Improving the clinical experience of working with undergraduate nursing students; a team approach.
Submitted by Randi Flexner, DNP, APN, FNP-BC,RN
Clinical practice hours are a requirement in nursing school curricula. As the need for increased nurses continues to rise to meet healthcare demands, there is greater competition and limitations for nursing programs to secure available clinical practice sites. Whether traditional hospital units or outpatient community settings, the strategic goal is to establish reliable and meaningful shared experiences between clinical affiliates and nursing academia having sustainability of the clinical-school contracts year after year.
Staff nurses often have mixed emotions with the additional responsibility and assignment of students during their scheduled work shift. Why is this? After-all, they were student nurses at one time too. While some staff nurses enjoy the opportunity to educate and mentor upcoming new nurses and potential colleagues, other nurses feel it is an invasion and nuisance to their work day. The patient’s also have mixed emotions. Some patients appreciate the extra hands on and personal attention to their morning care, assistance with meals, and someone to talk to when alone in their room. Other patient’s express concern of a novice involved in their care and do not want to be a practice subject for the student.
Student nurses are the future nursing workforce. The faculty is the liaison between the two worlds. Who has the greatest responsibility to implement change and promote the student’s clinical learning success? How can we improve the experience between all parties involved?
The key is team work and systems approach. The priority focus areas are communication, quality, safety, and accountability. Designated education units (DEU) have become the optimal clinical learning experience with high levels of satisfaction for both nurses and students(Smyth et al., 2015). The DEU is a joint collaboration between nursing education and clinical practice. The DEU model bridges the gap of student learning.by elevating the role of the staff nurse to clinical instructor and allows more one-on-one clinical instruction for the student compared to the traditional norm of 1 faculty instructor dividing time between 8 students in the clinical area (Glazer et al., 2011, Walker et al., 2012, Jeffries et al. (2012), Smyer et al., 2015). The relationship between the staff nurse as the clinical instructor and student is vital to learning. The student identifies with their future role as a nurse, via observing the professional behavior and expertise skills of their mentor. This positive relationship is key to the DEU model (Smyer et al, 2015).
Although DEUs are ideal in fostering enhanced student clinical practice opportunities and transition to practice, there are many barriers to implementing a DEU. It involves “buy in” from the hospital affiliate organization, takes time, commitment, planning, and financial resources to create, prepare, and sustain a DEU (Walker et al, 2012, Dapremeon & Lee, 2013). Although ideal, Smyer et al (2015) found that despite greater satisfaction with a DEU model compared to traditional clinical models, there was no significant difference in academic outcome measures. This supports the author’s recommendations that there are strategies within a traditional student clinical experience in how to improve student and staff nurse relationships in any clinical practice setting regardless of becoming a formalized DEU.
Quality and Safety: Everyone has a role and responsibility.
In response to the formerly known Institute to Medicine (IOM), now known as the National Academy of Medicine (NAM) report (2000, 2003, 2011) of building a safer health system including; charging the nursing profession to increase the future number of nurses, increase their scope of practice, and increase the level of education to meet the growing population needs, Quality and Safety Education in Nursing (QSEN) was created. QSEN developed six competencies to be threaded through out nursing curricula and clinical practice settings: 1) Patient Centered Care 2) Informatics 3) Quality Improvement 4) Evidence-based Practice 5) Teamwork & Collaboration & 6)Safety. It is recommended that these competencies be threaded through out the nursing education curricula and the key is systems thinking (Dolansky & Moore, 2013, Sherwood & Zomorodi, 2014, QSEN, 2010, 2016).
Simulation exercises through-out the nursing curricula assist in preparing students not only in technical skills, but in critical reasoning, confidence, teamwork, and communication (Bland, Topping, & Wood, 2011, Berragan, 2011, Rickets, 2011, Meakin et al, 2013) Students should become proficient in their skills lab before the application in clinical practice settings. To facilitate a beneficial staff nurse - student nurse experience, faculty must communicate with the staff what skills the student is currently proficient in and what areas the student still needs to practice. This information eliminates misconception, frustration, and faulty expectations. When the staff nurse is informed and involved as a team member along with faculty rather than parallel, it benefits everyone. The staff nurse can assist the student in reaching the learning objectives, seek out those learning opportunities, and mentor the student to complete new tasks in clinical.
Faculty and staff nurses both bring specific expertise to the student learning process and respectfully should acknowledge these attributes. Faculty may have a higher academic title, but the staff nurse is often more up to date to recent evidence based practice changes, and clinical institutional policy changes. More staff nurses are actively becoming nationally certified in their clinical areas of expertise (Academy of Medical Surgical Nursing, 2016).
In comparing a DEU and traditional clinical unit, DEUs are unique in that the staff and faculty have previously constructed the objectives and clinical outcomes together in advance as a team. In traditional clinical units, the staff nurse rarely and randomly is abreast of the students’ abilities and clinical objectives. Communication and collaboration between faculty and clinical staff nurses is the key to level the playing field and attaining similar results. Enhancing communication in clinical nursing education is key and having the students witness shared communication in clinical practice environments is paramount (Puppe & Neal, 2014). Faculty specifically and consistently should share weekly information with the staff. On traditional clinical units, the faculty student ratio is 1:8. In reality, the student spends more of their time 1:1 with the staff nurse, reemphasizing the importance of the staff nurse being well informed of the clinical objectives and expectations. This is key to patient safety on the clinical unit, especially with regards to medication administration. The faculty should clearly post each week at the nursing stations the student assignment and objectives for the day Appendix A Communication Form-Assignment.
Aim - A shared responsibility between the academic system, hospital/clinical affiliate, and individual student towards a model for quality improvement and satisfaction on the clinical practice unit
Goal - Nursing school faculty, students, and clinical unit affiliates can improve quality, safety, attitude, and relationships for a more positive and beneficial mentoring-student clinical experience.
Stages of Implementation Overview
- Contracts are formed between the nursing school and hospital affiliates, outlining the number of students per unit, day of week, and hours, immunization requirements, basic cardiopulmonary resuscitation, and malpractice insurance.
- The nursing program has the responsibility to provide the nursing foundation courses necessary before and/ or simultaneously to the students in theory and practice labs. Simulation activities prepare the student prior to clinical practice setting. Students must successfully pass lab tests in the following but not limited to: 1) medication delivery 2) intravenous monitoring 3) personal hygiene care 4) mobility and transfer 5) foley catheter insertion and care 6) nasogastric tubes and other feeding systems 7) osmotic care 8) tracheostomy care and oxygenation 9) wound care 10) maintaining sterile fields, etc. Table 1 Clinical Skills Competencies
- The student has the responsible to pass the theory and lab tests to safely tend to patients, follow guidelines, and collaborate with clinical faculty and staff accordingly
- Clinical faculty should be experienced in area of practice, current in licensure, up to date evidence practice, and completion of affiliate orientation to system policies regarding students, assigned clinical practice unit, and electronic health record system prior to student clinical.
- Clinical faculty should further familiarize and introduce themselves to key clinical affiliate representatives ie: education coordinator, IT coordinator, unit manager, charge nurse, infectious disease nurse coordinator. Patient selection should be discussed with the unit manager and process determined prior to the students’ arrival. Communication between the clinical faculty and unit manager is key to a successful clinical experience, as the unit manager is the liaison between the school faculty’s student learning objectives and affiliate staff nurse assisting in meeting those objectives. Clinical faculty should set up in advance reserved conference space to hold pre and/or post conference each week for debriefing, reflection, and further education.
- Faculty should further be conscientious in patient assignment that students are dispersed between staff nurses in order not to overload a single nurse. Faculty should also communicate with preceptors in advance in regards to the student’s final evaluation process. Permit the staff nurse to include their evaluation comments as they are with the student more. Empower the staff nurse as a collaborator in the student evaluation process.
Strategies to improve staff nurse satisfaction
How can staff nurses become more engaged? The unit manager and faculty together can assist in this process.
Unit manager contribution
- Identify staff nurses who voluntarily enjoy having students
- Review expectations and objectives in advance with staff at a staff meeting prior to clinical group arriving
- Provide student clinical day of week to staff to provide opportunity in their own work scheduling decisions
- Recognize union labor laws prevent individual incentives to preceptors, however recognition at staff meetings or other small identifiers for preceptor excellence should be encouraged and included in performance evaluations.
- Initiate a task force committee to become a designated educational unit and partnership with school of nursing, seek staff interest, and system buy in for support.
- Build will for change, close gap between what is and what could be, attract additional innovators to improve quality and safety in the student clinical experience.
- Identify stakeholders for Quality improvement; including patient, family, provider, administrators for system change
- Encourage staff nurses to assume leadership roles and committee roles for the unit
- Collaborate with staff nurse as a team with student and patient at the center. Do not work parallel.
- Communicate with staff nurse student learning objectives and student’s responsibilities for the shift. Recognize that miscommunication or lack of communication increases patient safety risks.
- Solicit staff nurse’s professional feedback and evaluation of student’s performance, include in evaluation process.
- Provide staff nurse a list of students baseline competencies and areas of needed improvement
- Communicate with staff nurse desired learning opportunities for student to participate in
- Offer staff nurse opportunity to become an adjunct clinical faculty if interested to formally become part of the school’s teaching faculty
- Invite staff to continual education programs associated with school or local organizations
- Come prepared to clinical
- Professional demeanor
- Consistent communication to faculty and assigned nurse
- Documentation recorded and communicated to staff nurse
- Patient advocate, therapeutic communication, and education
- Teamwork, assist classmates and other staff as needed
- Assist in discharge process
- Implement safety and quality in all aspects of care
- Abide by system’s policy and school policy regarding student role and limitations in patient care
DEU are ideal models to enhance the nursing student’s clinical experience and staff nurse’s preceptor role. However, much time, attention, and financial commitment is required in creating and implementing a DEU. Traditional clinical units, whether in patient or community based are still the mainstream of many nursing clinical settings. The success of a clinical experience is based more on teamwork and organization than designation. Together, faculty, students, and clinical affiliates can improve the student-staff nurse mentor experience with greater communication, shared respect, and participation in the process. How is this relevant to the future of clinical practice? Regardless of the clinical location or specialty, all parties involved, including the patient and patient’s family as prime recipients, can benefit from a clinical environment which demonstrates quality and safety skills, collaboration, communication, and positive attitudes with the process of molding future nurses. After all, the student nurse will become the nurse in the near future, serving the patient, working alongside a fellow nurse colleague, and one day “paying it forward” as a student nurse preceptor in the future. A successful team should have the vision, collectively establish the path to meet objectives, provide the example that others can follow, and which many may benefit.