreciation event was held at the SCHOOL, and continuing education was offered. These approaches were consistent with the approaches of others in the literature reviewed (Clare et al., 2003; Matsumura et al., 2004). An additional and sustainable approach to establishing collaborative learning environments in the regional area is through SCHOOL’s participation in a nationally funded consortium with the purpose of increasing nursing school collaboration. A few of the long-term visions stemming from this consortium include establishing a regional web-based scheduling system for clinical activities as no centralized placement system is currently accessible, as well as implementing a
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
comprehensive regional clinical evaluation system which will enhance the SCHOOL’s ability to identify positive experiences for students and stakeholders. SCHOOL faculty representatives continue collaboration with members of the project, and this partnership provides potential resources which will support the PENCIL project goals, such as a comprehensive regional clinical evaluation system which will enhance identifying positive clinical activities from both student and stakeholder perspectives. Standardized tools, the HESI and NCLEX, are monitored as part of the quality improvement process during this clinical expansion project. Students complete the HESI twice, and the final scores at the end of their senior year will be monitored. The baseline data for May 2011 graduates indicated that 93% (n ¼ 36) achieved a minimum score of 850, the score designated by this SCHOOL as indicating future success on NCLEX, based upon demographic similarities to other schools. The proportion of May 2012 graduates meeting the minimum score was 98% (n ¼ 53), a slight increase. The proportion of graduates achieving a passing score on NCLEX was similar from May 2011 baseline (91.5%, n ¼ 47) to May 2012 (91.7%, n ¼ 48). The ability to maintain 100% pass rates was not anticipated, as some fluctuation is expected based upon program influences; however, a significant statistical difference would warrant further exploration. Additional outcome measures that will be tracked are graduates’ and alumni’s satisfaction with the nursing program. Alumni surveys collected in the May 2011 document 100% of responding 2010 nursing program graduates (n ¼ 8) strongly agreed that they would likely recommend SCHOOL nursing program to others. SCHOOL alumni data collected in May 2012 remained consistent, with 100% (n ¼ 11) of the previous year’s alumni’s likely recommending SCHOOL nursing program to others. Exit surveys of May 2011 graduates document 93% (n ¼ 40) agreed they would likely recommend SCHOOL nursing program to others; however, this declined to 63% (n ¼ 43) for May 2012. These evaluation data will be collected each year, and the clinical committee will analyze results and identify trends across data sources and years.
Conclusion and recommendations The infrastructure established over the initial project phases supports the trajectory for long-term sustainability. A committee focused on the clinical aspects of
143
education developed a system for evaluating departmental priorities pertaining to clinical matters. The committee’s efforts have brought more attention to peripheral clinical education deficits, including coordination of contracts, tracking and evaluating clinical sites, as well as initiated approaches to resolve identified issues. These efforts coupled with the majority support of the faculty have resulted in a sustainable process to expand and evaluate clinical learning experiences. The PENCIL project has the potential to positively impact the nursing community in a number of ways. Improved clinical partner relationships are realized through use of enhanced communication structures, ongoing quality evaluation measures, and clinical partnership appreciation efforts. The project is enhancing collaboration with local health-care organizations and providing opportunities for service to the community. Thus, the project is providing opportunities for community involvement and support in efforts to supply local health-care facilities with qualified nursing graduates to alleviate staffing shortages. Emphasis on benefits for all stakeholders is key to creating sustainable relationships (Williams et al., 2002). Lessons learned from the PENCIL project can be applied to other settings. Smaller colleges of nursing that have been challenged with enrollment growth can appreciate the gap between organizational strategic plans and clinical capacity limitations. Effective infrastructure development and collaboration within the organization, as well as with external partners suggests a template for expanding clinical learning opportunities.
References American Association of Colleges of Nursing. (2006). State legislative initiatives to address the nursing shortage. (AACN Issue Bulletin). Retrieved from http://www.aacn.nche.edu/aacn-publications/issue-bulletin/state-legislative American Association of Colleges of Nursing. (2008) Nursing shortage fact sheet. Retrieved from http://www.aacn.nche.edu/ Media/FactSheets/NursingShortage.htm American Association of Colleges of Nursing. (2012). Guiding principles for academic-practice partnerships. Retrieved from http://www.aacn.nche.edu/leading-initiatives/academic-practice-partnerships/GuidingPrinciples.pdf Amerson, R. (2010). The impact of service-learning on cultural competence. Nursing Education Perspectives, 31, 18–22. Campus Compact. (1999–2014). National service learning clearinghouse. Retrieved from http://www.compact.org Clare, J., Brown, D., Edwards, H., van Loon, A., Leibbrandt, L., MalkoNyhan, K., & White, J. (2003). Learning outcomes and curriculum development in major disciplines: Nursing. Evaluating
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
144
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
clinical learning environments: Creating education-practice partnerships and benchmarking for nursing. Research report. Flinders University, Australia. Retrieved from March http:// nursing.flinders.edu.au/research/reports/special_pubs_Clare. pdf Delunus, L., & Rooda, L. (2009). A new model for the clinical instruction of undergraduate nurses. Nursing Education Perspectives, 30, 377–382. Edwards, H., Smith, S., Courtney, M., Finlayson, K., & Chapman, H. (2004). The impact of clinical placement location on nursing students’ competence and preparedness for practice. Nurse Education Today, 24, 248–255. Ellenbecker, C. O., O’Brien, E., & Byrne K. (2002). Establishing partnerships with social service agencies for community health education. Journal of Community Health Nursing, 19, 1–6. Elliott, M. (2002). The clinical environment: A source of stress for undergraduate nurses. Australian Journal of Advanced Nursing, 20, 34–38. Harrison, S. (2004). Overcrowded placements hinder student learning. Nursing Standard, 18, 7. Henderson, A., Heel, A., & Twentyman, M. (2007). Enabling student placement through strategic partnerships between a healthcare organization and tertiary Institutions. Journal of Nursing Management, 15, 91–96. Hoffart, N. D. (2006). Outcomes of cooperative education in a baccalaureate program in nursing education. Nursing Education Perspectives, 27(3), 136–143. Hunsberger, M., Baumann, A., Lappan, J., Carter, N., & Goddard, P. (2000). The synergism of expertise in clinical teaching: An integrative model for nursing education. Journal of Nursing Education, 39, 278–282. Hutchings, A., Williamson, G., & Humphreys, A. (2005). Supporting learners in clinical practice: Capacity issues. Journal of Clinical Nursing, 14, 945–955. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/ Reports/2010/The-Future-of-Nursing-Leading-ChangeAdvancing-Health.aspx Jeffries, P. (2009). Dreams for the future for clinical simulation. Nursing Education Perspective, 30(2), 71.
Joynt, J., & Kimball, B. (2008, May). Blowing open the bottleneck: Designing new approaches to increase nurse education capacity. Champion Nursing. Retrieved from http://championnursing.org/sites/default/files/1695_BlowingOpentheBottleneck. pdf Kaufman, K. A. (2010). Students are increasingly diverse but lack of educational capacity still stymies enrollment growth. National League for Nursing, 1(5), 95–97. Matsumura, G. C., Callister, L. C., Palmer S., Harmer, A. C., & Larsen, L. (2004). Staff nurse perceptions of the contributions of students to clinical agencies. Nursing Education Perspectives, 25, 297–303. McLaughlin, J. A., & Jordan, G. B. (2010). Using logic models. In J. S. Wholey, H. P. Hatry, & K. E. Newcomer (Eds.), Handbook of practical program evaluation (3rd ed., 55–80). San Francisco, CA: Jossey-Bass. Murray, S. C., & Williamson, G. R. (2009). Managing capacity issues in clinical placements for pre-registration nurses. Journal of Clinical Nursing, 18, 3146–3154. National League for Nursing. (2010, August). Nursing faculty shortage fact sheet. Retrieved from http://www.nln.org/governmentaffairs/pdf/NurseFacultyShortage.pdf Robert Wood Johnson Foundation. (2012). Partners investing in nursing’s future. Retrieved from http://www.rwjf.org/en/ grants/national-program-offices/P/partners-investing-in-nursing-s-future.html Seifer, S., & Vaughn, R. L. (2002). Partners in caring and community: Service-learning in education. Journal of Nursing Education, 41, 437–439. STATE Action Coalition. (2012). The future of nursing, leading change, advancing health. Retrieved from [blinded, complete address to be included later] Tanner, C. (2002). Clinical education: Circa 2010. Journal of Nursing Education, 41, 51–52. Williams, K., Cobb, A. K., Nowak, J., Domian, E. W., Hicks, V., & Starling, C. (2002). Faculty-agency partnering for improved client outcomes. Journal of Nursing Education, 41, 531–534. W.K. Kellogg Foundation. (2004). W.K. Kellogg Foundation logic model development guide. Retrieved from http://www.wkkf.org
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
Research Article Kathleen Andresen* and Pamela Levin
Enhancing Quantity and Quality of Clinical Experiences in a Baccalaureate Nursing Program Abstract: Nursing programs encounter barriers to clinical education, which may include limited clinical capacity for nursing students. Congestion of clinical placements compounded by multiple external influences prompted a need to develop an alternative approach for meeting program standards pertaining to clinical education. A curriculum improvement project was implemented within a school of nursing with the primary goal of expanding clinical learning opportunities while maintaining program quality. The unique aspect of this project was a comprehensive evaluative design, including qualitative responses from students, faculty, and clinical site stakeholders, as well as standardized student test scores. Augmenting the tools and processes for evaluation of clinical learning required collaboration from the faculty. Project outcomes include expanded clinical capacity, increased variety of clinical learning experiences, and improved quality of the clinical experiences. Collaborative partnerships yielded valuable lessons, which have implications for other nursing programs challenged with clinical placements. Keywords: clinical education, baccalaureate nursing education, expanding clinical capacity, collaborative partnerships DOI 10.1515/ijnes-2013-0053
In the past decade, there has been an increased emphasis on educating nurses in quality and varied experiences to prepare them for complex work environments. One influence driving nursing education is the Institute of Medicine’s Future of Nursing report (IOM, 2010). Additional influences include national initiatives (Robert *Corresponding author: Kathleen Andresen, Department of Nursing, St. Ambrose University, 1320 W. Lombard, Davenport, IA 52804, USA, E-mail: [email protected] Pamela Levin, College of Nursing, Rush University, Chicago, IL, USA, E-mail: [email protected]
Wood Johnson Foundation, 2012), as well as state and regional coalitions (STATE Action Coalition, 2012) that have formed to address recommendations to improve quality and safety within nursing care delivery. In addition to incorporating these recommendations, schools of nursing are challenged to meet the increased nursing workforce demands and are seeking methods to overcome these challenges. This paper outlines specific challenges experienced by a baccalaureate nursing program in the Midwestern United States and identifies a method for ensuring the quality of the clinical experience during a time of rapid increase in enrollment, thus also enhancing the quantity of clinical experiences within that program. The faculty in this nursing program are committed to addressing the challenge presented in the Future of Nursing report (IOM, 2010) of increasing the number of BSN-prepared nurses in STATE, as evidenced by the university mandate to increase the pre-licensure student enrollment rate by 20% by 2017. The nursing program has struggled to obtain clinical learning opportunities due to competition from nearby schools of nursing and an already rapid growth of the nursing program. The problem of a limited number and variety of quality clinical experiences prompted a need for infrastructure development to build capacity and to assure standards specified by nursing education accreditation agencies were met. The purpose of this paper is to describe a project designed to address this need (Promoting Expansion of Nursing Clinical Education & Learning [PENCIL]) and the process the nursing program at SCHOOL initiated to expand clinical capacity, enhance the variety of clinical experiences, and improve clinical education quality. The logic model (W.K. Kellogg Foundation, 2004) was the theory that guided the development of the PENCIL project from initially determining the context of the problem, as well as project mission, scope, and components, through to the program processes (e.g., activities, outputs) needed to achieve specific measurable and sustainable outcomes for this program. Based in change theory, the term “logic model” is used interchangeably
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
138
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
with “program theory” within the evaluation field (Kellogg, 2004; McLaughlin & Jordan, 2010). The model is designed to guide both planning and evaluation of a program’s structure and outcomes through a process that reveals an understanding of gaps between project vision and program resources. Program structure includes the necessary resources to support the actions needed to produce the program services; these services in turn result in changes in people served and in organizations – the short- and long-term outcomes. The logic model is promoted within the evaluation field to further understanding of program structure on intended outcomes and is applied in this SCHOOL’s setting toward understanding the context of clinical capacity augmentation.
Review of literature Quality education of nurses requires incorporating clinical learning experiences that increase the critical thinking skills necessary to provide patient care in complex health systems (American Association of Colleges of Nursing [AACN], 2006). High-quality clinical placements are required if students are to achieve the necessary experience and levels of competence (Murray & Williamson, 2009). The quality of the clinical learning environment is an important factor in determining the quality of students’ clinical experience in baccalaureate nursing curricula (Edwards, Smith, Courtney, Finlayson, & Chapman, 2004). However, a lack of clinical practice settings continues to be a critical constraint to expanding admissions to prelicensure programs nationwide, with 30% of baccalaureate schools of nursing identifying lack of clinical practice settings as the primary barrier for expanding enrollment (Kaufman, 2010). In a 2007 survey, baccalaureate nursing programs identified “insufficient clinical sites” as the second most limiting factor to accepting a greater number of applications, right behind faculty shortage (AACN, 2008). Clinical placement poses a challenge for schools of nursing due to competition among schools, limited inpatient care opportunities, and lack of clinical nurse educators (AACN, 2006, 2008; National League for Nursing [NLN], 2010; Tanner, 2002). Limited clinical education is an international issue, as nursing education programs worldwide are seeking strategies to increase the capacity of their program enrollment with extremely limited resources; there is no single
method for implementing clinical site expansion (Harrison, 2004; Hutchings, Williamson, & Humphreys, 2005; Murray & Williamson, 2009). Examples of how clinical education deficits are being addressed through a variety of alternative learning experiences include, but are not limited to (Delunus & Rooda, 2009; Joynt & Kimball, 2008): – Simulated patient experiences that augment traditional patterns of training nurses in a clinical setting and use of high-fidelity simulation (Jeffries, 2009); – Collaborative relationships with clinical facilities that focus on facility relationships versus a specific unit (Delunus & Rooda, 2009; Ellenbecker, O’Brien, & Byrne, 2002; Hoffart, 2006; Williams et al., 2002); Service-learning activities, as nurses’ working in an inter-professional team is an essential piece of nursing education today (IOM, 2010), and the benefits of, as well as opportunities for, integrating service learning in the clinical curriculum have been demonstrated (Amerson, 2010; Seifer & Vaughn, 2002). Service learning is an approach where students’ learning is enhanced through active participation in structured learning opportunities that address needs identified in collaboration with agency/community members; there is equal benefit to the students and the agency/community (Campus Compact, 1999–2014). To assure a quality experience, faculty need to (1) plan structured opportunities that align with outcomes to be achieved, (2) design opportunities for students to critically reflect, and (3) assess and evaluate with students and agency/community whether intended outcomes were met (Campus Compact, 1999– 2014). AACN (2012) supports formal partnerships between schools of nursing and clinical facilities; these partners collaboratively identify and capitalize on specific benefits that are attractive and useful to both partners and should result in enhanced clinical experiences for students. With a partnership or collaborative approach, faculty member capacity was doubled in the clinical setting; students were satisfied with their clinical experience; and the affiliation between the hospital and the school of nursing was strengthened (Delunus & Rooda, 2009; Hunsberger, Baumann, Lappan, Carter, & Goddard, 2000). Most of the collaborative approaches included developing effective working relationships between healthcare practitioners and the schools of nursing. Barriers cited in the literature for these efforts stemmed from clinician reluctance to precept nursing students (Elliott,
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
2002), which may relate to lack of satisfaction with faculty communication and uncertainty regarding student preparation for the clinical experience (Matsumura, Callister, Palmer, Harmer, & Larsen, 2004). However, these two factors have been remedied in other schools of nursing by establishing strategic partnerships (Henderson, Heel, & Twentyman, 2007) and including routine evaluations of the clinical learning environment and stakeholder’s perceptions of the clinical learning experience (Clare et al., 2003). Providing staff nurses with daily objectives for student learning and including skills development and positive feedback to staff are methods for enhancing clinical stakeholder partnerships (Matsumura et al., 2004). Additionally, strategies to solidify ongoing staff nurse support are crucial in motivating and recognizing nurses for their efforts. Some expressions of appreciation included inviting staff nurses to participate in lectures by guest professionals or extending academic privileges to nurse mentors, such as guest privileges to the university library. Awards, luncheons, and simple gifts, such as a college pin indicating preceptorship/mentorship status, are other ways that have demonstrated efficacy in recognizing and retaining staff nurses as preceptors (Matsumura et al., 2004). In summary, numerous obstacles exist for meeting the increasing demand of clinical experiences in nursing education. Improvement of clinical education deficits and methods for overcoming logistical barriers to implement possible solutions did not exist at SCHOOL, the nursing program of focus for this paper. Although several options were identified in the literature, when guided by the logic model through focusing on the problem in light of resources and desired results, the nursing department decided to narrow the project focus to service learning, simulation, and collaborative learning environments.
Project on promoting expansion of nursing clinical instruction and learning (pencil) Project scope and process The mission of the PENCIL project was to increase the number of available clinical learning opportunities for
139
students within the nursing program at SCHOOL. The mission has been supported by developing strategic alliances with community partners, as well as exploring additional methods for alternative learning experiences. The unique challenge of the project was to meet increased student enrollment demands without raising cost or compromising nursing education quality through such approaches as more efficient utilization of existing organizational and community resources as well as inclusion of alternative clinical learning opportunities. The scope of the project was guided by the logic model by focusing on the intended results in light of existing program resources; project scope included establishing a system for evaluating the quality of clinical learning experiences, incorporating alternative learning experiences, and expanding the capacity of the nursing department’s ability to meet an increased enrollment of 80 students per year. These changes occurred over an incremental period of time in three phases, from infrastructure development (April 2010–February 2011), through initial implementation and process evaluation (March 2011–December 2011), and to outcome evaluation and sustainability (January 2012 and continuing). As in the logic model, the process and outcome evaluations were designed to provide indication of whether intended actions or services were provided, as well as intended outcomes reached; project objectives guided these evaluations and are detailed in Table 1. This project was reviewed and approved by the human subjects review board at SCHOOL.
Setting There are currently six nursing programs in the area where SCHOOL is located, a bi-state Midwest rural and suburban community of 300,000 citizens. All nursing programs are competing for the same limited resources, which include two hospital systems, one of which houses its own baccalaureate nursing program. Individual instructors are responsible for all aspects of clinical scheduling, contractual agreements, and evaluating the clinical experience. Competition among clinical faculty for student experiences was problematic, due to limited clinical facilities. Clinical education consumes significant faculty and financial resources, due to the stipulations set by accrediting agencies and state boards of nursing specifying student-to-instructor ratio (Elliott, 2002). Because there were multiple individuals managing these
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
140
Table 1
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
PENCIL project objectives: process and outcome
Process
Outcome
– Establish and appoint members to nursing clinical committee – Faculty approve inclusion of alternative learning experiences in all courses, as defined by the clinical committee – 90% of faculty participate in faculty development sessions which focus on strategies for development and integration of alternative learning experiences in clinical courses – Pilot clinical satisfaction evaluation tools for students, faculty, and clinical sites in 10% of clinical courses – Pilot a quality review process incorporating student, faculty, and clinical site satisfaction evaluation tools in 10% of clinical courses – Explore development of a Web-based scheduling system with area health-care providers and nursing education programs – 90% of students, faculty, and clinical sites report the SCHOOL clinical experience meets expectations – 90% of clinical courses include alternative learning experiences
– Number of clinical sites hosting SCHOOL students will increase 20% over baseline – Students achieving an exit HESI test score of at least 850 will remain consistent or improve over baseline – Students achieving a passing NCLEX test score will remain consistent or improve over baseline – Nursing program graduates that would likely recommend SCHOOL nursing program to others will increase 10% over baseline
tasks, the overall quality of the student experience had not been evaluated consistently within SCHOOL. The SCHOOL nursing program had grown significantly in both student enrollment and faculty since it was established in 2000. Within 10 years, the full-time nursing faculty grew from 3 to 16 and one-third of the current full-time faculty have less than 5 years’ teaching experience. Additionally, several seasoned faculty members are eligible for retirement within the next 10 years. Somewhat unique to SCHOOL, the nursing program had no established committees, with decisions made by the entire faculty as opposed to smaller work groups bringing forth recommendations.
Table 2
Tools Instruments used to measure the outcomes for PENCIL include the Health Education Systems, Inc. (HESI) Examination and the National Council of Licensing Examination (NCLEX). In addition, three existing tools used in the nursing department were revised as an aspect of the project: BSN Alumni Questionnaire, Faculty Agency Evaluation tool, and the Student Clinical Course Evaluation tool. An additional fourth tool to measure clinical site perceptions, Nursing Agency Clinical Experience Evaluation, was developed as part of the project, with closed- and open-ended items (Table 2). Items are measured on a 4-point, Likert-type scale. The tool was reviewed for item clarity and face validity.
Agency clinical experience evaluation tool items
1. Information provided to you prior to the clinical experience at your facility prepared you for working with SCHOOL nursing students. 2. Expectations pertaining to the level of clinical skills students were prepared to perform were clearly communicated to you prior to this clinical experience. 3. SCHOOL Nursing students were prepared for their clinical experience at this facility. 4. SCHOOL Nursing students demonstrated adherence to facility policies pertaining to safety, HIPAA, and other client rights. 5. SCHOOL Nursing students demonstrated professional behaviors, including appropriate attire, grooming, timeliness, and communication skills. 6. Communication between SCHOOL faculty and your facility representatives was timely and clear for the duration of the clinical experience. 7. The experiences available at this facility provide ample opportunities for nursing students at this level of their nursing education. 8. You are willing to provide a clinical experience for SCHOOL nursing students in the future at this facility. 9. Please share additional comments, especially pertaining to individual students.
Project evaluation results The following summarizes the project efforts to date. These project evaluation results relate to meeting process objectives and beginning efforts in meeting the longerterm outcome objectives as detailed in Table 1.
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
One of the initial project efforts was establishing a five-member clinical committee; members were selected for their particular interest in clinical education and varied specialty clinical expertise. Members’ commitment to the process was indicated by their consistent attendance (90%), and the fact that their project activities were met within the anticipated timeframe. It is important to note that, prior to 2009, the work of the nursing department was completed by the faculty as a whole, as there were no individual committees. Therefore, a request to work on tasks outside of the whole faculty group was viewed as a threat by some faculty because it represented a shift in organizational culture. Methods to overcome the anticipated resistance to the clinical committee’s work were addressed through monthly updates for faculty pertaining to committee work that emphasized that the committee functions as a work group that makes recommendations to faculty for consensus. By the second phase of the project timeline, faculty voted to move this committee from an ad hoc status to permanent committee, which establishes long-term support for the committee work and provides a venue to build sustainability for future project work. At this time, four instructors have revised course syllabi to include alternative learning activities, including those in collaborative learning environments, simulation, and service-learning experiences, consistent with course objectives. An example includes collaborating with a local health facility to utilize nursing students for employee influenza administration and includes student reflection, client satisfaction, and number of clients vaccinated as metrics of outcome evaluation. Faculty implementing these experiences in their courses verbalized their commitment to providing active learning opportunities for students. The selection of additional courses in which to pilot alternative learning will coincide with demand for increased course capacity and instructor readiness for adopting a change. While the faculty at large has agreed to incorporate alternative learning experiences in their courses, difficulties with implementation are anticipated. An integral part of garnering support for this project included monthly opportunities for faculty development and discussion regarding the PENCIL activities, which took place at faculty meetings. All of the faculty have attended 90% of the faculty sessions on development and integration of alternative learning experiences in clinical courses. Inclusion of clinical satisfaction evaluation tools for students, faculty, and clinical sites in the pilot phase exceeded expectations, as 74% of clinical courses included these tools. While most clinical faculty expressed willingness to have these evaluation tools
141
included in their course evaluations for students, the distribution of electronic surveys to clinical site personnel was problematic. Contributing factors included some faculty reluctance to release site contact information to other faculty and the lack of a centralized tracking system for clinical sites, including contacts. This reluctance to share information was anticipated, based upon the historical nature of the department in which individual faculty seek and maintain their own clinical lists. Based upon strategies to address similar faculty resistance found in the literature (Clare et al., 2003; Hoffart, 2006), additional efforts to reassure faculty such as providing immediate results regarding survey responses as well as full transparency pertaining to barriers for completing a comprehensive clinical program evaluation produced additional site contact information. Unanticipated barriers for clinical site survey distribution included lack of a central location for tracking clinical sites currently utilized per course. This barrier served as an incentive to explore methods for accurately tracking all clinical information, including facility demographics, course utilized, contact information, and contract status (a requirement of the STATE Board of Nursing) in a cost-sensitive manner, as contacting with a proprietary student tracking systems was not feasible. Faculty actively pursued an opportunity to collaborate with graduate-level computer technology students on campus to develop a clinical tracking database which meets all the aforementioned needs. While the database was not complete until after the surveys were deployed, a system utilizing work study students for data entry is in place to ensure accurate tracking of all clinical components as the project moves forward. The clinical committee has established a system for annual distribution and review of evaluation results in courses. This system includes clinical committee oversight for annual review of clinical evaluation results, internal benchmarking with baseline results, and providing formal recommendations to faculty for clinical activity augmentation based upon these findings. Prior to establishing this process, a comprehensive system of review was not in place for clinical activities; rather, individual instructors utilized student evaluations to make changes within their own courses based on unilateral perceptions instead of multiple stakeholder feedback. Baseline evaluations conducted in May 2011 using the clinical evaluation tools indicate that clinical experience met expectations of students, faculty, and clinical sites. Student cohorts varied by grade level as how satisfied they were with clinical experiences meeting expectations; however, overall they reported high level of
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
142
Table 3
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
Satisfaction with clinical experience from students, clinical site personnel, and clinical nurse faculty
Respondents
Agreement May 2011 (n)
Agreement May 2012
Type of students and experiencea Sophomores: operating room Sophomores: medication administration in rehabilitation Juniors: acute care medical-surgical Juniors: WIC Seniors: WIC Seniors: visiting nurses, home care, and hospice
88% (n ¼ 33)
– – – – 86% (n ¼ 22) 79% (n ¼ 42)
Clinical Site Personnel From all sites used
97% (n ¼ 70)
100% (n ¼ 30)
100% (n ¼ 12)
90% (n ¼ 10)
Clinical Nurse Faculty Clinical instructors from all sites used
92% (n 87% (n 82% (n 79% (n
¼ ¼ ¼ ¼
43) 43) 35) 35)
Notes: aStudent Clinical Course Evaluation tool item: This clinical environment met my expectations as a student for nursing education in this course. b Nursing Agency Clinical Experience Evaluation tool item: You are willing to provide a clinical experience for SCHOOL nursing students in the future at this facility. cFaculty Agency Evaluation tool item: This clinical environment met my expectations as an instructor for nursing education in this course.
satisfaction, ranging from 79% to 92% (see Table 3). Narrative student comments suggested dissatisfaction with negative staff attitudes toward students, as well as overcrowded clinical settings. Due to course changes at the sophomore level, comparable data for 2012 were not available. At the junior level, a change in faculty utilization of the evaluation tool resulted in non-comparable results. One significant change in clinical placement involved moving the Women, Infants and Children (WIC) experience to the senior level as a result of 2011 data. While respondent numbers were lower due to agency capacity for this experience, the overall improvement in satisfaction with this site suggests that this change has been favorable for students. Clinical faculty and clinical site personnel also reported being highly satisfied with the clinical experience (See Table 3). Despite high levels of reported satisfaction on the questionnaire, clinical site personnel’s narrative comments contained several remarks pertaining to lack of communication with scheduling students and coordinating student activities for the clinical day. Additional comments from clinical site personnel were positive and emphasized that most nurses want to have nursing students at their facility. Clinical site personnel noted several faculty members by name as being efficient with scheduling and communicating. While a potential barrier with this process is inability to follow up with specific comments (because the surveys were distributed anonymously), the clinical committee supports continuing the current approach because the purpose is to gather aggregate data as opposed to specific concerns. A process for students and clinical site personnel to submit specific
concerns to faculty will be explored further within the clinical committee. Competition for clinical sites in the area surrounding SCHOOL remains, and efforts toward increasing experiences in collaborative environments resulted in two new clinical site contracts, as well as establishing 14 new clinical sites within existing contracts. An additional nine sites were acquired during the 2011–2012 school year, while sustaining use of formerly established clinical sites. This expansion resulted from an effective practical application by faculty of concepts from the literature in expanding learning opportunities. For example, a screening process for newly acquired sites has been useful in establishing communication with a faculty member and designated agency personnel. Learning objectives are provided to agencies prior to student arrival. Ongoing faculty communication with agency personnel throughout the clinical experience, as well as post-experience evaluations, has been implemented. Finally, a clinical partner appreciation event was held at the SCHOOL, and continuing education was offered. These approaches were consistent with the approaches of others in the literature reviewed (Clare et al., 2003; Matsumura et al., 2004). An additional and sustainable approach to establishing collaborative learning environments in the regional area is through SCHOOL’s participation in a nationally funded consortium with the purpose of increasing nursing school collaboration. A few of the long-term visions stemming from this consortium include establishing a regional web-based scheduling system for clinical activities as no centralized placement system is currently accessible, as well as implementing a
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
comprehensive regional clinical evaluation system which will enhance the SCHOOL’s ability to identify positive experiences for students and stakeholders. SCHOOL faculty representatives continue collaboration with members of the project, and this partnership provides potential resources which will support the PENCIL project goals, such as a comprehensive regional clinical evaluation system which will enhance identifying positive clinical activities from both student and stakeholder perspectives. Standardized tools, the HESI and NCLEX, are monitored as part of the quality improvement process during this clinical expansion project. Students complete the HESI twice, and the final scores at the end of their senior year will be monitored. The baseline data for May 2011 graduates indicated that 93% (n ¼ 36) achieved a minimum score of 850, the score designated by this SCHOOL as indicating future success on NCLEX, based upon demographic similarities to other schools. The proportion of May 2012 graduates meeting the minimum score was 98% (n ¼ 53), a slight increase. The proportion of graduates achieving a passing score on NCLEX was similar from May 2011 baseline (91.5%, n ¼ 47) to May 2012 (91.7%, n ¼ 48). The ability to maintain 100% pass rates was not anticipated, as some fluctuation is expected based upon program influences; however, a significant statistical difference would warrant further exploration. Additional outcome measures that will be tracked are graduates’ and alumni’s satisfaction with the nursing program. Alumni surveys collected in the May 2011 document 100% of responding 2010 nursing program graduates (n ¼ 8) strongly agreed that they would likely recommend SCHOOL nursing program to others. SCHOOL alumni data collected in May 2012 remained consistent, with 100% (n ¼ 11) of the previous year’s alumni’s likely recommending SCHOOL nursing program to others. Exit surveys of May 2011 graduates document 93% (n ¼ 40) agreed they would likely recommend SCHOOL nursing program to others; however, this declined to 63% (n ¼ 43) for May 2012. These evaluation data will be collected each year, and the clinical committee will analyze results and identify trends across data sources and years.
Conclusion and recommendations The infrastructure established over the initial project phases supports the trajectory for long-term sustainability. A committee focused on the clinical aspects of
143
education developed a system for evaluating departmental priorities pertaining to clinical matters. The committee’s efforts have brought more attention to peripheral clinical education deficits, including coordination of contracts, tracking and evaluating clinical sites, as well as initiated approaches to resolve identified issues. These efforts coupled with the majority support of the faculty have resulted in a sustainable process to expand and evaluate clinical learning experiences. The PENCIL project has the potential to positively impact the nursing community in a number of ways. Improved clinical partner relationships are realized through use of enhanced communication structures, ongoing quality evaluation measures, and clinical partnership appreciation efforts. The project is enhancing collaboration with local health-care organizations and providing opportunities for service to the community. Thus, the project is providing opportunities for community involvement and support in efforts to supply local health-care facilities with qualified nursing graduates to alleviate staffing shortages. Emphasis on benefits for all stakeholders is key to creating sustainable relationships (Williams et al., 2002). Lessons learned from the PENCIL project can be applied to other settings. Smaller colleges of nursing that have been challenged with enrollment growth can appreciate the gap between organizational strategic plans and clinical capacity limitations. Effective infrastructure development and collaboration within the organization, as well as with external partners suggests a template for expanding clinical learning opportunities.
References American Association of Colleges of Nursing. (2006). State legislative initiatives to address the nursing shortage. (AACN Issue Bulletin). Retrieved from http://www.aacn.nche.edu/aacn-publications/issue-bulletin/state-legislative American Association of Colleges of Nursing. (2008) Nursing shortage fact sheet. Retrieved from http://www.aacn.nche.edu/ Media/FactSheets/NursingShortage.htm American Association of Colleges of Nursing. (2012). Guiding principles for academic-practice partnerships. Retrieved from http://www.aacn.nche.edu/leading-initiatives/academic-practice-partnerships/GuidingPrinciples.pdf Amerson, R. (2010). The impact of service-learning on cultural competence. Nursing Education Perspectives, 31, 18–22. Campus Compact. (1999–2014). National service learning clearinghouse. Retrieved from http://www.compact.org Clare, J., Brown, D., Edwards, H., van Loon, A., Leibbrandt, L., MalkoNyhan, K., & White, J. (2003). Learning outcomes and curriculum development in major disciplines: Nursing. Evaluating
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
144
K. Andresen and P. Levin: Enhancing Quantity and Quality of Clinical Experiences
clinical learning environments: Creating education-practice partnerships and benchmarking for nursing. Research report. Flinders University, Australia. Retrieved from March http:// nursing.flinders.edu.au/research/reports/special_pubs_Clare. pdf Delunus, L., & Rooda, L. (2009). A new model for the clinical instruction of undergraduate nurses. Nursing Education Perspectives, 30, 377–382. Edwards, H., Smith, S., Courtney, M., Finlayson, K., & Chapman, H. (2004). The impact of clinical placement location on nursing students’ competence and preparedness for practice. Nurse Education Today, 24, 248–255. Ellenbecker, C. O., O’Brien, E., & Byrne K. (2002). Establishing partnerships with social service agencies for community health education. Journal of Community Health Nursing, 19, 1–6. Elliott, M. (2002). The clinical environment: A source of stress for undergraduate nurses. Australian Journal of Advanced Nursing, 20, 34–38. Harrison, S. (2004). Overcrowded placements hinder student learning. Nursing Standard, 18, 7. Henderson, A., Heel, A., & Twentyman, M. (2007). Enabling student placement through strategic partnerships between a healthcare organization and tertiary Institutions. Journal of Nursing Management, 15, 91–96. Hoffart, N. D. (2006). Outcomes of cooperative education in a baccalaureate program in nursing education. Nursing Education Perspectives, 27(3), 136–143. Hunsberger, M., Baumann, A., Lappan, J., Carter, N., & Goddard, P. (2000). The synergism of expertise in clinical teaching: An integrative model for nursing education. Journal of Nursing Education, 39, 278–282. Hutchings, A., Williamson, G., & Humphreys, A. (2005). Supporting learners in clinical practice: Capacity issues. Journal of Clinical Nursing, 14, 945–955. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/ Reports/2010/The-Future-of-Nursing-Leading-ChangeAdvancing-Health.aspx Jeffries, P. (2009). Dreams for the future for clinical simulation. Nursing Education Perspective, 30(2), 71.
Joynt, J., & Kimball, B. (2008, May). Blowing open the bottleneck: Designing new approaches to increase nurse education capacity. Champion Nursing. Retrieved from http://championnursing.org/sites/default/files/1695_BlowingOpentheBottleneck. pdf Kaufman, K. A. (2010). Students are increasingly diverse but lack of educational capacity still stymies enrollment growth. National League for Nursing, 1(5), 95–97. Matsumura, G. C., Callister, L. C., Palmer S., Harmer, A. C., & Larsen, L. (2004). Staff nurse perceptions of the contributions of students to clinical agencies. Nursing Education Perspectives, 25, 297–303. McLaughlin, J. A., & Jordan, G. B. (2010). Using logic models. In J. S. Wholey, H. P. Hatry, & K. E. Newcomer (Eds.), Handbook of practical program evaluation (3rd ed., 55–80). San Francisco, CA: Jossey-Bass. Murray, S. C., & Williamson, G. R. (2009). Managing capacity issues in clinical placements for pre-registration nurses. Journal of Clinical Nursing, 18, 3146–3154. National League for Nursing. (2010, August). Nursing faculty shortage fact sheet. Retrieved from http://www.nln.org/governmentaffairs/pdf/NurseFacultyShortage.pdf Robert Wood Johnson Foundation. (2012). Partners investing in nursing’s future. Retrieved from http://www.rwjf.org/en/ grants/national-program-offices/P/partners-investing-in-nursing-s-future.html Seifer, S., & Vaughn, R. L. (2002). Partners in caring and community: Service-learning in education. Journal of Nursing Education, 41, 437–439. STATE Action Coalition. (2012). The future of nursing, leading change, advancing health. Retrieved from [blinded, complete address to be included later] Tanner, C. (2002). Clinical education: Circa 2010. Journal of Nursing Education, 41, 51–52. Williams, K., Cobb, A. K., Nowak, J., Domian, E. W., Hicks, V., & Starling, C. (2002). Faculty-agency partnering for improved client outcomes. Journal of Nursing Education, 41, 531–534. W.K. Kellogg Foundation. (2004). W.K. Kellogg Foundation logic model development guide. Retrieved from http://www.wkkf.org
Brought to you by | Dalhousie University Authenticated Download Date | 5/19/15 12:19 PM
