The long-established approach to nursing education prescribes 1 faculty member to be solely responsible for a group of 8 to 12 students on a single nursing care unit.1 Faculty assigns students to patients with illness states and nursing needs that are being studied. Students rely almost completely on faculty to assist them with medication administration, procedures, and any skill they are not allowed to independently perform. Students are rotated every semester to different hospitals that require multiple orientations and clinical resources. This conventional approach has 2 significant limitations. First, shortages of faculty can make it difficult to hire and retain faculty with current clinical expertise. Second, large clinical groups can make simultaneous supervision of students difficult and possibly increase the risk of error. Valuable "just in time" learning opportunities are lost waiting for faculty availability. Students are not active participants in the "real world" of the clinical nursing staff. In the conventional model, the precepted experience is usually reserved for the final semester. During that preceptorship, all cognitive learning is applied as the student provides total patient care to a full assignment under the supervision of a nurse preceptor.
Breaking tradition is not for the faint of heart; it takes courage to turn the familiar upside down. Although we had the only baccalaureate nursing program in our region, it was small, and the graduates were not the first choice of local employers. The NCLEX pass rates were variable and sometimes barely acceptable at 85%. Only 70 students were admitted annually, whereas many more graduates were needed to meet the employment needs in the region. The relationship with our clinical partners was distant and lacked commitment and collaborative effort. A new paradigm for clinical teaching was needed to jumpstart the baccalaureate program and required a commitment from chief nursing officers, clinical educators, preceptors, and, very importantly, clinical faculty. We proposed such a paradigm shift to our clinical partners, inviting them to operationalize a teaching partnership that would provide a steady supply of baccalaureate-prepared staff nurses into their organizations. We expected NCLEX rates to improve, more graduates prepared to meet the practice needs of the region, and a community partnership that shares resources. Together, we created a shared vision to facilitate student transition to the staff nurse role within the organizational culture and provide clinical immersion opportunities for the students throughout the curriculum in an evidence-based practice model.
Literature Review
The Institute of Medicine (IOM)2 clearly articulates a transformation imperative of the nursing education system so that nurses may achieve the increasingly complex competencies required in today's healthcare system. Competencies in areas such as leadership, performance improvement, evidence-based practice, teamwork, and collaboration challenge nursing educators to reinvent how nurses can be prepared to practice in a fast-paced, complex environment. Teaching strategies common to the 20th century are no longer effective in the 21st century.2 Rather than increase curriculum content, the IOM report suggests that educators provide the tools that students need to respond to changes in science, technology, and patient demographics.2 Because it is not possible to discuss every issue related to patient care that may arise, students instead must learn to apply broad concepts to everyday situations.
The IOM report also supports the model of nurse residency programs in acute care settings to improve retention rates of graduate nurses. Kovner and colleagues3 surveyed more than 3200 nurses following their first year of practice. Although 21.4% of their respondents participated in a formal internship or residency program, 34.1% left their first job anyway. Although generating a robust national sample, the questionnaire did not include any items regarding the student clinical experiences that might influence the new graduate's fit or familiarity with an organization. Because many nursing schools use a traditional model of clinical education, it is possible that fit and familiarity with an organization may influence new-graduate retention rates.
Cooper Brathwaite and Lemonde4 implemented a "team preceptorship model" for baccalaureate students in a public health clinical course and conducted focus groups to evaluate the outcomes. Their purpose was to create a supportive learning environment of shared responsibility and increase collaboration between the university and the clinical practice environment. The themes that emerged from preceptors included supportive relationships, collaboration, and good communication among team members. The student responses contributed to themes including preceptor accessibility and expertise. These themes resonate with our experiences of the preceptorship model, implemented on a larger scale.
The University of Portland has implemented an innovative clinical teaching method, the "Dedicated Education Unit" (DEU), which provides students with an optimal learning environment.5 Only students from one school are assigned to a DEU at a time, under the guidance of a clinical faculty. The clinical faculty works with the nurses on the DEU who serve as preceptors, coaching them in their role. The DEU nurses are prepared for their role in DEU orientation and a preceptor workshop. They establish a mentoring relationship with the students, guiding them toward the expected learning outcomes. The university collaborates with the nurse managers to coordinate and integrate the needed resources to help staff and students provide quality care. Although outcomes of the model are expected to benefit students, preceptors, and the partner hospital, the design enables student learning to be centered in fewer clinical units, thus reducing student burden to more clinical units. This model shares many important characteristics of the Clinical Collaborative Model (CCM), although the "team" concept does not appear to be included.
MacIntyre and colleagues6 were funded by the Robert Wood Johnson Foundation Executive Nurse Fellows Program to made recommendations for clinical education, based on their concerns about the national faculty shortage and the limited capacity of clinical sites. Three of their 5 recommendations are operationalized by the CCM: "Reenvision nursing student-staff nurse relationships, reconceptualize the clinical faculty role, and enhance development for school-based faculty and staff nurses working with students."6(p448) The same group described the CCM7 in a qualitative study of innovative approaches to clinical education. They reported 4 common themes among all the programs studied: supportive relationships, goodness of fit, flexibility, and communication.
Development of the CCM
The CCM was first proposed in 2001 to the hospitals in the Tampa Bay region that hosted our College of Nursing (CON) students. Located in Tampa, the CON is part of USF Health at the the University of South Florida, the ninth largest university in the United States serving more than 1300 undergraduate and 700 graduate nursing students. Because a radical change was desired, only those institutions that would embrace and adopt the new CCM would continue to host CON baccalaureate students. Obtaining support for a new way of educating baccalaureate students took time and was contingent upon developing good working relationships with the practice partners. Inviting them to the table to discuss and plan how the CON could help them best meet their staffing needs proved to be the most effective idea.
The primary concern for both hospital nurse educators and staff nurses, as potential preceptors, was the potential responsibilities associated with clinical teaching. They viewed the CCM as "doing the instructors work for them." These concerns were allayed with several visits to each hospital over 4 to 6 months that supported relationship development and enabled discussions with staff nurses and managers regarding the payoff of their investment and the assurance that a faculty member would be on site. All but one hospital system decided to join the clinical collaborative (CC) to begin the process changing the way nursing students interacted with hospital nursing staff. Nursing representatives from each partner hospital in the CC agreed to serve on an advisory board to facilitate collaboration. The hospital system that originally declined participation joined 18 months later, after missing the opportunity to attract baccalaureate-prepared new graduates to their facility by hosting them in their nursing service. Another high-profile hospital recently joined the collaborative as a strategy to increase baccalaureate-prepared nurses.8
Components of the CCM
The Hospital Team
One of the most important characteristics of the CCM is that students complete the majority of their student experiences at a single healthcare organization.8 The goal of partner hospitals is retention of students as RNs after graduation. Nurse recruiters, senior nursing leaders, and staff nurses find many opportunities to engage the students in the culture of their organization during the 4 or 5 semesters of clinical experiences. This model of education delivery provides an extended period to evaluate the students' work ethic, learning potential, and potential fit in the organization before the interview process occurs. Many CC partner members offer nursing students part-time employment in "Learn and Earn" programs. Students and clinical faculty also benefit from a single day of orientation, saving valuable clinical time in future semesters. Orientation to the clinical placement within the CC is planned once at the start of the first clinical semester. Students become immersed in the hospital culture and develop relationships with RNs and a potential future employer. With this clinical immersion in a single organization, students achieve competency with the documentation system and equipment that secures confidence and skill through the clinical experience, an important theme when nursing students learn how to interact with patients.9 Other benefits for students include the ability to establish consistent routines for car pooling, study groups, and child care.
The method used to facilitate the clinical team experience is "Match Day." Representatives from the hospitals are invited to present their hospital as the most desirable choice to the newly admitted nursing students. The students also talk individually with representatives during the lunch break and then rank their choices for a clinical team. Hospitals that do not provide every clinical specialty are grouped with others to form a "system" that provides all clinical experiences. The faculty sort the match forms by first choice; teams that have more first choices than can be accommodated are reviewed to find matches for the second choice and sometimes third choice. Students who indicate they car pool are placed together, and international students may not be placed at the Veterans Administration hospital. The results of Match Day are announced on the last day of orientation, when the students have their first meeting as a team with their designated faculty. At this point, every team has 12 upper-division or second-degree students. Although students attend classes with everyone, the teams attend designated clinical, laboratories, and simulations together.
Most students (94%) participated in a "Match Day Satisfaction" survey prior to graduation in 2011 (Table 1). Students who did not get their first choice were asked how that affected them during their program. Most students (60%) who did not get their first choice reported that it was a better match, presumably based on their positive experiences. Even so, 53% applied to their first-choice hospital for a position, possibly reflecting the importance of job opportunities and location in selecting where to begin a career.
Preceptor Partners as Faculty
The clinical faculty works with the hospital nurse educators to identify a preceptor for each student before the start of the semester. Students consistently report that the biggest influence in developing critical thinking and establishing a strong nursing identity lies with their preceptor, so they must be carefully and purposefully selected. Ideally, the student and preceptor work together all semester, but in reality more than 1 preceptor often work with a student. The preceptor is responsible for only 1 student, so students are often assigned to 4 to 6 clinical units to avoid undue burden on any single unit. Potential preceptors are nominated by the hospital nursing administrator, based on their demonstrated competencies, and are minimally prepared at the baccalaureate level. Nurses whose education reflects competencies not required in the lower-level programs are the desired role models for professional practice such as those identified by the IOM.2 The partnership is more robust when the dyad shares a common educational background. Preceptors play a critical role in the curriculum and students' ease in the hospital setting. The CON clinical faculty is always on site, working continuously with the preceptors and the students.
Although the preceptor role is commonly used with experienced students in a senior capstone course, it is very different with a beginning student in the first "fundamental" course, or when students are just beginning to learn medication administration. The CON provides specialized training to the targeted staff who will serve as preceptors. Preceptor workshops are held in each hospital setting for continuing education hours. Content focuses on the model, role of the preceptor and faculty, evidence-based practice, and developing critical-thinking skills. Incorporating evidence-based practices into clinical settings will promote success on the board examination for RNs.10 Preceptors are evaluated by the students and faculty at the end of every semester with a simple evaluation instrument.
The preceptor partnership enables students a close view of the challenges faced by the RN in a changing and complex environment.5 The preceptors ensure that the clinical expertise of the population is brought to the learning experience of the student. Preceptors help each student learn and adjust to the patterns, procedures, and culture of their hospital. They work closely with the CON to assist the student to translate theory into clinical practice. The preceptor guides the student's learning and skill development continuously throughout the shift and the semester.
The collaborative relationships between the students and their preceptors provide the nursing students with a wide ranging clinical skill set, while enhancing their ability to prioritize and organize patient assignments. Students gain both confidence and competence through these relationships and are able to more readily actualize the role of the professional nurse when they enter the workforce. This student experience translates into optimum care for the patients and their families.
Clinical Faculty
The clinical faculty assigned to teach the clinical course is either a hospital-based faculty (HBF) or a CON faculty. The HBF is a master's degree-prepared nurse employed by the practice partner appointed as courtesy faculty. Appointment of a HBF is a financial investment of the practice partner, confirming their commitment to the CC. As with any other clinical faculty, the HBF is chosen based on their clinical expertise and is assigned to a team of students in the corresponding clinical rotation, such as medical/surgical, psychiatric, pediatrics, or women's health nursing. The role of the HBF is exactly the same as any clinical faculty member in the CCM. They ensure every student has a preceptor when illness or changes to the schedule occur. They make rounds on the units hosting the students, continuously working with the students and preceptors to ensure that course objectives are being met and the student is critically thinking. They also provide preconference and postconference for the students. Clinical faculty facilitates student formative evaluations with the preceptor.
Team Coordinator
A team coordinator (TC) from the CON faculty is assigned to each hospital team as a part of their annual assignment. The major role of the TC is to serve as the liaison between the CON and the hospital. The TC attends regional planning meetings to negotiate student placement each term, ensures students meet all hospital and CON requirements, and serves as a resource for all clinical faculty. They arrange the required hospital orientation and mandatory in-service education for beginning students. The TC has a relationship with every student on the team and is cognizant of each student's clinical and academic progress. The TC oversees the student experiences and ensures that clinical faculty and preceptors are facilitating hands-on learning for the students. They solve problems at all levels and meet regularly to ensure standardization among the teams. It is a demanding role that requires many leadership skills.
Outcomes
The CON faculty expected implementation of the CCM to improve NCLEX pass rates, greater numbers of graduates prepared to meet the practice needs of the region, and a strong community partnership. The outcomes have exceeded every expectation, largely due to the enthusiastic response and engagement of the community. When preceptorship was extended to all the undergraduate clinical courses, the student NCLEX-RN pass rates increased. Prior NCLEX pass rates at the CON in the conventional model were 85% to 94%, whereas today the CON enjoys a pass rate of 94% to 100%. Students report that their clinical experiences immerse them in practice with their preceptor. As a student remarked, "Last semester I was still apprehensive. Now I'm more independent and ask to do what I want to do. I'm learning the culture of nursing and feel like I'm becoming a nurse."
The CC model, in part, has also enabled the CON to increase enrollment from 70 once a year to 96 students twice a year. This outcome demonstrates not only the ability to increase enrollment, but also the strength of the community partnership and engagement. Although we employ many more faculty now, the hospitals offset some of the faculty costs by providing at least 1 instructor each semester, reflecting their investment in the partnership. These are the HBF appointed as courtesy faculty for a specific clinical course based on their area of expertise. The hospital also benefits from this arrangement because their employee serves as an ambassador, demonstrating the culture and benefits of working in the hospital. As an insider, the HBF has more influence in finding the best preceptors and clinical experiences for the students. Furthermore, the HBF can assess the clinical, professional, and interpersonal skills as well as the work ethic of each student over time, providing valuable input into hiring decisions upon graduation.
The faculty also expected the hospitals to appreciate cost savings when they hired students who spent their entire clinical experience with them. They anticipated that students would be very familiar with the hospital culture, medical record documentation, pumps, and monitors. Many develop close, mentoring relationships with their preceptors. For a time, students who were offered employment at their clinical site spent less time in orientation, with one reporting up to 50% less time. Most of the clinical partners now, however, require new graduates to enter into a "residency" program or "onboarding unit" that tend to follow a rigid schedule. We are pursuing other student outcomes that may demonstrate a different fiscal advantage for the hospitals.
As the CON's fiscal investment of the partnership, it offers one 3-credit course for every 70 hours of preceptor service. It is an investment that has increased the numbers of staff nurses who enroll in baccalaureate and graduate programs, which benefit the preceptors, hospitals, and CON. Preceptors do not have any obligations for using the tuition waiver, as they might when they use the hospital tuition benefit. For the hospital, it reduces requests for tuition reimbursement from their employees. Together, we serve more students. The tuition benefit increases the stream of students into the RN and graduate programs. Since 2005, an average of 63 courses has been taken annually by preceptors as a benefit of serving, the vast majority at the graduate level. To date, 428 preceptors have taken advantage of the tuition waivers with 1 or more courses that help to offset the hospital cost associated with HBF (Figure 1).
The CCM prepares students for the reality of patient care and may help the student evaluate their fit with the organization and develop familiarity for a continued relationship between student and hospital upon graduation. Students master complex systems such as electronic charting because their entire clinical education is in 1 hospital setting. We believe the success of this model rests with the enormous efforts of the clinical partners, as well as the learner-centric paradigm it uses. This CC team has fostered a sense of community spirit among the students and their hospital teams, demonstrated by the end-of-program surveys.
Challenges
The clinical partners in the region each provide unique learning opportunities for the CON students and were invited to participate in the CC because of their previous history with the CON. Not all, however, are designated as Magnet(R) hospitals, nor do all have trauma center designation. The representatives from those hospitals sometimes find it hard to compete with others that include exciting stories about trauma and the virtues and promises of Magnet(R) designation. Magnet(R) hospitals are commonly the first choice, so not all students get their first choice. Foreign nationals are not given the option to select the Veteran's Administration team, because they do not hire them upon graduation. Furthermore, there are no opportunities to switch teams once the match is finalized because of scheduling and other conflicts.
Admissions and enrollment procedures ensure that every team is filled at the beginning of the program, and the retention rate is very high. Students who fall out of sequence because of withdrawal or failure pose challenges to themselves and their faculty. A failure forfeits their place and creates a vacancy as the team moves forward without them. Faculty may not accept more students that the mandated ratio allows, so the student must wait for a vacancy on another team at the appropriate point in the program plan. Students can sit out a semester or two waiting for a team assignment, which occurs only when another student fails, posing the additional challenge of maintaining clinical skills. The result is that the students who need the most support from their team members find themselves on a new team in an unfamiliar hospital. Pressure to succeed with their teammates is a significant challenge faced by the students.
Negotiating clinical sites with the other colleges of nursing in the region is always challenging, especially when those other colleges need preceptors for their capstone clinical course. The CON TCs work hard to be good citizens and participate in good-faith negotiations with the other colleges. The HBFs are challenged by competing demands for clinical placements by other area nursing programs. Issues are worked out between the HBF and the TC to minimize the impact and stress on the unit preceptors. Issues may include unforeseen scheduling conflicts with other schools, lack of student preparedness, student errors, injury, lateness, or lack of professional behavior. Preceptor consistency can also pose a challenge to the faculty. Whereas some preceptors work their schedules around the student clinical rotations (working every Tuesday during the semester, for example), others do not and schedule time off during a semester. The TC and HBF collaborate to assign preceptors who are well prepared and can differentiate the CCM from the teaching models used by the other nursing programs.
The faculty celebrates and appreciates the members of the CC and the enormous amount of time that preceptors spend teaching CON nursing students. Of course, we both benefit from this mutual collaboration. The hospitals have ready access to well-prepared graduates who are completely immersed into their culture with a demonstrated work ethic and ability to learn, and the CON enjoys outstanding student successes and collaborative partnerships with community leaders.
Acknowledgment
The authors acknowledge Dr Patricia A. Burns, former dean of the CON, USF, for her visionary leadership and outstanding ability to build and sustain relationships with their clinical partners in the Tampa Bay region.
References