- Email: [email protected]
Paying for nursing student clinical placements, ethical considerations
Journal of Professional Nursing xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Journal of Professional Nursing journal homepage: www.elsevier.com/locate/jpnu
Paying for nursing student clinical placements, ethical considerations☆ Darcy Copelanda,b, a b
⁎
University of Northern Colorado, Campus Box 125, Gunter Hall, Greeley, CO 80639, USA St Anthony Hospital, 11600 W 2nd Place, Lakewood, CO 80228, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Nursing ethics Nursing education Nursing Nurse administrator
Ethics is foundational to nursing practice, including the practice of nursing education. Many schools of nursing are struggling to find adequate clinical placements for students; the root causes of this shortage are complex. Although it has not historically been the practice, some schools of nursing are considering offering clinical agencies payment for this valuable resource. Given the importance of clinical experience in nursing education, relationships between schools of nursing and clinical agencies are crucial. This paper explores some of the advantages and disadvantages that may present if schools of nursing pay clinical agencies to host nursing students, specifically pre-licensure students. Prior to establishing such relationships, schools of nursing and clinical agencies should carefully consider this decision. Questions informed by the American Nurses Association Code of Ethics and the National League for Nursing Ethical Principles for Nursing Education are provided as examples.
Introduction Nursing educators across the United States are increasingly facing a dilemma. Numerous initiatives to increase nursing student capacity arose in response to the global nursing shortage and the Institute of Medicine's call for an 80% baccalaureate prepared nursing workforce by the year 2020 (Institute of Medicine, 2011). In some cases, however, initiatives to increase nursing student capacity at colleges and universities have outpaced the availability of clinical placement sites; nursing programs were already reporting to boards of nursing that clinical opportunities for students were becoming saturated (Spector, 2009). In fact, a lack of clinical placement settings has been cited by 45% of baccalaureate programs and 50% of associate degree programs as the primary impediment to admitting qualified applicants (National League for Nursing, 2016). The American Association of Colleges of Nursing (AACN) reported that in 2017, 69,188 qualified applicants were not accepted into a nursing program as a result of lack of faculty and clinical teaching spaces (AACN, 2018). At the same time these issues are arising in educational settings, major changes are also occurring in clinical healthcare settings. The nursing workforce in the United States is losing experienced nurses. The Health Resources and Services Administration (HRSA) estimates that by 2028 roughly one-third of the nursing workforce will reach retirement age; meanwhile, the number of first-time licensure exam test takers has
more than doubled in the past decade (HRSA, 2013). Experienced nurses are needed to orient new nurses, limiting their ability to precept student nurses during clinical rotations, and newly oriented nurses are not prepared to precept students. Finally, the Centers for Medicare and Medicaid Services (CMS) Hospital Value Based Purchasing Program, tying reimbursement to performance on quality measures, has forced hospitals to improve the quality of care provided. It has also forced hospitals to adjust to CMS payment withholding which is now at 2% (CMS, 2017). As hospitals are facing increasing financial pressure, the Affordable Care Act has placed greater emphasis on improving the public health system, disease prevention, and coordination of care over time and between healthcare settings. The full effects of payment withholding, improved care coordination and preventive health have yet to be realized; among these, however, will be changes in nursing roles. Hospital based nurses are already working differently than they have in the past. Nurses currently assume roles as care coordinators, nurse navigators, and attending RNs, positions that did not exist in the United States ten years ago (Robert Wood Johnson Foundation, 2015). Efforts to allow hospital-based nurses to practice to the top of their licensure have resulted in decreased emphasis on performance of tasks and increased emphasis on delegation, care coordination, and patient/ family education (The Advisory Board, 2013). Nurses in outpatient settings are also working differently, but schools of nursing continue to
☆ ⁎
The author would like to thank Robin Chappell and Laura Rogers for reviewing this manuscript. University of Northern Colorado, Campus Box 125, Gunter Hall, Greeley, CO 80639, USA. E-mail address: [email protected].
https://doi.org/10.1016/j.profnurs.2020.01.008 Received 18 October 2019; Received in revised form 15 January 2020; Accepted 31 January 2020 8755-7223/ © 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Darcy Copeland, Journal of Professional Nursing, https://doi.org/10.1016/j.profnurs.2020.01.008
Journal of Professional Nursing xxx (xxxx) xxx–xxx
D. Copeland
rely heavily on hospital based clinical placements for pre-licensure students. A combination of inexperienced clinical preceptors, changing nursing roles, expansion of nursing education programs, and changing care delivery models has contributed to a shortage of clinical placement opportunities for students. Regardless of the causes, the shortage has forced academic programs to evaluate ways to achieve clinical outcomes. Possible solutions include the following: finding new clinical spaces and developing relationships with sites not being utilized, reconceptualizing clinical expectations, better utilization of existing clinical sites, and increased use of simulation. Relationships between schools of nursing and future employers of nursing students should be reciprocal rather than transactional and many professional organizations are emphasizing the importance of academic-clinical partnerships. The AACN and the AONE developed principles for these partnerships that call for formal relationships among senior leaders, shared goals, mutual respect and trust, shared knowledge, and commitment to one another (AACN-AONE Task Force on Academic-Practice Partnerships, 2012). If clinical agencies participated in curricular decisions and faculty members were actively engaged in clinical settings, mutual goalsetting and strategizing clinical placements might be enhanced. According to the National Council of State Boards of Nursing, students should have supervised clinical experiences with patients across the lifespan (Spector, 2009); and based on their clinical simulation study, 50% of clinical time can safely consist of simulation (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). The American Association of Colleges of Nursing (2008) and the American Organization of Nurse Executives (2004) both call for clinical experiences with actual patients without recommendations regarding what proportion of clinical experiences can be attained through simulation. What is indisputable, is that nursing students must spend time with actual patients as a fundamental component of their clinical education. Schools of nursing and clinical agencies are working on reconfiguring clinical nursing education. Meanwhile, increased competition for this valuable resource has resulted in another solution, schools of nursing paying for clinical sites or spots for students. Medicine has a long history of paying for clinical sites and/or preceptors. In the United States, nursing does not have this history and has instead relied on a history of obligation to the future of the profession, and collegiality and collaboration between schools of nursing and clinical agencies based on shared goals. In university affiliated schools of nursing the shared goal of training nurses to meet the needs of clinical settings is potentially direct; university affiliated healthcare systems might have direct mechanisms to communicate its needs to the university's academic departments. Nursing schools without direct healthcare system affiliations have established partnerships with community based clinical agencies; many of these are built on historical relationships, proximity, and even personal connections between colleagues. Affiliation agreements are easily established, but the actual relationships between schools of nursing and clinical agencies span from words on paper to true partnerships such as those established with Dedicated Education Units (Hunt, Milani, & Wilson, 2015). Since paying clinical agencies to host student nurses would be a major change in practice and philosophical shift, it deserves thoughtful deliberation.
Table 1 Nine provisions of the Code of Ethics for Nurses (ANA, 2015, p. v). 1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. 2. The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population. 3. The nurse promotes, advocates for and protects the rights, health, and safety of the patient. 4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. 5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. 6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. 7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. 8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. 9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
that funding for schools of nursing to pay clinical agencies would need to come from somewhere, either increases in fees for students, or reallocation of funds from an existing school of nursing budget. Additionally, pre-licensure nursing education is the emphasis and it is assumed that no policy constraints exist prohibiting either the clinical agency or the educational program from entering into such a financial arrangement. First, the consequences of this change in practice are examined; the potential advantages and disadvantages from the perspectives of schools of nursing, clinical agencies and students are presented in Table 2. An attempt to consider both immediate and long-term consequences was made. It is important to note that these advantages and disadvantages might be drastically exaggerated if only some schools of nursing and/or some clinical agencies participated. With potential consequences outlined, the ANA Code of Ethics (American Nurses Association, 2015) and the NLN Ethical Principles for Nursing Education (National League for Nursing, 2012) can provide guidance regarding questions to be asked prior to the establishment of such financial relationships. The questions posed are reflective of the interpretive statements and descriptions of the principles which are completely described in the original documents referenced. 1. If all other factors are equal, and school A offers payment for clinical spaces and school B does not, will the offer of payment manipulate the agency into accepting students from school A instead of school B? (ANA Code of Ethics Provision 1) 2. Does acceptance of payment from schools of nursing for clinical spaces constitute a conflict of interest based on economic self-interest? If schools of nursing pay clinical agencies for clinical spaces and/or clinical agencies accept payment for clinical spaces will that be made transparent and/or communicated to stakeholders? What amount will be deemed appropriate per student/rotation, etc.? Is the intent of payment to clinical agencies to prioritize access to those sites over other schools, to claim exclusive rights to a clinical site, to compensate preceptors, etc.? (ANA Code of Ethics Provision 2) 3. How should student access to limited clinical spaces be prioritized, for example, by ability to pay? (ANA Code of Ethics Provision 3) 4. Is the quality of education and/or the quality of care provided in an organization likely to change if schools pay for clinical spaces? Nurse educators and administrators are responsible for their decisions; does offering and/or accepting payment for clinical spaces
Should schools of nursing pay clinical agencies to host nursing students? In the United States, when questions arise regarding what ought to be done, the American Nurses Association (ANA) Code of Ethics can provide guidance. The 9 provisions outlined in the most recent version of the code (ANA, 2015) are listed in Table 1. Nursing educators might also consult the National League for Nursing's Ethical Principles for Nursing Education (National League for Nursing, 2012). These principles include: caring, integrity, diversity, and excellence. Therefore, the question is examined in relation to these two documents. It is assumed 2
Journal of Professional Nursing xxx (xxxx) xxx–xxx
D. Copeland
Table 2 Potential advantages and disadvantages of paying for/accepting payment for clinical spaces.
Advantages
Disadvantages
Schools of nursing
Clinical agencies
Students
Provide incentive to clinical agency to host nursing students
Revenue generating
Access to a range of clinical sites
Gain access to needed clinical placements
Pipeline for future nurses
Increasing costs to students may alter applicant pool
May compensate nurse preceptors for working with students Saturation of nurse preceptors would require balance between revenue generated and preceptor burnout and availability
Funds may not be available to re-allocate May create an environment of the “haves” versus the “have nots” between nursing programs
If payment is received the agency cannot claim precepting time as a community benefit for tax purposes
Size or cost of program may impact resources available to negotiate the “best” or the greatest number of clinical placements
Higher student fees or reduction in other student services May impact students' desire or ability to apply to a program Might equate program's ability to pay for clinical sites as indicative of program quality/outcomes
Inequality in the cost of clinical spaces could create a hierarchy in clinical settings in which cost of placement becomes a proxy for value, i.e., long term care sites valued less than acute care sites Paying clinical agencies may not equate to staff availability/ capability to precept students
participating in quality improvement and/or joint research projects, and inviting agency representatives to help inform curricular decisions. Offering library access, providing adjunct faculty status, and public recognition are additional incentives some nurse practitioner programs have instituted (AACN, 2015) that could perhaps be expanded to include undergraduate preceptors. The education of nursing students must be regarded as a joint exercise and these alternatives align with nursing's Code of Ethics and educational values. It is unclear if payment to a clinical agency would result in exclusivity of the use of the agency to one school or if money paid to an agency would be used to compensate individual preceptors or the agency itself. Increasing the cost of nursing education may negatively impact the diversity of the applicant pool and therefore the nursing workforce. Other situations to consider are price-setting, the role of inflation, capped payments, and whether bidding wars would be acceptable. While it may be customary for other health disciplines to pay clinical agencies to host students, in the United States it has not historically been the case in nursing, and over time, if instituted, the practice in nursing education would seem routine. If this is a direction schools of nursing and clinical agencies in the United States are considering taking, thoughtful deliberation of some of the issues raised here can help ensure that decisions are made in accordance with nursing education ethics and values.
violate any moral principles? (ANA Code of Ethics Provision 4) 5. Would students' ability to afford nursing school or their enrollment in a specific nursing school impact their ability to achieve competence? Are students, nursing educators, and nursing administrators participating in this decision-making process together? (ANA Code of Ethics Provision 5) 6. Would payment arrangements between clinical agencies and schools of nursing be made in fair, just, and equitable ways? Would schools of nursing pay all clinical agencies or only some of them? Would clinical agencies accept payment from all schools of nursing or only some of them? (ANA Code of Ethics Provision 6) 7. Would offering and/or accepting payment for clinical spaces impact access to nursing education or workforce sustainability? (ANA Code of Ethics Provision 9) 8. What should the relationship between clinical sites and schools of nursing look like? Would offering and/or accepting payment for clinical spaces shift the emphasis of interactions from relationships and shared goals to an emphasis on economic prosperity? (NLN Core Value Caring) 9. Are decisions about offering and/or accepting payment for clinical spaces made transparently, fairly, equitably, and in the best interest of nursing professional values and beliefs? (NLN Core Value Integrity) 10. Will offering and/or accepting payment for clinical spaces jeopardize the potential contributions of future nurses from diverse backgrounds? Will this practice introduce discriminatory practices of any kind? (NLN Core Value Diversity) 11. Does offering/accepting payment for clinical spaces embrace collegiality among nurse educators and administrators? What other innovative, creative strategies have been implemented to improve the education of future nurses with respect to clinical education? (NLN Core Value Excellence)
Declaration of competing interest The author has no conflicts of interest to declare. This project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References AACN-AONE Task Force on Academic-Practice Partnerships (2012). Guiding principles to academic-practice partnerships. Retrieved from https://www.aacnnursing.org/ academic-practice-partnerships/the-guiding-principles. American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from https://www. aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf. American Association of Colleges of Nursing (2015). White paper: Re-envisioning the clinical education of advanced practice registered nurses. Retrieved from https:// www.pncb.org/sites/default/files/2017-03/APRN-Clinical-Education.pdf. American Association of Colleges of Nursing (2018). Annual report. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/Annual-Reports/2018AACN-Annual-Report.pdf. American Nurses Association (2015). The code of ethics for nurses with interpretive
Conclusion While the long-term consequences of paying clinical sites are unknown, the potential disadvantages appear to outweigh the advantages, at least numerically. In order to avoid educational programs and clinical agencies coming to regard one another as mere commodities alternatives should be attempted. Faculty members can become more actively involved in clinical settings by offering professional development opportunities, particularly those that expand preceptor skills, 3
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D. Copeland
Washington DC: The National Academies Press. National League for Nursing (2012). Ethical principles for nursing education. Retrieved from http://www.nln.org/docs/default-source/default-document-library/ethicalprinciples-for-nursing-education-final-final-010312.pdf?sfvrsn=2. National League for Nursing (2016). Findings from the 2016 NLN biennial survey of schools of nursing academic year 2015–2016 executive summary. Retrieved from http://www.nln.org/docs/default-source/newsroom/nursing-education-statistics/ biennial-survey-executive-summary-(pdf).pdf?sfvrsn=0. Robert Wood Johnson Foundation (2015). Nurses take on new and expanded roles in health care. Retrieved from https://www.rwjf.org/en/library/articles-and-news/ 2015/01/nurses-take-on-new-and-expanded-roles-in-health-care.html. Spector, N. (2009). Clinical education and regulation. In N. Ard, & T. Valiga (Eds.). Clinical nursing education: Current reflections (pp. 181–198). New York: National League for Nursing Press. The Advisory Board (2013). Achieving top-of-license nursing practice. Retrieved from https://www.advisory.com/research/nursing-executive-center/studies/2013/ achieving-top-of-license-nursing-practice.
statements. Silver Spring, MD: Author. American Organization of Nurse Executives (2004). Position statement: Pre-licensure supervised clinical instruction. (Author). Centers for Medicare and Medicaid Services (2017). Hospital value based purchasing. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ ICN907664.pdf. Hayden, J., Smiley, R., Alexander, M., Kardong-Edgren, S., & Jeffries, P. (2014). The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2 supplement), s3–s64. Health Resources and Services Administration (2013). The U.S. nursing workforce: Trends in supply and education. Author, Washington DC. Retrieved from https:// bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/ nursingworkforcetrendsoct2013.pdf. Hunt, D., MIlani, M., & Wilson, S. (2015). Dedicated education units: An innovative model for clinical education. American Nurse Today, 10(5), 46–49. Institute of Medicine (2011). The future of nursing: Leading change, advancing health.
4
Contents lists available at ScienceDirect
Journal of Professional Nursing journal homepage: www.elsevier.com/locate/jpnu
Paying for nursing student clinical placements, ethical considerations☆ Darcy Copelanda,b, a b
⁎
University of Northern Colorado, Campus Box 125, Gunter Hall, Greeley, CO 80639, USA St Anthony Hospital, 11600 W 2nd Place, Lakewood, CO 80228, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Nursing ethics Nursing education Nursing Nurse administrator
Ethics is foundational to nursing practice, including the practice of nursing education. Many schools of nursing are struggling to find adequate clinical placements for students; the root causes of this shortage are complex. Although it has not historically been the practice, some schools of nursing are considering offering clinical agencies payment for this valuable resource. Given the importance of clinical experience in nursing education, relationships between schools of nursing and clinical agencies are crucial. This paper explores some of the advantages and disadvantages that may present if schools of nursing pay clinical agencies to host nursing students, specifically pre-licensure students. Prior to establishing such relationships, schools of nursing and clinical agencies should carefully consider this decision. Questions informed by the American Nurses Association Code of Ethics and the National League for Nursing Ethical Principles for Nursing Education are provided as examples.
Introduction Nursing educators across the United States are increasingly facing a dilemma. Numerous initiatives to increase nursing student capacity arose in response to the global nursing shortage and the Institute of Medicine's call for an 80% baccalaureate prepared nursing workforce by the year 2020 (Institute of Medicine, 2011). In some cases, however, initiatives to increase nursing student capacity at colleges and universities have outpaced the availability of clinical placement sites; nursing programs were already reporting to boards of nursing that clinical opportunities for students were becoming saturated (Spector, 2009). In fact, a lack of clinical placement settings has been cited by 45% of baccalaureate programs and 50% of associate degree programs as the primary impediment to admitting qualified applicants (National League for Nursing, 2016). The American Association of Colleges of Nursing (AACN) reported that in 2017, 69,188 qualified applicants were not accepted into a nursing program as a result of lack of faculty and clinical teaching spaces (AACN, 2018). At the same time these issues are arising in educational settings, major changes are also occurring in clinical healthcare settings. The nursing workforce in the United States is losing experienced nurses. The Health Resources and Services Administration (HRSA) estimates that by 2028 roughly one-third of the nursing workforce will reach retirement age; meanwhile, the number of first-time licensure exam test takers has
more than doubled in the past decade (HRSA, 2013). Experienced nurses are needed to orient new nurses, limiting their ability to precept student nurses during clinical rotations, and newly oriented nurses are not prepared to precept students. Finally, the Centers for Medicare and Medicaid Services (CMS) Hospital Value Based Purchasing Program, tying reimbursement to performance on quality measures, has forced hospitals to improve the quality of care provided. It has also forced hospitals to adjust to CMS payment withholding which is now at 2% (CMS, 2017). As hospitals are facing increasing financial pressure, the Affordable Care Act has placed greater emphasis on improving the public health system, disease prevention, and coordination of care over time and between healthcare settings. The full effects of payment withholding, improved care coordination and preventive health have yet to be realized; among these, however, will be changes in nursing roles. Hospital based nurses are already working differently than they have in the past. Nurses currently assume roles as care coordinators, nurse navigators, and attending RNs, positions that did not exist in the United States ten years ago (Robert Wood Johnson Foundation, 2015). Efforts to allow hospital-based nurses to practice to the top of their licensure have resulted in decreased emphasis on performance of tasks and increased emphasis on delegation, care coordination, and patient/ family education (The Advisory Board, 2013). Nurses in outpatient settings are also working differently, but schools of nursing continue to
☆ ⁎
The author would like to thank Robin Chappell and Laura Rogers for reviewing this manuscript. University of Northern Colorado, Campus Box 125, Gunter Hall, Greeley, CO 80639, USA. E-mail address: [email protected].
https://doi.org/10.1016/j.profnurs.2020.01.008 Received 18 October 2019; Received in revised form 15 January 2020; Accepted 31 January 2020 8755-7223/ © 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Darcy Copeland, Journal of Professional Nursing, https://doi.org/10.1016/j.profnurs.2020.01.008
Journal of Professional Nursing xxx (xxxx) xxx–xxx
D. Copeland
rely heavily on hospital based clinical placements for pre-licensure students. A combination of inexperienced clinical preceptors, changing nursing roles, expansion of nursing education programs, and changing care delivery models has contributed to a shortage of clinical placement opportunities for students. Regardless of the causes, the shortage has forced academic programs to evaluate ways to achieve clinical outcomes. Possible solutions include the following: finding new clinical spaces and developing relationships with sites not being utilized, reconceptualizing clinical expectations, better utilization of existing clinical sites, and increased use of simulation. Relationships between schools of nursing and future employers of nursing students should be reciprocal rather than transactional and many professional organizations are emphasizing the importance of academic-clinical partnerships. The AACN and the AONE developed principles for these partnerships that call for formal relationships among senior leaders, shared goals, mutual respect and trust, shared knowledge, and commitment to one another (AACN-AONE Task Force on Academic-Practice Partnerships, 2012). If clinical agencies participated in curricular decisions and faculty members were actively engaged in clinical settings, mutual goalsetting and strategizing clinical placements might be enhanced. According to the National Council of State Boards of Nursing, students should have supervised clinical experiences with patients across the lifespan (Spector, 2009); and based on their clinical simulation study, 50% of clinical time can safely consist of simulation (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). The American Association of Colleges of Nursing (2008) and the American Organization of Nurse Executives (2004) both call for clinical experiences with actual patients without recommendations regarding what proportion of clinical experiences can be attained through simulation. What is indisputable, is that nursing students must spend time with actual patients as a fundamental component of their clinical education. Schools of nursing and clinical agencies are working on reconfiguring clinical nursing education. Meanwhile, increased competition for this valuable resource has resulted in another solution, schools of nursing paying for clinical sites or spots for students. Medicine has a long history of paying for clinical sites and/or preceptors. In the United States, nursing does not have this history and has instead relied on a history of obligation to the future of the profession, and collegiality and collaboration between schools of nursing and clinical agencies based on shared goals. In university affiliated schools of nursing the shared goal of training nurses to meet the needs of clinical settings is potentially direct; university affiliated healthcare systems might have direct mechanisms to communicate its needs to the university's academic departments. Nursing schools without direct healthcare system affiliations have established partnerships with community based clinical agencies; many of these are built on historical relationships, proximity, and even personal connections between colleagues. Affiliation agreements are easily established, but the actual relationships between schools of nursing and clinical agencies span from words on paper to true partnerships such as those established with Dedicated Education Units (Hunt, Milani, & Wilson, 2015). Since paying clinical agencies to host student nurses would be a major change in practice and philosophical shift, it deserves thoughtful deliberation.
Table 1 Nine provisions of the Code of Ethics for Nurses (ANA, 2015, p. v). 1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. 2. The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population. 3. The nurse promotes, advocates for and protects the rights, health, and safety of the patient. 4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. 5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. 6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. 7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. 8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. 9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
that funding for schools of nursing to pay clinical agencies would need to come from somewhere, either increases in fees for students, or reallocation of funds from an existing school of nursing budget. Additionally, pre-licensure nursing education is the emphasis and it is assumed that no policy constraints exist prohibiting either the clinical agency or the educational program from entering into such a financial arrangement. First, the consequences of this change in practice are examined; the potential advantages and disadvantages from the perspectives of schools of nursing, clinical agencies and students are presented in Table 2. An attempt to consider both immediate and long-term consequences was made. It is important to note that these advantages and disadvantages might be drastically exaggerated if only some schools of nursing and/or some clinical agencies participated. With potential consequences outlined, the ANA Code of Ethics (American Nurses Association, 2015) and the NLN Ethical Principles for Nursing Education (National League for Nursing, 2012) can provide guidance regarding questions to be asked prior to the establishment of such financial relationships. The questions posed are reflective of the interpretive statements and descriptions of the principles which are completely described in the original documents referenced. 1. If all other factors are equal, and school A offers payment for clinical spaces and school B does not, will the offer of payment manipulate the agency into accepting students from school A instead of school B? (ANA Code of Ethics Provision 1) 2. Does acceptance of payment from schools of nursing for clinical spaces constitute a conflict of interest based on economic self-interest? If schools of nursing pay clinical agencies for clinical spaces and/or clinical agencies accept payment for clinical spaces will that be made transparent and/or communicated to stakeholders? What amount will be deemed appropriate per student/rotation, etc.? Is the intent of payment to clinical agencies to prioritize access to those sites over other schools, to claim exclusive rights to a clinical site, to compensate preceptors, etc.? (ANA Code of Ethics Provision 2) 3. How should student access to limited clinical spaces be prioritized, for example, by ability to pay? (ANA Code of Ethics Provision 3) 4. Is the quality of education and/or the quality of care provided in an organization likely to change if schools pay for clinical spaces? Nurse educators and administrators are responsible for their decisions; does offering and/or accepting payment for clinical spaces
Should schools of nursing pay clinical agencies to host nursing students? In the United States, when questions arise regarding what ought to be done, the American Nurses Association (ANA) Code of Ethics can provide guidance. The 9 provisions outlined in the most recent version of the code (ANA, 2015) are listed in Table 1. Nursing educators might also consult the National League for Nursing's Ethical Principles for Nursing Education (National League for Nursing, 2012). These principles include: caring, integrity, diversity, and excellence. Therefore, the question is examined in relation to these two documents. It is assumed 2
Journal of Professional Nursing xxx (xxxx) xxx–xxx
D. Copeland
Table 2 Potential advantages and disadvantages of paying for/accepting payment for clinical spaces.
Advantages
Disadvantages
Schools of nursing
Clinical agencies
Students
Provide incentive to clinical agency to host nursing students
Revenue generating
Access to a range of clinical sites
Gain access to needed clinical placements
Pipeline for future nurses
Increasing costs to students may alter applicant pool
May compensate nurse preceptors for working with students Saturation of nurse preceptors would require balance between revenue generated and preceptor burnout and availability
Funds may not be available to re-allocate May create an environment of the “haves” versus the “have nots” between nursing programs
If payment is received the agency cannot claim precepting time as a community benefit for tax purposes
Size or cost of program may impact resources available to negotiate the “best” or the greatest number of clinical placements
Higher student fees or reduction in other student services May impact students' desire or ability to apply to a program Might equate program's ability to pay for clinical sites as indicative of program quality/outcomes
Inequality in the cost of clinical spaces could create a hierarchy in clinical settings in which cost of placement becomes a proxy for value, i.e., long term care sites valued less than acute care sites Paying clinical agencies may not equate to staff availability/ capability to precept students
participating in quality improvement and/or joint research projects, and inviting agency representatives to help inform curricular decisions. Offering library access, providing adjunct faculty status, and public recognition are additional incentives some nurse practitioner programs have instituted (AACN, 2015) that could perhaps be expanded to include undergraduate preceptors. The education of nursing students must be regarded as a joint exercise and these alternatives align with nursing's Code of Ethics and educational values. It is unclear if payment to a clinical agency would result in exclusivity of the use of the agency to one school or if money paid to an agency would be used to compensate individual preceptors or the agency itself. Increasing the cost of nursing education may negatively impact the diversity of the applicant pool and therefore the nursing workforce. Other situations to consider are price-setting, the role of inflation, capped payments, and whether bidding wars would be acceptable. While it may be customary for other health disciplines to pay clinical agencies to host students, in the United States it has not historically been the case in nursing, and over time, if instituted, the practice in nursing education would seem routine. If this is a direction schools of nursing and clinical agencies in the United States are considering taking, thoughtful deliberation of some of the issues raised here can help ensure that decisions are made in accordance with nursing education ethics and values.
violate any moral principles? (ANA Code of Ethics Provision 4) 5. Would students' ability to afford nursing school or their enrollment in a specific nursing school impact their ability to achieve competence? Are students, nursing educators, and nursing administrators participating in this decision-making process together? (ANA Code of Ethics Provision 5) 6. Would payment arrangements between clinical agencies and schools of nursing be made in fair, just, and equitable ways? Would schools of nursing pay all clinical agencies or only some of them? Would clinical agencies accept payment from all schools of nursing or only some of them? (ANA Code of Ethics Provision 6) 7. Would offering and/or accepting payment for clinical spaces impact access to nursing education or workforce sustainability? (ANA Code of Ethics Provision 9) 8. What should the relationship between clinical sites and schools of nursing look like? Would offering and/or accepting payment for clinical spaces shift the emphasis of interactions from relationships and shared goals to an emphasis on economic prosperity? (NLN Core Value Caring) 9. Are decisions about offering and/or accepting payment for clinical spaces made transparently, fairly, equitably, and in the best interest of nursing professional values and beliefs? (NLN Core Value Integrity) 10. Will offering and/or accepting payment for clinical spaces jeopardize the potential contributions of future nurses from diverse backgrounds? Will this practice introduce discriminatory practices of any kind? (NLN Core Value Diversity) 11. Does offering/accepting payment for clinical spaces embrace collegiality among nurse educators and administrators? What other innovative, creative strategies have been implemented to improve the education of future nurses with respect to clinical education? (NLN Core Value Excellence)
Declaration of competing interest The author has no conflicts of interest to declare. This project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References AACN-AONE Task Force on Academic-Practice Partnerships (2012). Guiding principles to academic-practice partnerships. Retrieved from https://www.aacnnursing.org/ academic-practice-partnerships/the-guiding-principles. American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from https://www. aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf. American Association of Colleges of Nursing (2015). White paper: Re-envisioning the clinical education of advanced practice registered nurses. Retrieved from https:// www.pncb.org/sites/default/files/2017-03/APRN-Clinical-Education.pdf. American Association of Colleges of Nursing (2018). Annual report. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/Annual-Reports/2018AACN-Annual-Report.pdf. American Nurses Association (2015). The code of ethics for nurses with interpretive
Conclusion While the long-term consequences of paying clinical sites are unknown, the potential disadvantages appear to outweigh the advantages, at least numerically. In order to avoid educational programs and clinical agencies coming to regard one another as mere commodities alternatives should be attempted. Faculty members can become more actively involved in clinical settings by offering professional development opportunities, particularly those that expand preceptor skills, 3
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