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This pilot project describes the use of the Revised Professional Practice Environment scale to identify inpatient acute care units suitable for implementation of dedicated education units. Staff development professionals may use the suggested model to assess and plan phases of a dedicated education unit.
The 2010 American Association of Colleges of Nursing (AACN) survey of "Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing" reported significant growth in enrollments to baccalaureate nursing programs. From 2009 to 2010, there was an 8.6% increase in qualified applicants. However, data also showed that from 565 nursing programs surveyed, 52,115 (36%) qualified applicants were turned away from entry-level nursing programs. Primary barriers to accommodating the demand were cited as shortages of faculty and clinical sites (AACN, 2010). To gain access to clinical sites and clinical faculty to teach growing numbers of nursing students in the clinical setting, an innovative model for clinical education has emerged. Many schools of nursing (SONs) are forming collaborative relationships with healthcare agencies to establish clinical units devoted to the education of nursing students. These clinical sites are referred to as dedicated education units (DEUs). Although models may differ slightly between programs, the basic premise of the DEU is that staff nurses serve as the students' clinical instructors. Faculty from the student's SON make rounds at the agency to support, coach, and mentor staff and students and to ensure that overall learning outcomes of each clinical course are achieved (Moscato, Miller, Longsdon, Weinberg, & Chorpenning, 2007).
National organizations that support safety and quality in health care, including the Institute of Medicine and the Robert Wood Johnson Foundation, are encouraging the proliferation of DEUs (Institute of Medicine, 2003, 2010). In response, SONs and healthcare agencies are establishing DEUs and are reporting positive outcomes for both service and academia (Edgecombe, Wotton, Gonda, & Mason, 1999; Gonda, Wotton, Edgecombe, & Mason, 1999; Haas et al., 2004; Henderson, Heel, Twentyman, & Lloyd, 2006; Miller, 2005; Moscato et al., 2007; Ranse & Grealish, 2007).
The SONs that establish DEUs typically form collaborative agreements with units in clinical agencies that have, historically and anecdotally, been "good sites" for nursing students. However, to promote the likelihood of achieving desired outcomes for the agency and the SON, SONs and agencies should be thoughtful and deliberate when selecting these educational environments. There is paucity in the literature regarding methods by which to select a unit that is "ready" to be a DEU whose culture and staff support a professional practice and learning environment. Identification of a reliable instrument to measure unit readiness to be a DEU will contribute to appropriate DEU selection. The purpose of this project was to pilot test an instrument, the Revised Professional Practice Environment (RPPE) scale (Ives Erickson, Duffy, Ditomassi, & Jones, 2009), which may demonstrate efficacy in the DEU selection process of clinical sites for baccalaureate nursing students. The RPPE scale results can assist in the development of a comprehensive orientation program for DEU staff and clinical instructors. Nurse educators in staff development, unit-based nurse educators, and staff nurses have an important role in preparing for and sustaining a successful DEU.
Nursing has long recognized that to master both the empirics and the art of the nursing discipline, it is essential that students engage in practical as well as theoretical learning. According to the AACN's 2008 document "Essential Clinical Resources for Nursing's Academic Mission," "[horizontal ellipsis]learning to perform as a 'nurse' is predicated on engaging in experiential learning with actual patients" (p. i). Examples of the opportunities that clinical site-based learning provides to students are the provision of care along a continuum; encounters with interdisciplinary teams; diverse environments, communities, and populations; occasions to practice appropriate delegation and management skills; exposure to technologies and managing patient data using electronic medical records; and participation in research (AACN, 2008). An important caveat to the development of core nursing competencies is they are to be learned in an environment where altruism, autonomy, human dignity, integrity, and social justice are personal values and behaviors exemplified by the professional nurses who act as role models and precept or mentor the students (AACN, 2008).
Knowles (1975) defined self-directed learning (SDL) as "[horizontal ellipsis]a process in which individuals take the initiative, with or without the help of others, in diagnosing their needs, formulating learning goals, identifying human material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes" (p.18). Self-directed learning is similar to experiential learning but requires the important component of initiative on the part of the learner.
Self-directed learning is an educational concept that has received renewed attention in recent years, particularly in the context of higher education and nursing education. It is suggested that SDL increases students' confidence and their ability to learn in dynamic and challenging educational and work environments. Further, SDL allows learning to progress beyond knowledge acquisition to a memorable and motivating experience (Levett-Jones, 2005). According to Levett-Jones (2005), a self-directed approach to learning increases not only nursing students' confidence in their own ability but also their capacity to learn in novel situations. Self-directed learning is an essential means by which nursing students develop independent learning skills and a commitment to lifelong learning. Dedicated education units are the ideal settings in which SDL opportunities for nursing students may exist (Gonda et al., 1999; Miller, 2005).
Donabedian's (1980) universally accepted model of structure-process-outcome provides a useful framework to identify and manipulate variables and measure the outcomes of a DEU (see Figure 1).
Benner, Sutphen, Leonard, and Day (2010) noted that clinical placements are often overcrowded environments where students report experiencing "uncivil, if not hostile, behavior from staff nurses" (p. 226). The authors urged employers to improve work environments, focusing on patient and nurse safety, workload, and implementing a zero tolerance for uncivil behavior among healthcare team members, including those in training. Another recommendation to improve nursing education was to provide ongoing opportunities for staff nurses to learn how to teach and coach students (Benner et al., 2010). Having staff function as clinical instructors in the DEU environment allows this opportunity.
Qualitative research examining nursing students' perceptions of traditional clinical experiences suggested that many nursing students find clinical experiences to be anxiety provoking, and they often feel vulnerable in the clinical environments for a variety of reasons (Chan, 2003). Students found it challenging to learn how to navigate new clinical environments and determine how things are done as they frequently rotated to new facilities or units (Grindel, Patsdaughter, Medici, & Babington, 2003). Students also reported that once they learned where things are on a unit and how things were done and were finally feeling accepted by the clinical site staff, it was time to move on (Beck, 1993; Leners, Sitzman, & Hessler, 2006; Levett-Jones, 2005; Pearcey & Elliot, 2004).
The significance of workplace culture in determining the success of the learning experience was revealed in research conducted by Hart and Rotem (1994). Students described the importance of positive relationships with unit staff, as they enabled the students to feel a sense of belonging. A receptive environment from staff increased students' self-esteem and decreased their anxiety level over the course of the clinical placement (Andrews et al., 2006; Beck, 1993; Chesser-Smyth, 2005; Newton, Billet, & Ockerby, 2009; Pearcey & Elliott, 2004). For many students, relationships with staff were of more significance to their learning than was the relationship with the clinical supervisor (Hart & Rotem, 1994).
Quantifying students' clinical experience was described in a study by Smedley and Morey (2010), who used Chan's (2003) Clinical Learning Environment Inventory to assess senior baccalaureate nursing students' perceptions of the characteristics of the clinical learning environment. When the researchers compared the Clinical Learning Environment Inventory findings with those of other SONs, they found that student nurses of different ages, studying in different contexts and different countries, had very similar perceptions of the relative importance of the characteristics of the clinical learning environment. Consistent with qualitative studies, quantitative findings indicated the need for further development of positive relationships between clinical staff and students and that students wished to become valued members of the clinical community (Smedley & Morey, 2010).
Few researchers have examined the impact of student nurses on the clinical site and on its nursing staff and other professionals. However, Leners et al. (2006) examined nursing education issues associated with student clinical placements from the staff nurse perspective. Key themes that emerged included the belief that staff nurses were inconsistently prepared to precept students, that there were too many students and too many schools, and that there were too many student levels, such as licensed practical nurse students, associate degree students, and registered nurse students, with differing skill levels and learning needs to track. Staff nurses expressed a desire to be more engaged with the students and would appreciate tokens of gratitude. These nurses stated that clinical education is like an assembly line with too many students, too often. The researchers also revealed that staff desired more of a sense that "we are in this together" (Leners et al., 2006, p. 8). Research by Hawthorn (2006) revealed that staff nurses believed that nursing education and service should establish more effective communication between staff nurses and faculty/students by providing the staff nurses with specific job descriptions and role expectations while working with students. Staff nurses also wanted to be informed of the student's learning objectives and competencies. Most importantly, the staff nurses wanted to be educated about their legal liability and responsibilities when working with students (Hawthorn, 2006).
A recent ethnographic study collected observation and focus group data from 29 nurses in Sweden who were staff nurse preceptors for nursing students over a 10-month period. The preceptors described conditions necessary for precepting and reported that nurses "value the rewards and benefits of personal satisfaction, personal growth, and competence development" over the material benefits of precepting (Carlson, Pilhammar, & Wann-Hansson, 2009, p. 439).
Dedicated education units attempt to remedy the shortcomings of the traditional undergraduate clinical experiences highlighted in the nursing research. Nursing students and clinical site staff agreed that it is a much better experience for the students and agency staff when the clinical instructor is also an agency employee who is familiar with routine unit operations (Hart & Rotem, 1994). Rebeschi and Aronson (2009) found that the precepted experience socialized the student to the role of the nurse and made the student feel more like a "real nurse" (p. 8). Further, it has been reported that nurses who work in a DEU experience many benefits such as higher satisfaction levels, increased unit retention, returning to school themselves, and taking pride in the learning and professional growth of the students (Grindel et al., 2003; Hawthorn, 2006; Moscato et al., 2007).
Discussion regarding drawbacks to DEUs is limited at this time because DEUs are fairly new models of clinical education in the United States (Moscato et al., 2007). There currently are two studies funded by the Robert Wood Johnson Foundation evaluating a number of DEU outcomes, including teaching capacity, faculty productivity and work satisfaction, and institutional costs (http://www.evaluatinginnovationsinnursing.org/our-grantees/).
This project was a descriptive study wherein the RPPE scale was used to assess unit readiness for establishing a DEU. The pilot study was granted institutional review board approvals by the participating institutions. The Professional Practice Environment scale was first developed in 1998 by a team at Massachusetts General Hospital to evaluate the effectiveness of the environment in supporting the clinician's delivery of patient care in the acute care setting. The scale underwent revision in 2005. The RPPE scale is a revision of its predecessor, the Professional Practice Environment scale, designed to improve identification of conflict and disagreement by incorporating two additional items intended to more precisely determine the origin of conflicts and disagreements (Ives Erickson et al., 2009). The 39-item instrument contains eight subscales that survey different components of the acute care professional practice environment to include examining handling disagreement and conflict, leadership and autonomy in clinical practice, internal work motivation, control over practice, teamwork, communication about the patient, cultural sensitivity, and staff relationships with physicians. In 2009, the revised instrument underwent rigorous testing of its psychometric properties by Ives Erickson and associates. All eight components of the RPPE scale were deemed "sufficiently reliable and construct valid" (p. 241) with Cronbach's alpha values of .93 for the calibration sample (n = 775) and .92 for the validation sample (n = 775).
The RPPE scale components closely parallel the core elements necessary in the professional practice models of many Magnet-designated healthcare institutions (Ives Erickson et al., 2009). The RPPE scale was selected for use in this study because the scale components are also key characteristics of unit cultures yielding high student satisfaction feedback (Andrews et al., 2006; Beck, 1993; Chesser-Smyth, 2005; Hart & Rotem, 1994; Newton et al., 2009; Pearcey & Elliott, 2004; Smedley & Morey, 2010).
In the fall of 2010, a convenience sample consisting of 72 practicing registered nurses and licensed practical nurses completed a voluntary, confidential, 10-minute online RPPE survey. Participants recruited provided care on inpatient acute care units in two small community hospitals, one a Magnet facility, located in Western New York. The staff nurses were of varying ages, ethnic backgrounds, educational preparation, and work experiences in nursing. Of the 209 nurses recruited via flyers and work e-mails, 72 nurses completed the RPPE survey for an overall response rate of 35%.
The majority of nurses who took part in the survey were from Hospital B (n = 52), or 72.2% of respondents. The remaining 20 survey participants, or 27.8%, were from Hospital A (Note - numbers differ slightly as some respondents did not designate their inpatient units). The age of survey respondents ranged from 21 to 69 years in Hospital A and 25 to 69 years in Hospital B. Most nurses (n = 11, 15%) reported to be between the ages of 40 and 59 years. Most respondents (n = 36, 50%) held an associate degree in nursing. The majority of nurses (n = 46, 64%) were employed full-time. Most of the nurses (n = 19, 26%) reported being employed for 6 to 10 years (range of 0-11 months to more than 25 years) and most (n = 20, 28%) had worked for 6 to 10 years. The subscale scores and the internal consistency of the subscales are shown in Table 1.
The advantages when a SON and its healthcare agency partner thoughtfully plan a DEU, such as increased staff satisfaction, recruitment, and retention, as well as improved new graduate role transition, can be realized (Edgecombe et al., 1999; Gonda et al., 1999; Haas et al., 2004; Henderson et al., 2006; Moscato et al., 2007). This project suggests that an initial survey using the RPPE scale produces reliable data regarding the readiness of an acute inpatient unit prior to becoming a DEU. The RPPE subscales measure many of the key unit characteristics that can guide the DEU selection process and can also identify the unit-specific content in a DEU staff orientation program. The DEU Planning and Implementation Process model provides a means by which to identify, manipulate, and evaluate the augmenting and mitigating factors identified for the DEU environment.
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