Building capacity for the clinical placement of nursing students

Collegian (2008) 15, 55—61

available at www.sciencedirect.com

Building capacity for the clinical placement of nursing students Tony Barnett, RN, BAppSc(AdvNsg) MEd, FRCNA, FRSA a,∗, Merylin Cross, RN, DipAppSci(Nsg Ed), BA(Hons) a, Elisabeth Jacob, RN, DipAppSci(Nsg), Grad Dip Crit Care, MEd b, Lina Shahwan-Akl, RN, PhD, MSc, BSc c, Anthony Welch, RN, RPN, Dip Counselling Communications, DipAppSci(Nsg Ed), BEd, MEd, PhD d, Alison Caldwell, RN, BN c, Robyn Berry, RN, MN e a

School of Nursing & Midwifery, Monash University, Northways Road, Churchill, 3842 Victoria, Australia Bairnsdale Regional Health Service, Australia c Division of Nursing and Midwifery, School of Health Sciences, RMIT University, Australia d School of Nursing and Midwifery, QUT, Australia e Alfred Hospital, Melbourne, Australia b

Accepted 24 September 2007

KEYWORDS Clinical education; Student placements; Collaboration; Learning community; Rural nursing

∗

Summary The current workforce crisis mandates that education providers increase the number of graduates from nursing courses. In a practice-based profession however, any growth in student numbers is constrained by the ability of clinical venues to accept students for clinical experience. Factors within the operating environment such as bed capacity, staffing mix and shortage of experienced clinicians to act as preceptors, clinical teachers, mentors or role models; limit the number of students that can be accommodated and both the quality and level of educational support provided. These factors are compounded in rural hospitals, where opportunities for placements can be also overlooked or ineffectively utilised. This paper reports on a project undertaken by a rural health service, two universities and a TAFE institute. It demonstrates that a greater number of students can be accommodated when all major stakeholders accept responsibility and agree to work together to create a learning community and find ways to overcome barriers and impediments that constrain capacity. It is concluded that the capacity of a rural hospital to accept students for placement can be increased when cancellation rates are reduced, the clinical timetable rationalised and more collaborative approaches to clinical education are implemented. © 2008 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

Corresponding author. Tel.: +61 3 99026636; fax: +61 3 99026527. E-mail address: [email protected] (T. Barnett).

1322-7696/$ — see front matter © 2008 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

doi:10.1016/j.colegn.2008.02.002

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Introduction There is a shortage of nurses in Australia with proportionately fewer nurses in rural and remote areas than in major capital cities (AIHW, 2004). This shortage has been attributed to an insufficient supply of nurses, ageing of the nursing workforce, less than optimal separation rates, increased casualisation and loss through migration (Heath, 2002; Productivity Commission, 2005). Strategies need to be adopted to increase both the size and effectiveness of the nursing workforce (Department of Human Services, 2006). One strategy to increase the size of the nursing workforce is to increase the number of graduates from universities and other education providers (Preston, 2002). However, a major factor that constrains the overall number of students that can be accepted into nursing programs is the capacity of the health care system to make available a sufficient number of appropriate clinical areas for practical experience. Reduced bed numbers, higher patient throughputs and the shortage of experienced registered nurses in both rural and metropolitan hospitals, coupled with workload factors including the sense of burden associated with having students placed on a ward (Saunders et al., 2006); limit the ability of a clinical agency to accept an increased number of students. Fewer students placed in an agency can have a direct impact on subsequent recruitment, as studies have shown that a positive clinical placement in a health care facility can increase the likelihood of a student considering that facility as a preferred place of employment upon graduation (Collins, Hilde, & Shriver, 1993; Courtney, Edwards, Smith, & Finlayson, 2002; Croxon & Maginnis, 2006; Glover, Clare, Longston, & De Bellis, 1998; Wood, 1998). The effectiveness of the workforce can be increased by better preparing students for the realities of nursing work and their transition to employment. As a practicebased discipline, nursing students should have access to well supervised clinical learning opportunities to assist them translate theory into practice. Clinical placements that provide opportunities to work with and learn directly from practicing nurses has been associated with enhanced clinical reasoning, problem solving, time management and interpersonal communication skills; enabling students to capitalise on informal or opportunistic as well as more structured learning opportunities (Rowan & Barber, 2000). Since the transfer of nursing education to the university sector in the late 1980s, clinical education was in the main, the responsibility of sessional clinical teachers appointed and employed (either directly or indirectly) by the university and often seconded from clinical agencies. Clinical teachers have sometimes been described as ‘outsiders’ (MacCormick, 1995) and can find it challenging to facilitate optimal learning when required to supervise students in unfamiliar environments (Conrick, Lucas, & Anderson, 2001; Grealish & Carroll, 1998). Workforce shortages and changes in skill mix (with fewer RNs) have made it increasingly difficult to recruit sufficient numbers of suitably qualified and experienced nurses willing to act or be intermittently released to the role. The sporadic short-term nature of clinical teacher appointments, working conditions, lack of job security and disruption to entitlements, has compounded this difficulty (Conrick et al., 2001).

T. Barnett et al. The ability of the clinical teacher to function effectively is also limited by the mandated or ‘‘rule of thumb’’ clinical teacher to student ratio of 1:8 (Grant, Ives, Raybould, & O’Shea, 1996). Few patient care areas or units can accommodate eight students at any one time, so almost invariably students are dispersed throughout an organisation (Williams, Wellard, & Bethune, 2001). This dissipates the time a clinical teacher can spend with each student and can result in more time being spent with the less capable student rather than encouraging excellence or accelerating the performance of the more able. When less than eight students are placed at a hospital, the costs of employing a full-time clinical teacher can often remain the same, especially where other student supervision arrangements are not possible or cannot be negotiated. The overall costs of a clinical placement can therefore increase significantly (Saunders et al., 2006). In smaller hospitals, it is extremely difficult to accommodate eight students on one shift at any one time and because of fewer staff, also difficult to release an experienced staff member to fulfill the clinical teacher role if one is not available externally. The clinical teacher model has therefore been acknowledged as less than ideal in a number of circumstances. Over time, greater use has been made of supplementary and other approaches to clinical education that include the appointment of clinical facilitators, preceptors or mentors (Clare et al., 2003; Phillips & Duke, 2001; Rowan & Barber, 2000; Wottan & Gonda, 2004). More flexible models of clinical education, better suited to the idiosyncrasies of rural and other smaller agencies, have been proposed in order to better access and privilege the capacity available at these sites for clinical education. Apart from increasing clinical placement capacity, several other solutions to promote skill development whilst growing student numbers have been suggested. Greater use of clinical skills or patient simulation laboratories has been advocated as a way to help improve the acquisition of clinical skills, including clinical problem-solving (DeLong & Bechtel, 1999; Dent, 2001) and to reduce dependence on clinical agencies for clinical experience. The adoption of interprofessional education (IPE) has also been encouraged as a way, not only to use existing resources more efficiently, but to promote a better understanding of the relationship between the health professions and to promote team work (Department of Human Services, 2006; Duckett, 2004; Mayne & Glascoff, 2002). The development of ‘collaborative clinical education models’, ‘service learning models’ where students alternate between academic study and paid employment and ‘dedicated education units’ (DEUs) are other examples of emerging industry education partnerships designed to facilitate and promote clinical learning (Hoffart, Diani, Connors, & Moynihan, 2006; Wottan & Gonda, 2004). Whilst these aim to promote academic—industry partnership and reality-based clinical experience, they do not address problems associated with competition for existing clinical places, nor do they necessarily expand clinical capacity. Suggestions have also been made to centralise the management of clinical placements using, for example, a web-based system that enables education providers’ needs for placements to be matched with the availability of placements across the sector (Kline & Hodges, 2002). A

Building capacity for the clinical placement of nursing students centralised process would be in marked contrast to current practice, in which each university submits a request to clinical agencies for student placements, often far in advance of knowing the precise number of places really needed. Most agencies receive (and encourage) multiple requests and then balance the capacity of the organisation to accommodate students within the contracted semester timeframe in which universities typically operate. To compound an already difficult situation, a university may later cancel a request for a placement resulting in last minute juggling to accommodate students from another institution or a net loss of the placement to the system. Not withstanding the constraints to clinical placements, education providers and health care agencies must work together to increase the number of nurses graduating without compromising students’ clinical competence and confidence or standards of care (Ironside & Valiga, 2006; MacCormick, 1995; Wottan & Gonda, 2004). In this project, we sought to find ways to increase the capacity of a health service to accommodate and support a larger number of undergraduate students in a sustainable way. Our aim was to find ways to increase both the number of students placed and the total number of student placement weeks over a 12-month period.

Setting The setting for the study was a Victorian rural health service in which there was concern about the age and fractional work profile of staff, though a keen desire to accommodate both university and TAFE student nurses in ways that would improve the recruitment of graduates and contribute to a reduction in workforce separation rates. The facility provides a range of acute, residential aged care and community services and receives regular requests for student placements from a number of education providers. Students are usually supervised and taught by a full-time clinical teacher released by the health care agency and paid for the education provider, though BN students are often preceptored in the second semester of their final year of study. The service, not unlike many others in rural areas, relies heavily on enrolled (Division 2) nurses to meet its staffing needs (AIHW, 2005). Approximately 25% of nurses employed by the hospital are enrolled nurses and, excluding the nurse in charge of the shift, it is not unusual for a general ward in the 83 bed acute care facility to roster only one RN per shift. This staffing pattern, together with the restrictions on student supervision mandated by the regulatory authority, severely limits the number of students that can be placed and supported in the hospital at any one time in a costeffective way. The proportion of part time (60%), casual (25%) and full-time (15%) staff also impact on the service’s capacity to accommodate student placements. More than half the clinical staff is employed for three shifts or less per week. Full-time staff are predominantly engaged in management or leadership positions. Inevitably therefore, almost all clinical staff who preceptor undergraduate students work part time.

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Methods This project commenced in 2005 with a genuine desire and formal commitment from two universities, an Institute of Technical And Further Education (TAFE) and a medium-sized rural health service to ‘‘do things better’’ with respect to the provision of clinical placements for nursing students. Representatives, including senior staff from these stakeholder organisations, met regularly to provide a platform for identifying and tackling placement issues as a team. By scheduling a series of meetings and workshops, opportunities were provided to identify and explore barriers that were perceived to impede the provision of quality clinical placements. The working environment created, enabled key stakeholders (clinical, academic and teaching staff) to freely discuss issues and concerns related to the clinical education of students. Through this process, the stakeholders developed a relationship of trust and moved from being competitors to collaborators. A range of strategies were investigated to improve clinical education both practically and theoretically. For example, the team considered expanding the range of facilities used by students to include GP clinics and school nurses; and also presented and discussed current models of clinical education published in the literature (Turner, Davies, Beattie, Vickerstaff, & Wilkinson, 2006). The team then sought to reconceptualise how clinical education could be reframed in more creative ways within the local rural context. As part of this process, the team also summarised placement data from the health care service for the years 2004—2006. The information gathered included the total number of nursing students (from TAFE and universities) allocated across the service, the total number of weeks used for student placements, and the total number of student placement weeks. This latter measure was regarded as the more robust indicator of capacity and was calculated simply by summing the number of complete weeks each student had been placed with the facility. For example, two students, each placed for 3 weeks, represented six student placement weeks. Data was drawn from the health service’s clinical placement roster and then verified by reviewing the financial invoices sent to the education providers. Any discrepancies in student numbers were clarified by contacting the education provider to verify actual student numbers and the length of clinical placement. Data that identified ‘‘cancellations’’ was also collated. A cancellation was defined as an initial request made for a placement that was not realised either through a ‘no show’ or a later request to reduce the number of students placed without replacement. Cancellations were assessed in terms of student numbers and also placement weeks lost. A working group was formed to re-shape the student clinical placement timetables from the three major education providers. The group identified areas in which there was competition for placements and obvious peaks and troughs. It then worked to accommodate a greater number of students more evenly, ensuring that the venue was not saturated with too many students at any one time.

58 Table 1

T. Barnett et al. Barriers to student placements

Category

Barrier/impediment

Student-related factors

Lack of suitable accommodation Transport costs (to and from the clinical venue) Negative perception of clinical venue Lack of preparation for the placement (clinical skills) Lack of enthusiasm, motivation or initiative whilst on placement

Planning for clinical placements

Peaks and troughs in numbers of students placed Lack of coordination/planning Too great a variation in length of placements Competition from other education providers and other health professional disciplines Lack of congruency in expectations (between education providers and clinical staff)

Clinical teaching and supervision

Shortage of suitably qualified and experienced preceptors and clinical teachers Escalating cost of clinical education Confusion with and lack of preparation for the role Reluctance of clinicians to engage in student teaching (sense of students as a ‘‘burden’’) Lack of reward or recognition (especially for preceptors) ‘‘Good’’ clinical staff overutilised resulting in burnout

Education providers

Variation in curriculum (and therefore different preparation of students at the same year level) Lack of consistency in documentation such as the tools/instruments used to evaluate students Underutilisation of more non-traditional settings for placements Cancellation of placements

Clinical agencies

Agencies’ interests and priorities Staff shortages Staffing mix, lack of experienced staff Resistance or hostility to students (organisational culture and climate) Part-time workforce (therefore lack of continuity in student supervision) Lack of physical infrastructure to support clinical education

Regulatory and policy environment

Regulatory authority restrictions on placements and supervision of students Placement in some areas of clinical practice sometimes mandated

Approval was sought and obtained from the relevant institutional research ethics committee for the project.

Results and discussion The project team consulted widely to identify those barriers that constrained the placement of students at the health service. These data were then grouped into six categories: student-related factors, clinical placement planning and organisation, problems directly associated with clinical teaching and supervision; as well as challenges associated with the education provider, the clinical agency and the regulatory and policy framework in which clinical education occurs (Table 1). Consistent with an action research cycle (Street, 2004), the team regularly engaged with the literature related to clinical teaching, preceptorship, mentoring, reflective practice and emerging models of clinical education including the clinical facilitator role (Clare et al., 2003; Rowan & Barber, 2000), to find practical solutions to some of the barriers

identified and to explore new ways in which to re-energise the process of clinical education. Having identified those barriers over which the team felt it had some influence and control, we prioritised our strategies and began work on the collaborative development of a • clinical calendar to achieve a more coordinated approach to planning clinical placements; • common set of clinical learning objectives and skills for students at each year level; • shared clinical evaluation tool that could be applied to all students; • common orientation program for staff involved in teaching and preceptoring students; • industry-based (virtual) on-line orientation program for all students undertaking a clinical placement at the agency. As part of this collaborative process, we found it useful to view clinical education as a process that occurs within

Building capacity for the clinical placement of nursing students Table 2

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Student placement metrics

Variable

2004

2005

2006

Change 2004/2006 (%)

Number of weeks used for clinical placements Number of students placed (a) Number of student placement weeks (b) Cancellations—–number of students (c) Cancellations—–number of student placement weeks (d) Potential capacity—–number of students placed (a + c) Potential capacity—–number of student placement weeks (b + d)

33 130 275 27 42 157 317

36 136 261 39 78 175 339

39 170 321 52 81 222 402

18 31 17 93 93 41 27

an activity or learning space (vide: Billett, 2004). Using this idea, the team began thinking about clinical education from the perspectives of the learning environment; the space in which learning takes place and both the culture and capital that is represented by this space (Crow, 2002; Johns, 2001; Walker, 2006). The people within the learning space represented a ‘‘learning community’’ which included all those clinical staff who had some contact with students. Other occupants of the learning space were seen to be visiting academics, the ward clerk, other professionals who worked in or visited the ward as well as education staff from the hospital and the university. The idea of this broader learning community further encouraged us to move away from the traditional clinical teacher model of education towards one that engaged a greater number of clinical staff as members of the teaching team and also embraced the principles of preceptorship. This was especially important given the large number of part time staff employed and the high likelihood that they would have some exposure to and responsibility for student learning. What was also important was to recognise that as adult learners, students interacted with and learnt from a wide variety of people in addition to their preceptor or clinical teacher. Although the learning from this broader learning community had rarely been formally recognised or planned for, we saw it as central to the placement experience. We therefore built this perspective into all our orientation briefings to staff and students and also into the placements schedules for students. From 2007, this included visits and short rotations to a variety of more specialist and allied health areas of the health service and greater participation in IPE opportunities. With a number of strategies in progress, we were particularly interested about the impact changes to the clinical calendar and a more coordinated approach to placement planning had on capacity. As summarised in Table 2, there was a 31% increase in the number of students placed at the facility and a 17% increase in the total number of student placement weeks over the 3-year period. The proportionate increase in student placement weeks (17%) was very similar to that for the ‘‘number of weeks used’’ across the year (18%), though the average number of placement weeks per student decreased slightly over this period from 2.1 to 1.9 weeks. From the data in Table 2, it can also be noted that an increase in the number of weeks used for placements across the year was associated with much larger increases in the ‘‘potential capacity’’ for both student numbers (an increase of 41%) and student placement weeks (27%). A reconfiguration of the clinical timetable to reduce peaks and troughs,

more flexible rostering of students and an increase the total number of weeks used for placements, was seen to have a significant effect on capacity. In our project, this was associated with greater cooperation between the three education providers and the clinical agency over clinical placement planning. Disturbingly, our results also revealed a phenomenon not previously highlighted in the clinical education literature; a large and increasing number of placement cancellations. These cancellations represented a net loss of clinical capacity ranging from 42 student clinical placement weeks in 2004 to 81 weeks in 2006. Although the composite clinical timetable increased the potential capacity of the facility to accommodate 402 student placement weeks in 2006, only 321 weeks were realised. This represented a net 20% wastage of student placement weeks (Table 2). Securing clinical placements is a major priority for education providers. It is likely that in a highly competitive environment where health care agencies want to know placement needs at least 6 months in advance, many education providers, for planning purposes and fear of ‘‘missing out,’’ submit ambit bids for placements, well in advance of knowing the actual number of students requiring placement. Predicting student progression rates or student preferences for placements at a particular clinical agency is somewhat imprecise. This factor and the reluctance of students to travel extra distances and bear the additional accommodation costs associated with this placement when other (less expensive) placement options were available, accounted for most of the cancellations recorded. Cancellations are problematic for both the health service and education providers. An agency may receive requests from a large number of providers, each seeking placement for small numbers of students. However, when more than one provider cancels their requests, the additive effect can mean a significant net reduction in the total number of students placed with the agency. This not only increases the cost of clinical education because a clinical teacher would be engaged for a smaller number of students, but also reduces opportunity for other students to benefit from the placement experience and become more informed about future employment at the agency.

Conclusion In this project, we have demonstrated that the capacity for clinical placement of nursing students can be increased when organisations collaborate to achieve a common goal.

60 Clinical capacity was increased by making changes to the clinical calendar and student rostering, accompanied by strategies that minimised the impact differences between the education providers had on staff. This included the development of a shared student clinical evaluation tool, common student clinical learning objectives and more efficient approaches to staff and student orientation. The project has generated considerable support, good will and enthusiasm from the health care agency, participating education providers, students, preceptors and clinical educators. The next phase is to investigate ways to further build the capacity of the health care agency in a sustainable way. This will mean further articulation and refinement of the clinical education model as we systematically address each of the barriers identified and, most importantly, activate strategies to reduce placement cancellation rates. Some of the barriers identified in this project may be different in other contexts such as larger hospitals or those located in major cities. There will be similarities however for those clinical agencies in which a number of educational institutions compete for student placements. We are cognisant of the fact that increasing the spread of dates, times and shifts over which students can be placed may create other tensions and barriers to success. There are clearly limits on the extent to which a health care agency can increase the number of students it can accommodate. The introduction of some relatively simple measures, if accompanied by support strategies that recognise the complexities and opportunities for clinical learning, can help build capacity and contribute to improved recruitment and retention over time. A critical condition for success however, is the ability of stakeholder organisations to work together in a genuinely collaborative way, to create a workplace culture which fosters the development of a learning community.

Acknowledgements This project was supported by funding from the Department of Human Services (Victoria) Clinical Placements Innovation Project. The authors wish to thank the Department, the Nurse Policy Branch and participating organisations for their support.

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