The Journal of Continuing Education in Nursing

Administrative Angles 

Creating the Optimal Clinical Learning Environment

Jean Shinners, PhD, RN-BC; Mary G. Harper, PhD, RN-BC; Mary A. Dolansky, PhD, RN, FAAN

Abstract

Hospitals, clinics, and community agencies serve as clinical learning environments (CLEs) for both health care professionals and students. To achieve the Quadruple Aim, the CLE must be optimized to support team-work, problem solving, and innovation. This article reviews the National Collaborative for Improving the Clinical Learning Environment initiative and provides implications for both academic and practice nursing education. [J Contin Educ Nurs. 2019;50(11):485–489].

Abstract

Hospitals, clinics, and community agencies serve as clinical learning environments (CLEs) for both health care professionals and students. To achieve the Quadruple Aim, the CLE must be optimized to support team-work, problem solving, and innovation. This article reviews the National Collaborative for Improving the Clinical Learning Environment initiative and provides implications for both academic and practice nursing education. [J Contin Educ Nurs. 2019;50(11):485–489].

For a long time, nursing has recognized the need for healthy work environments, as evidenced by the American Association of Critical-Care Nurses' (AACN, 2005) leadership in investigating and identifying standards for healthy work environments for critical care nurses. Research demonstrates that implementation of these standards results in an increase in nurses' job satisfaction, as well as improved retention (Cassidy, Barden, & Ulrich, 2019). The National Collaborative for Improving the Clinical Learning Environment (NCICLE) initiative presented in this article builds on the AACN's work by expanding the environment to include interprofessional practice and education.

About the NCICLE

The NCICLE was formed as:

A forum for organizations committed to improving the educational experience and patient care outcomes within clinical learning environments (CLEs). NCICLE seeks to simultaneously improve the quality of learning and patient care within CLEs through shared learning and collaborative practice among its member organizations.

In October 2017, the NCICLE met in Chicago, Illinois, for a 2-day interprofessional symposium to create a vision of what the optimal CLE would look like (Hawkins, Silvester, Passiment, Riordan, & Weiss, 2018). Following the symposium, a second group representing the diversity of symposium participants met to identify the characteristics of a high-functioning, interprofessional, CLE. The result of their work included a second publication, titled Achieving the Optimal Interprofessional Clinical Learning Environment (Weiss, Passiment, Riordan, & Wagner, 2019). The work group identified the characteristics of an optimal interprofessional CLE that they thought would significantly influence patients, learners, health systems, and academic medical centers. Table 1 lists these characteristics and demonstrates the alignment of the NCICLE characteristics with other initiatives aimed at promoting quality care: Quality & Safety Education for Nurses (QSEN) and the Institute of Medicine quality and safety competencies.

NCICLE Characteristics and QSEN and IOM Competenciesa

Table 1:

NCICLE Characteristics and QSEN and IOM Competencies

Clarification of Terms

Dickerson and Bernard (2018) noted that “terminology used in the field of continuing nursing education and nursing professional development can be confusing” (p. 19). Although the article addresses terminology specific to continuing education and nursing professional development, it is true of any initiative when terms cross professions and initiatives. For that reason, Table 2 provides a list of key terms and cross walks with NCICLE characteristics, QSEN competencies, and NPD language.

Key Terms

Table 2:

Key Terms

The CLE and Quality and Safety Competencies (Mary A. Dolansky, PhD, RN, FAAN)

The CLE is where the “rubber hits the road” for quality and safety competencies to emerge for both students and health care professionals. Quality and safety competencies in academic nursing education date back to 2005 when the QSEN initiative developed prelicensure and graduate-level competencies for nurses (Cronenwett et al., 2007). These competencies were originally used to assist faculty with curriculum development in education in recognizing QSEN alignment with the Institute of Medicine quality and safety competencies (Association for Nursing Professional Development, 2016; National Research Council, 2003). The QSEN competencies have since been adopted in practice (Koffel, Burke, McGuinn, & Miltner, 2017). Quality and safety competencies in all professions align with health care's Quadruple Aim that includes improving the patient experience, population health, care team well-being, and reducing costs. Quality and safety can be achieved when there is an interprofessional CLE that supports students and health care professionals to work together.

The QSEN competencies of (a) teamwork and collaboration, (b) quality improvement, (c) evidence-based practice, (d) safety, (e) informatics, and (f) patient-centered care and alignment with an optimal CLE are listed in Table 1. The NCICLE report includes reliable communication and shared accountability—these two dimensions highlight the need for interprofessional collaboration in the delivery of care. For example, in order for the Quadruple Aim to be achieved, we must learn together with reliable communication that incorporates common goals, clear roles, and psychological safety that enables us to speak up to share our unique interprofessional perspectives. Additionally, shared accountability must be emphasized in all that we do so that safe and reliable care is delivered.

The NCICLE report provides a vital dimension to quality and safety competencies by raising awareness of the contextual elements that must be in place to promote these competencies. The clinical environments in which we practice must support interprofessional learning and technological enhancements at all levels—from the microsystem to the macrosystem. For example, at the microsystem, we can provide opportunities for professionals to test innovative solutions for some of our pressing quality problems and incentivize departments to test innovative approaches to care delivery. At the macrosystem level, we can offer programs for continuing interprofessional education, facilitating interprofessional quality improvement teams, and jointly offering morbidity and mortality forums.

The NCICLE report provides ideas for new resources that could be added to the QSEN website ( http://qsen.org/). For example, the inclusion of teaching strategies that support faculty in addressing substandard CLEs may offer ways to help students (a) increase awareness of ineffective environments, (b) think about what needs to be changed, and (c) develop potential change strategies to make the environment conducive to support meeting the Quadruple Aim. Sharing the NCICLE report on the QSEN website for both faculty and students would ensure that faculty and students are aware of the influence of the environment on the delivery of high-quality and safe care. The QSEN competencies delivered in an interprofessional CLE are a powerful combination to ensure that all student and health care professionals achieve the Quadruple Aim.

Clinical Learning Environment and Nursing Professional Development (Mary G. Harper, PhD, RN-BC)

For the NPD practitioner, the connection between the CLE and NPD lies in the NPD practitioner's roles and responsibilities for creating and maintaining positive practice and learning environments. The Association for Nursing Professional Development's Scope and Standards of Practice directs the practice of the NPD practitioner and recognizes the interprofessional practice and learning environments, acknowledging the NPD practitioner's responsibility for professional development of the entire health care team, instead of only nurses (Harper & Maloney, 2016).

According to Scope and Standards of Practice, the NPD practitioner functions in seven roles—including the role of leader. In this role, the NPD practitioner “influences the interprofessional practice and learning environments” (Harper & Maloney, 2016, p. 16). In addition, the Scope and Standards of Practice mandates that NPD practitioners facilitate both positive practice and learning environments. This promotion includes activities such as identifying and meeting ongoing development needs, facilitating transitions into practice, acknowledging and meeting the needs of diverse learners, and incorporating education into healthy work environments.

In the role of partner for practice transitions, the NPD practitioner develops and implements transition programs for nurses and other health care professionals who are new to practice, transitioning from one specialty area to another, or transitioning from one role to another such as from staff nurse to charge nurse or from charge nurse to nurse manager (Harper & Maloney, 2016). Furthermore, in their responsibility for role development, NPD practitioners develop preceptors who facilitate these transitions in the practice environment. Often, these same preceptors work with students in their practicum experience. Ensuring that preceptors are prepared to provide positive learning experiences for their preceptees and protect them from lateral violence is a key responsibility of the NPD practitioner.

Finally, NPD practitioners are responsible for collaborative partnerships (Harper & Maloney, 2016). These partnerships often include academic and practice partnerships in which the NPD practitioner coordinates all aspects of students' clinical experiences. The NPD practitioner is responsible to promote a CLE that provides the psychological safety needed for students to question and learn.

Within each of the roles and responsibilities of the NPD practitioner, and within the context of the interprofessional learning and practice environments, integration of ethical principles is paramount. Standard seven of the Association for Nursing Professional Development's Scope and Standards of Practice challenges NPD practitioners to “protect the autonomy, dignity, confidentiality, and rights of all individuals involved in the learning process” (Harper & Maloney, 2016, p. 42). Recognizing each of these components as integral in maintaining a healthy and positive CLE promotes an environment in which all learners can flourish.

Conclusion

Working with patients, families, and care providers in multiple settings has become increasingly complex. This complexity has resulted in a call for teamwork and innovative thinking to create a work and learning environment based on healthy, patient-centered interactions and shared responsibilities aimed at improving patient and provider experiences. The NCICLE initiative provides all health care professionals with strategies to make a connection between clinical learning and practice environments and quality patient care. It has the potential to bridge academia and practice environments as noted by Drs. Dolansky and Harper. For the nursing profession, it provides us with an opportunity to reach out to the interprofessional team to find common ground and renewed excitement that can be part of the patient care experience. Readers should note that pursuant to the 2017 workshop, NCICLE held another workshop in August 2019 in Minneapolis, Minnesota, to identify structures, processes, and outcomes to guide leaders of health care organizations in optimizing their CLEs. Approximately 60 interprofessional participants from 24 NCICLE member organizations participated in a variety of engaging activities focused on three specific areas:

  • Ensuring ongoing interprofessional input.
  • Integrating interprofessional learning and collaborative care into the strategic plan.
  • Building team-oriented structures.

The actionable recommendations from this workshop will be published on the NCICLE website in the near future.

References

  • American Association of Critical-Care Nurses. (2005). AACN standards for establishing and sustaining healthy work environments: a journey to excellence. American Journal of Critical Care, 14, 187–197.15840893
  • American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.
  • Association for Nursing Professional Development. (2016). Quality and safety education for nurses. Retrieved from http://www.anpd.org/page/anpd-position-statements
  • Cassidy, L., Barden, C. & Ulrich, B. (2019). 2018 AACN Critical Care Work Environment Survey results: Implementing the HWE standards matters. Retrieved from https://sigma.nursingrepository.org/bitstream/handle/10755/16749/CassidyBardenUlrich_25124_SpSH05.pdf?sequence=1&iisAllowe=y
  • Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P. & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]17524799
  • Dickerson, P.S. & Bernard, A. (2018). What's in a word? Understanding terms in continuing nursing education and professional development. The Journal of Continuing Education in Nursing, 49, 19–25. doi:10.3928/00220124-20180102-06 [CrossRef]29384584
  • Harper, M.G. & Maloney, P (Eds.). (2016). Nursing professional development: Scope and standards of practice (3rd ed.). Chicago, IL: Association for Nursing Professional Development.
  • Hawkins, R., Silvester, J.A., Passiment, M., Riordan, L. & Weiss, K.B. (2018). Envisioning the optimal interprofessional clinical learning environment: Initial findings from an October 2017 NCICLE symposium. Retrieved from https://storage.googleapis.com/wzukusers/user-27661272/documents/5a5e3933a1c1cKVwrfGy/NCICLE%20IP-CLE%20Symposium%20Findings_011218%20update.pdf
  • Koffel, C., Burke, K.G., McGuinn, K. & Miltner, R.S. (2017). Integration of Quality and Safety Education for Nurses into practice: Academic-practice partnership's role. Nurse Educator, 42(Suppl. 1), S49–S52. doi:10.1097/NNE.0000000000000424 [CrossRef]28832463
  • National Collaborative for Improving the Clinical Learning Environment. (2019). About NCICLE. Retrieved from https://ncicle.org/about-us
  • National Research Council. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press.
  • Weiss, K.B., Passiment, M., Riordan, L. & Wagner, R. (2019). Achieving the optimal interprofessional clinical learning environment: Proceedings from an NCICLE symposium. Retrieved from https://storage.googleapis.com/wzukusers/user-27661272/documents/5c51b3628dae7ExACzM9/1071%20NCICLE%20IP-CLE%20SymPro%20Booklet-DIGITAL%20FINAL.pdf doi:10.33385/NCICLE.0002 [CrossRef]

NCICLE Characteristics and QSEN and IOM Competenciesa

NCICLEQSENIOM
Patient centerednessPatient-centered carePatient-centered care
Continuum of learningQuality improvement and continual learningFocusing on quality improvement
Reliable communicationCommunication through informatics and teamwork and collaborationPositive communication is considered an outcome when competencies are incorporated
Team-based careTeamwork and collaborationWorking as part of interdisciplinary teams
Shared accountabilitySafety
Evidence-based practice centered on interprofessional careEvidence-based practicePracticing evidence-based medicine

Key Terms

TermNCICLEQSEN NotesNPD Notes
Clinical learning environmentHospitals, medical centers, and other clinical settings in which new clinicians trainQSEN uses the terms systems and systems thinking and expands the nurses' understanding of the connections between the delivery of individual nursing care and the systems in which they work.The Association for Nursing Professional Development's (ANPD) Scope and Standards of Practice used the term interprofessional practice environment and defines it as the “structural, social, and cultural setting in which health care occurs” (p. 9). It encompasses any setting where “health care is delivered to individuals, families, and communities” (p. 11). It includes all health care settings—not only the acute care hospital setting (Harper & Maloney, 2016).
Interprofessional learning environmentRefers to the clinical learning environment and other patient care settingsQSEN acknowledges the interprofessional learning environment and promotes teamwork and collaboration.According to the ANPD's Scope and Standards of Practice, an interprofessional learning environment refers to “any context in which learning occurs” (Harper & Maloney, 2016). While most commonly associated with the classroom, the learning environment may be a simulation laboratory, conference room, staff lounge, or a virtual setting. In health care, the learning environment often overlaps with the practice environment.
Patient centerednessThe patient should be at the center of every aspect of health care delivery. This is accomplished by viewing health care as being co-created with the patient and his or her family and community, as well as by considering the patient as an integral member of the health care team.QSEN: Patient-centered care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient's preferences, values, and needs.
Continuum of learningEveryone in the clinical environment—not only students and new clinicians—is a learner. There is a commitment to lifelong learning in ensuring that interprofessional learning is integrated and reinforced into the clinical workflow and all key health care activities.QSEN approaches the continuum of learning to consider the implementation of quality and safety competencies into prelicensure and postlicensure education, as well as into clinical practice.According to the ANPD's Scope and Standards of Practice, lifelong learning is: “The continual acquisition of knowledge and skills throughout life in preparation for and in response to different roles, situations, and environments encountered; occurs in formal and informal education systems, both within and outside the workplace” (Harper & Maloney, 2016, p. 62).
Team-based careInterprofessional team-based care thrives in a culture that is value based, rewards team-based innovation, and fosters leadership skills at all levels.QSEN: Teamwork and collaboration:Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.The ANPD Scope and Standards of Practice uses the American Nurses Association's (2015, p. 88) definition of team-based care: “Integrated enactment of knowledge, skills, and values and attitudes that define working together across the professions.”
Interprofessional education: Both academic and continuing professional educationRefers to learning in teams.QSEN emphasizes the need for interprofessional education, care delivery, and quality improvement.ANPD's Scope and Standards of Practice (Harper & Maloney, 2016) defines interprofessional continuing education as “informal and formal educational experiences that occur after initial academic preparation for the professional role” (p. 61) and involves individuals from two or more professions. The goal is collaboration and quality care.
Authors

Dr. Shinners is Executive Director, Versant Center for the Advancement of Nursing, Hobe Sound, Florida, and was a participant representing the American Nurses Credential Center at the October 2017 National Collaborative for Improving the Clinical Learning Environment (NCICLE) Symposium; Dr. Harper is Director of Nursing Professional Development, Association for Nursing Professional Development (ANPD), a supporting member of NCICLE, serves as ANPD's representative for the NCICLE member group, and was on the planning committee for the 2019 Interprofessional Clinical Learning Environment Workshop; and Dr. Dolansky is Associate Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, and Associate Director of the Veterans Administration Quality Scholars (VAQS) program and senior VAQS faculty at the Louis Stokes Cleveland VA Medical Center, Director of the Quality and Safety Education for Nurses (QSEN) Institute, Cleveland, Ohio, and was a member of the planning and writing work group for the October 2017 NCICLE Symposium on Envisioning the Optimal Interprofessional Clinical Learning Environment. The QSEN Institute is a supporting member of NCICLE.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jean Shinners, PhD, RN-BC, Executive Director, Versant Center for the Advancement of Nursing, P.O. Box 401450, Las Vegas, NV 89140; e-mail: jshinners@versant.org.

10.3928/00220124-20191015-02

Sign up to receive

Journal E-contents