Older adults residing in nursing homes lack access to quality professional (i.e., RN) nursing care. On average, nursing home residents receive 30 minutes of care from RNs per day (Harrington, Swan, & Carrillo, 2007). The current vacancy rate of RNs in nursing homes is more than 16%, and the turnover rate is more than 40% (American Health Care Association, 2008). In a 2007 survey of nursing facilities conducted by the American Health Care Association (2008), 51% reported it was more difficult to recruit RNs than the previous year.
A significant contributing factor to this unacceptable lack of access to professional nursing care for nursing home residents is the nursing education pipeline. While the goal of professional nursing programs is to ensure that students have a basic level of competency to care for older adults in a variety of care settings, the greatest challenge is to garner students’ enthusiasm about caring for older adults in nursing homes. A related challenge is creating and implementing exemplary clinical experiences for students that highlight the pivotal role of the RN in the nursing home and ultimately ignite their interest in a career in this setting.
To increase and strengthen the professional nursing workforce in nursing homes, schools of nursing must ensure that students have appropriately placed, well-designed, and innovative clinical experiences in nursing homes with faculty who are knowledgeable about the nursing home environment and the professional nursing care needs of its residents. Therein lies the challenge. Schrader (2009) examined nurse educators’ perspectives of using nursing homes as clinical sites for student learning and found that faculty viewed the nursing home environment as an unpleasant experience for students and that the setting was not clinically challenging for students. Further, nurse educators were influenced by the students’ negative attitudes about clinical experiences in nursing homes.
Faculty at the University of Minnesota School of Nursing have successfully taken on the challenge of clinical teaching in nursing homes and developed a conceptual model (Figure 1) based on four factors identified as keys to success for developing exemplary clinical experiences for students in nursing homes. These factors are described below.
Figure 1. Conceptual Model for Creating Exemplary Learning Experiences in Nursing Homes.
Nursing homes used for clinical teaching must be committed to providing quality care for residents and have the resources to do so. Four indicators to guide the selection of nursing homes used for clinical teaching include evaluating:
- The quality of care provided in the nursing home.
- RN staffing and the role(s) of the RNs.
- Use of evidence-based practices and clinical guidelines for the patient population.
- Commitment to a resident-directed philosophy.
The quality of care provided to residents can be evaluated using several strategies. The Centers for Medicare & Medicaid Services’ website, Nursing Home Compare ( http://www.medicare.gov/nhcompare), provides regularly updated data on quality measures (e.g., physical restraint use, pressure ulcers, weight loss, pain), staff time, and nursing home inspection results. In addition, some states have their own public report card for nursing homes that can be used to evaluate similar and other quality measures. Other ways in which quality of care can be evaluated is whether the facility actively participates in the Advancing Excellence Campaign ( http://www.nhqualitycampaign.org). The progress a facility is making on the three quality indicators it selected for improvement as part of its participation in the campaign can be viewed on the website. In addition to the nursing home’s community reputation, an essential strategy to evaluate the quality of care is to conduct a site visit to the nursing home and interview the director of nursing and administrator; talk with nursing staff, residents, and families; and observe staff interactions with residents, as well as care practices.
An essential element for a nursing home used for clinical teaching is that the RN staffing is higher than the state or national average. This can be evaluated on the Nursing Home Compare website. Further, it is important that the role of the RN is distinguished from those of licensed practical nurses and nursing assistants. Ideally, the director of nursing should have at least a baccalaureate degree in nursing.
Another component of staffing to evaluate is nursing staff turnover and retention rates, because there is strong evidence that both higher RN staffing (Decker, 2006; Dorr, Horn, & Smout, 2005; Horn, Buerhaus, Bergstrom, & Smout, 2005) and low nursing staff turnover (Kash, Castle, Naufal, & Hawes, 2006) are associated with higher nursing home quality. In addition to the number and type of nursing staff is the care delivery model used to provide resident care; specifically, how RNs are engaged in assessing, planning, directing, and evaluating resident care.
Nursing students should learn in an environment that supports the use of evidence-based care practices. Some common clinical issues in nursing homes include dementia care and the prevention of falls, urinary incontinence, and pressure ulcers. Research related to these clinical issues has led to clinical practice guidelines that should be implemented in nursing homes. Ensuring that nursing homes used for clinical teaching integrate evidence-based geriatric practice guidelines into their policies, procedures, and protocols is an important strategy in evaluating the quality of care provided by the nursing home staff.
Finally, nursing homes should use a non-institutional, resident-directed model of care that promotes autonomy and control for residents and those who work most closely with them. This care philosophy is congruent with the nursing home culture change movement (Pioneer Network, n.d.). In addition to environmental modifications to provide a home-like environment for residents, the care practices support and respect the preferences of residents, such as when, where, and what they want to eat; when to rise for the day or go to bed; and even preferences about taking medications.
School of Nursing and Faculty
Most nursing faculty have had little to no experience in a nursing home and are unfamiliar with the nursing home environment. This unfamiliarity, and even discomfort, will invariably have a negative effect on students’ perspectives and attitudes toward the role of the RN in nursing homes. Nursing faculty teaching in nursing homes require a solid orientation to the nursing home environment, which includes becoming familiar with the “lingo” used in nursing homes (Table 1), staff roles, care practices, as well as current trends in nursing home care.
Table 1: Common Abbreviations Used in Nursing Homes
Having faculty consistently assigned to clinical teaching in the same nursing home is critical to developing and strengthening the relationship between the school and the nursing home, as well as ensuring students have a faculty member who is familiar with the clinical setting. At the University of Minnesota, when new faculty members are assigned to teach in a nursing home for the first time, they are provided an orientation to the nursing home environment by the course coordinator and spend orientation time in the nursing home prior to having students in the setting. One of the learning modules for students used in the course is an introduction to the nursing home environment, a module that all nursing faculty have reviewed.
Faculty enthusiasm for teaching in the nursing home setting accompanied by knowledge in geriatric nursing can have a positive influence on students’ attitudes about learning in this clinical setting. Such enthusiasm is developed when faculty have opportunities for development of expertise in geriatric nursing and/or have had previous experience in the nursing home setting. A website developed by the Minnesota Hartford Center of Geriatric Nursing Excellence ( http://www.nursing.umn.edu/Hartford/facultyteachingresources/home.html) provides a wide variety of resources for teaching geriatric nursing.
After ensuring a nursing home provides quality care and the nursing faculty are familiar with the nursing home environment, both the school of nursing and the nursing home need to share a commitment to providing a quality learning experience for students. Such a commitment includes a shared understanding of each other’s goals and needs: The nursing home staff must be knowledgeable about the school’s curriculum and the clinical learning objectives, and the school/faculty must be knowledgeable about the nursing home setting and practices. This commitment is further defined by nursing home staff engaged in teaching students (e.g., nursing assistants demonstrating how they bathe a resident with dementia), serving as role models, and being receptive to providing a variety of learning opportunities for students (e.g., shadowing the director of nursing, administering medications to a group of residents). Schools of nursing have access to a number of resources such as journal articles and books that are beneficial to and can be shared with the nursing home staff. Inviting nursing home staff to school of nursing events such as journal clubs, guest presentations, and research conferences can further solidify partnerships and assist nursing home staff in their professional development, as well as increase their confidence in teaching nursing students.
A successful strategy used by faculty at the University of Minnesota to strengthen partnerships between the faculty/school and the nursing homes used for clinical teaching involved a half-day workshop with the faculty and nursing home staff. The nursing home staff learned about the school’s curriculum and students’ clinical learning objectives, and the nursing faculty learned about the unique practice environment of the nursing home. Together, they engaged in problem solving of case scenarios depicting situations that had the potential to result in a negative experience for students. For example, one case scenario involved the students arriving on the nursing unit and the staff stating that they did not know the students were going to be there that day. Another scenario involved nursing students observing a staff member engaging in a care practice that was not congruent with what they learned in school. The situation was switched in another scenario where a staff member observed a student engaging in a care practice that was not congruent with acceptable care practices. The faculty and staff identified a number of effective strategies for how they could work together to provide positive learning experiences for students and mitigate or address the negative situations that were provided in the case scenarios.
Creative and Innovative Clinical Teaching Strategies
When the nursing staff view themselves as partners in the learning experience for students and the faculty are comfortable with the practice setting, the opportunities for creative and innovative clinical learning opportunities are limitless. A major clinical objective for the students is to understand and experience the role of the RN in a nursing home setting. Nursing homes serving as clinical partners can provide students opportunities to shadow and learn from RNs in a variety of roles (e.g., staff development, MDS coordinator), manage care for a group of residents, makes rounds with nurse practitioners, and attend and participate in a variety of meetings (e.g., care plan, quality assurance). In addition, this partnership allows students the opportunity to learn about the roles and responsibility of delegation. For instance, when working with a group of residents, students are able to work with their peers to manage the care of the resident and practice the important nursing function of delegation as they collaborate with the nursing assistants to ensure that care is completed in a timely and satisfactory manner.
An innovative assignment to help students discover the meaning of resident-directed care involves developing a plan of care for a resident in the voice of the resident. In doing so, students approach a nursing care plan in a way that is completely different from care plans developed in other clinical rotations. The students are asked to discover the resident’s desires regarding his or her care in different aspects of the resident’s life, such as communication/memory, mental wellness, mobility, regaining or maintaining bladder and bowel continence, safety, nutrition and hydration, and religion/spirituality. The students write the care plan in a narrative format from the resident’s point of view and include the need/problem and goals from the resident’s perspective. The nursing interventions are woven into the narrative by the resident “telling a story” of how the nursing staff can best help him or her.
During the clinical experience, students have shared with faculty from the University of Minnesota that they find the assignment very enjoyable because they get to know a lot more about the resident and find it interesting to see what the resident wants versus what really happens in the day-to-day care. In addition, students find the assignment meaningful, as they have a number of weeks to actually carry out the care in the way the resident would like his or her care to be directed and can have the experience of implementing, evaluating, and modifying a care plan. These care plans are shared with the staff and have been instrumental in changes made on the residents’ care plans used by the facility. An excerpt of a student’s resident-directed care plan is provided in Figure 2.
Figure 2. Excerpt from a Student-Written Resident-Directed Care Plan.
Another assignment is an in-depth examination of a clinical issue that is commonly experienced by nursing home residents (e.g., pressure ulcers, falls, dementia). The objective of this assignment is for students to conduct an analysis of the issue as well as identify current evidence-based clinical guidelines or practices that guide the care of residents. In addition, the students compare the organization’s clinical practices to what they have learned from their examination of the research specific to the clinical issue.
The assignments of the resident-directed care plan and the clinical issue paper are person-centered and evidence-based ways in which students become engaged with the nursing home residents and staff. Both of these assignments serve as educational strategies that expose students to new ways of thinking about providing care for older adults in the nursing home setting. On one hand, students apply the nursing process through the direct engagement of the resident viewpoint, while on the other hand, they examine a clinical issue using evidence-based practice, as well as using techniques of observation, interviewing, investigation, evaluation, and recommendation.
In addition to these assignments, students prepare for their weekly clinical experience in the nursing home by completing online education modules providing the latest evidence-based practice guidelines on issues commonly experienced by nursing home residents (e.g., dementia, falls, end of life). Students use the assessment tools from the Hartford Institute for Geriatric Nursing’s Try This® series ( http://hartfordign.org/Resources/Try_This_Series) that are specific to the focus of the week’s module. In addition, postclinical conference topics and questions are included in the module so that students are prepared to engage in an active discussion that is informed by the module-related learning activities they engaged in during their clinical day (Table 2).
Table 2: Examples of Postclinical Conference Discussions