Academic Progression in Nursing: A Model for Partnership and Innovation
Academic Progression in Nursing: A Model for Partnership and Innovation
By Tina Gerardi, MS, RN, CAE, deputy director, APIN National Program Office, AONE
reprinted from with permission from Nurse Leader, August 2013
AONE, representing the Tri-Council for Nursing (American Association of Colleges of Nursing, American Nurses Association, American Organization of Nurse Executives and the National League for Nursing) was selected by the Robert Wood Johnson Foundation (RWJF) as the National Program Office (NPO) for Academic Progression in Nursing (APIN). This initiative supports the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, recommendation to increase the proportion of nurses with a baccalaureate degree in nursing (BSN) to 80 percent by 2020.
APIN provides $300,000 over two years to each of nine state Action Coalitions that have developed or made substantial progress toward statewide or regional action plans to achieve the IOM’s advanced education goal of 80 percent BSN or higher workforce goal. After a competitive process, in August 2012, the states of California, Hawaii, Montana, Massachusetts, New Mexico, New York, North Carolina, Texas and Washington were each awarded APIN grants. The APIN grantees were funded to work on at least one strategy related to academic progression that included at least one goal related to employer support for BSN nurses, to ensure demand for their services. Thus, academic-practice partnerships are a key strategy to the success of this effort. The program also encourages partnerships between community colleges and universities to ensure seamless transition for nurses with associate degrees who want to pursue their BSN degree.
Progress is already being made through innovative practices being implemented in the nine states to meet the needs for student clinical placements from both the academic and practice perspective. The following are examples of the progress being made:
The Academic Challenges
Limitation in the number and scope of clinical practice sites is one of the most significant factors limiting enrollment in schools of nursing. The traditional model of clinical education is taxing faculty, facilities, students and staff. To meet the increased demand for student clinical placements, schools of nursing have become quite innovative in how nursing students can achieve the needed patient care experiences to successfully graduate and transition from student to novice practitioners. Many schools are making the most of simulation laboratory experiences wherever possible; however, state regulations and accreditation standards present challenges related to maximum number of clinical hours that can be met in a simulated experience. For example, AONE Board member, KT Waxman, DNP, MBA, RN, CNL, CENP, Assistant Professor, University of San Francisco (USF) School of Nursing and Health Professions, who is also the Project Director, Department of Defense Grant for Simulation Study and Director of the California Simulation Alliance shares, “At USF, we utilize 25 percent of all student clinical hours per course in clinical simulation. This is an upcoming trend in clinical education and California is one of the few states in which their Board of Registered Nursing has a regulation allowing schools of nursing to provide 25 percent of clinical hours in simulation.” Because of difficulty securing adequate clinical placements in acute care, USF also utilizes clinics, home care, doctors’ offices, hospice and long-term care facilities for a portion of the experience along with the 25 percent in simulation.
Cindy Hollinsworth, MSN, Director of Nursing at Bellingham Technical College (Bellingham TC) in Bellingham, WA, shares Dr. Waxman’s support for utilization of clinical sites other than the traditional acute care hospital. Faculty at Bellingham TC have adapted the Oregon Consortium for Nursing Education (OCNE) Clinical Education Model that was launched in February 2006 in combination with Enriched Clinical Learning Environment through Partnerships (ECLEPS) to create clinical learning activities that implement innovative educational strategies. The OCNE model is a project that proposes five types of learning experiences:
1. Concept-Based Experience is designed to support student learning of pattern recognition. Through multiple encounters with clients experiencing the same problem, students learn pattern recognition associated with a specific concept, illness, disease or health problem.
2. Case-Based Experience presents students with authentic clinical problems they will likely encounter in practice and provides opportunities for students to learn to think like a nurse through client case exemplars. It encompasses seminar discussion of faculty-designed or computer-based cases, as well as a variety of simulations, including use of high-, mid- and low-fidelity environments using human patient simulators, standardized patients and role-playing.
3. Intervention Skill-Based Experience builds proficiency in the “know-how” and “know-why” of nursing practice. These experiences include psychomotor skills, as well as communication, teaching, advocacy, coaching and interpersonal skills among others.
4. Focused Direct Client Care Experience enables the student to gain progressive experience in the actual delivery of nursing care and to build and understand the role of developing relationships with patients. The assigned focus for a care experience allows the student to apply a growing knowledge and skill base to client care. Students learn to establish and nurture the nurse/client relationship and integrate the ethics of caring for individuals.
5. Integrative Practicum provides opportunity for the student to apply all elements of prior learning into an authentic clinical practice situation. The purpose is also to begin the transition into practice. Rather than the student being assigned to a particular client, the student is assigned to work with a registered nurse and provide client care with, and under the direction of, the registered nurse. The student practices integration of knowledge, clinical judgment and competencies while providing client care, and studies the role of the registered nurse as it is expressed in a particular organizational environment.1
Enriched Clinical Learning Environments through Partnerships (ECLEPs) is a model for clinical academic partnerships in long-term care (LTC) settings, including nursing homes, home, and community-based care facilities such as assisted living and residential care. The model is used by associate and baccalaureate nursing programs. The primary aims of ECLEPs are to promote faculty development in gerontological nursing, recognize and use the expertise of LTC nurses and support these nurses through multiple resources and staff development. They also provide student nurses an opportunity to experience excellent LTC nursing and understand the nurse’s role in long-term management of chronic illness.2
Several faculty members at Bellingham TC have backgrounds in LTC and have expanded the focus in this clinical area for student experiences. In the first clinical course, faculty members have created the Patient Assessment Clinical Experience (PACE) model for teaching assessment fundamentals to their students. Traditionally most schools have assigned one faculty member for ten nursing students who care for one or two patients each. Hollinsworth shared, “Utilizing the PACE model, those ten students have progressive experiences scaffolding upon the skills and concepts implemented the previous day and weeks.” Students deliver comprehensive care for the same patients in the LTC setting over multiple weeks while working with staff nurses and faculty support. In the second clinical course, the faculty members rotate four students out of the traditional acute care hospital experience to long-term care for work on prioritizing and organizing a client load with medically fragile, chronically ill and elderly residents. The key is to have the students return to the same facility they were assigned to for the first clinical course. Facility nursing staff at these locations are supportive and understand the goals of the student assignment. The student works alongside the licensed nurse in the facility assuming the licensed nurse role for a progressively larger caseload over three days. On the first day of rotation the student cares for two residents, the second day, three residents and the third day, four residents. The student then rotates back to the acute care facility with enhanced strategies to manage and prioritize an acute care patient load.
Additionally, Bellingham TC has utilized non-traditional units within an acute care setting such as the short stay procedure area for admission and discharge processes and related patient teaching. The family practice clinic is a non-traditional site for pediatric clinical rotations, and the local health department immunization and flu clinics are used to teach patient screening, proper injection technique and completion of required paperwork and mandatory department of health reporting.
Texas is interested in a promising practice referred to as an “immersion clinical.” Helen Reid, EdD, MSN, RN, CNE, Provost at Trinity Valley Community College shared this concept-based experience at an APIN site visit. “The goal of the clinical experience is to promote in-depth understanding of a specific concept and the need for patient-specific care planning,” said Reid. This new clinical experience is being utilized at El Centro Community College in the Dallas area and is based on work shared by Carol Thorn, MS, RN, Department of Nursing Chair, Clackamas Community College, and a member of the Oregon Consortium for Nursing Education. For example, a clinical experience while studying the concept of fluid and electrolyte imbalance could enfold as follows. The faculty member would be responsible for ten students, five students would each be assigned to and provide total care for a patient with this problem, the other five students would randomly pick five or six patients on the unit who are receiving intravenous fluids, blood transfusions or tube feedings to “investigate” for this learning activity. These students would then answer a series of questions about each patient related to fluid and electrolyte balance while reviewing the chart and patient care plan to facilitate more in-depth understanding of the diagnosis and plan of care. Halfway through the shift, the students would give report and swap assignments. This immersion into the concept of fluid and electrolyte imbalance provides the students with understanding beyond the care of one patient and promotes understanding of diagnostic and patient care nuances for the same diagnosis. The concept of an immersion clinical was also noted on a Washington site visit referencing the utilization of a diabetic clinic to help students in the understanding of diabetes and related complications of this chronic disease, as well as student skill building related to histories, physicals and insulin injections.
Kathryn Tart, EdD, RN, Founding Dean and Professor at the University of Houston-Victoria campus has created student clinicals that support the needs of their practice partners as well as their students. Students in their RN to BSN program have classes and clinicals on the same day each week. The employer knows who will be unable to work on which day due to their academic progression needs. The employer makes a commitment to the employee to have that specific day off during the academic year. This allows the employer to plan staffing in a systematic way. In the pre-licensure program clinical experiences are for six weeks each semester, however, UH-Victoria books clinicals for twelve hours each day, thus allowing a double rotation of students each semester. The twelve-week student clinical experience includes, for example, six weeks of medical-surgical, three weeks of psychiatric and three weeks of pediatrics experiences. Faculty members stay in place (med-surg, peds or psych) while supervising twenty students each week on a specific day. In addition to being a win-win for the students and student employers, it benefits the faculty and the clinical site partner. Tart shared, “The faculty members like this clinical experience as they are only doing on-site clinical one day each week, and the clinical site likes knowing they will have students from that one university on a specific day each week.”
Practice Site Challenges
While academic institutions are looking for clinical placement sites, those clinical sites are faced with the challenges of working with multiple schools of nursing competing for clinical experiences resulting in student overload and preceptor fatigue. Although all of the APIN states are dealing with these issues, two institutions highlight work that many facilities are doing to help with the challenges.
Cathy Gage, MHA, RN-BC, Nursing Professional Development Coordinator at the University of North Carolina (UNC) Hospitals shared what their institution is doing to help ease the coordination of a successful student experience. UNC Medical Center is not unique in that they have contracts with twenty-six schools of nursing. Nine of those schools bring students traditionally to the site, while the others may use the site for non-traditional clinicals including clinics or specialty areas such as psychiatry or for the precepted experience. There is a North Carolina Board of Nursing regulation that faculty student ratios may not exceed 1:10. Gage shares, “Many of our nursing units have two nursing stations allowing us to have one nursing school cohort of students per nursing station. Each student clinical can be six hours, traditionally running from 7:00 am to 1:00 pm and from 2:00 to 8:00 pm, so two schools can be accommodated each day.” Many other schools utilize the twelve hour experience using fewer days. She also noted that they can only accommodate about 50 percent of the preceptor requests. Generally, each student does a 6 to 8 week rotation with a preceptor, based on student need and preceptor availability. To help facilitate consistent student understanding and a safe clinical experience, Gage has assisted in the development of the Triangle Clinical Consortium. The consortium currently includes eleven hospitals and ten schools of nursing in the triangle area of the state. The consortium has been able to agree on a core orientation that students complete prior to coming on-site for their clinical experiences. This orientation covers Health Insurance Portability and Accountability Act (HIPAA) and National Patient Safety Goals. The individual facility then provides a shortened, hospital-specific orientation that all students must complete prior to caring for patients. Having students complete this orientation prior to coming to any of the hospitals who are part of the consortium allows the students to focus on specific curriculum content while at any site, and allows the sites to know that the students are up-to-date on patient confidentiality and safety requirements. Additionally, the consortium has standardized the clinical request and approval process and developed a clinical request and approval form utilized within the triangle area. Gage has identified all the clinical experiences available within her facility. As schools place students, the slots are filled so that when other schools call to request clinical experiences, she has a system that immediately can identify where and when clinical experiences are available. The system is working well for them and now other hospitals throughout the state are looking to implement similar systems.
Candy Baptist, MHSM, BSN, RN, Texas Health Resources Director of Clinical Education and Academic Partnerships, helps oversee the placement of 700 nursing students each year in their fourteen hospital system. Texas Health hospitals in the Dallas-Fort Worth system range from 30 beds to 1,000 beds. Baptist works to accommodate schools within their community first as well as trying to accommodate the increasing demand for specialty care placements from across the region. In addition to supporting nursing student clinical placements, Texas Health Resources sponsors the Youth Prodigy program, introducing nursing to promising high school students, as part of their strategic plan. Each summer, twenty-five high school students begin their educational progression at a Texas Health facility as patient care assistants. They are supported in becoming nationally certified over the summer and then begin working as patient care technicians in September while in school. They then can access tuition reimbursement funds as Texas Health employees and progress to El Centro Community College to receive their associate’s degree in nursing. After that, through a basic work agreement, they can continue on to receive their bachelor’s degree in nursing through the online program at the University of Texas at Arlington.
Baptist, along with area hospitals and schools of nursing has received a grant to purchase software to help with clinical placements similar to the work Gage is doing in North Carolina. The software program shows each hospital by unit, clinical slots by shift, and the number of students that can be accommodated per unit. Schools can request spots in the clinical rotation. Clinical placements are available 24/7, however, each unit blocks quiet or rest times when students are not accommodated. Weekend rotations have opened up in the past three-years with some students and faculty preferring weekend clinicals. Baptist shared, “Using the software has helped us measure and evaluate our capacity for students and allows Texas Health to adapt more quickly to the changing needs in our community.” Texas Health has also seen an increase in the use of long-term care for student experiences in nursing fundamentals such as taking histories, performing physical assessments and passing meds, as well as the use of clinics and primary care offices for pediatric experiences. Use of these nontraditional areas has lessened the burden on some acute care units, thus giving staff a break in the clinical rotation system.
APIN initiative projects are meant to be shared and adapted
Increased enrollment in schools of nursing and the focus on the IOM report recommendation to increase the proportion of BSN-educated nurses to 80 percent by 2020 has placed undue burdens on schools of nursing and health care institutions for student clinical placements. Without innovative strategies and the continuing transformation of the traditional clinical experience, the US health care system will not be able to accommodate this increasing demand. The work being implemented by APIN through collaboration with the nine state partners has identified several promising practices for meeting these needs. These practices should be studied in other areas of the country and implemented or adapted as needed.
Oregon Consortium for Nursing Education. Information accessed from http://www.ocne.org/clinicaled.html.
Enriched Clinical Learning Environments through Partnerships (ECLEPs). Information accessed from http://www.ecleps.org/replicationmanual.html.
|by Academic Progression in Nursing National Program Office | August 26, 2013|