Dr. Mulready-Shick is Clinical Assistant Professor and Undergraduate Nursing Program Director, and Ms. Kafel is Lecturer, University of Massachusetts Boston, College of Nursing and Health Sciences, Nursing Department, Dr. Banister is Executive Director, The institute for Patient Care, and Dr. Mylott is Director, Clinical Teaching and Evidence-Based Practice, Center for Nursing Excellence, Brigham and Women’s Hospital, Boston, Massachusetts.
This pilot phase evaluation study was supported by the Robert Wood Johnson Foundation Quality and Safety Education for Nurses QSEN) grant. The authors graciously thank the QSEN Pilot Schools Collaborative (QSEN, 2007), the nursing units, the college nursing department, students, staff, and college and agency nursing administration leadership involved with the DEU Task Force and this pilot study. For further information about the UMass Boston project, see Pilot Schools on the QSEN website.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to JoAnn Mulready-Shick, EdD, RN, CNE, Clinical Assistant Professor and Undergraduate Nursing Program Director, University of Massachusetts Boston, College of Nursing and Health Sciences, Nursing Department, 100 Morrissey Boulevard, Boston, MA 02125; e-mail: firstname.lastname@example.org.
An important purpose of implementing quality and safety competencies in nursing education is to bridge the gap between nursing education and practice. In the clinical setting, an innovative model of clinical education, the dedicated education unit (DEU), offers a concrete strategy to more closely connect nursing units and education programs. Dedicated education units involve new partnerships among nurse executives, staff nurses, and faculty for transforming patient care units into environments of support for nursing students and staff nurses while continuing the critical work of providing quality care to acutely ill adults (Moscato, Miller, Logsdon, Weinberg, & Chorpenning, 2007).
The DEU model also facilitates stronger relationship-building between nurses situated in academia and practice (Wotton & Gonda, 2004). The DEU requires role changes for college faculty and staff nurses. Staff nurses become students’ clinical instructors and faculty no longer directly teach students but primarily coordinate, educate, and support the staff nurses’ development in clinical instruction. The staff nurse as clinical instructor works closely with college faculty to assist students in gaining the clinical knowledge, skills, and values needed for entry into professional nursing practice.
Quality of instruction is enhanced because instructors have significantly more time on the unit to address students’ individual learning needs (Miller, 2005). Earlier studies have reported significant differences (p < 0.05) in the learning experiences of students on DEUs compared with students receiving traditional clinical instruction. Students on DEUs were significantly more likely to report that nurses helped them develop clinical learning skills and that they felt more in charge of their own learning during the clinical experience (Moscato et al., 2007).
In addition, the nursing unit can provide an ideal setting for integrating competencies in patient-centered care, quality improvement, safety, teamwork and collaboration, informatics, and evidence-based practice into clinical teaching strategies (Day & Smith, 2007). Therefore, students and nurses participating in the DEU model for clinical education are well positioned for acquiring new nursing knowledge, skills, and attitudes about the six quality and safety competencies.
In spring 2007, our college initiated a strategic response to address the education-practice gap and the need to integrate new quality and safety competencies into teaching and learning experiences for students and faculty with our clinical education agency partners. The college invited two partners to help create a DEU task force, a clinical partnership model, between the college and two agencies specifically involving the nursing program’s junior level adult health clinical course and two patient care units at the agencies.
The clinical partnership was designed to foster a collaborative milieu whereby resources, knowledge, and experiences would be both shared and reciprocated, allowing nursing practice to more deliberately inform nursing education and vice versa. Staff nurses who expressed interest in DEU participation were approved by their nurse managers, met the college’s clinical instructor guidelines, and received an extended orientation to the clinical instructor role by the faculty coordinators. In addition, through implementing unit-specific DEUs, new relationships were forged at many levels across the nursing education program and health care agencies, including students and staff nurses, staff nurses and clinical faculty coordinators, clinical faculty coordinators and nurse managers, and nursing education and staff development program directors.
The DEU task force’s stated goals included the integration of quality and safety competencies at the nursing course and clinical unit levels. The DEU initiative requires the active involvement of students and staff nurse instructors in shaping new learning experiences for enhancing quality and safety, particularly in teamwork and collaboration, defined as the ability “to function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care” (Cronenwett et al., 2007). Students develop new skills in working collaboratively with unit nurse educators and nurse managers in ascertaining unit-based teaching-learning needs. Students, faculty coordinators, staff nurses, nurse managers, and unit educators mutually identified nursing practice issues on each unit in need of quality improvement and amenable to unit-based education.
Unit-based quality improvement and teaching-learning projects began with students completing annotated bibliographies and thorough literature reviews with assistance from the hospitals’ librarians. One group of students presented a PowerPoint® presentation on alternatives to restraints, including the reintroduction of “activity boxes” and the required documentation for implementing patient restraints. A second group of students created a poster presentation, pamphlet, and unit-specific tool for the early identification of pressure ulcers postsurgery, along with associated nursing interventions for prevention.
Dedicated education unit nurses, along with managers, educators, and nursing staff and students from other units attended presentations. In subsequent semesters, new groups of students have built on these identified projects, including related changes in Medicare reimbursement and further development of new documentation tools with the full support of hospital quality and safety staff and nursing leadership.
Pilot Phase Evaluation Study
To assess whether the DEU clinical education model facilitates students’ learning of the six quality and safety competencies and also to examine additional DEU clinical education outcome measures, the DEU task force members conducted a pilot evaluation study following the initial phase, or the first semester implementation, of the model. The study method was drawn from constructivist perspectives as students and nurses learned together in pedagogically and socioculturally situated and contextualized clinical environments. The multifaceted pilot phase evaluation study collected data from students and staff nurses via focus groups and written surveys and examined satisfaction, quality of clinical learning experiences, and quality and safety competency development.
Approval for the study was granted by institutional review boards at both the university and health care institutions. An external evaluator and one DEU task force member created open-ended questions for the focus group interviews, revising questions from earlier DEU studies. Items were reviewed by all task force members for content validity.
Eighteen students (23% of the total class) enrolled in the junior level adult health course were selectively chosen to participate on the first DEUs during the spring semester 2008. All students had completed one previous fundamentals of nursing clinical experience prior to this semester. Twelve students were assigned to the DEU unit at one agency, and six students were assigned to the participating DEU at the second agency.
Because all of the students enrolled in the college’s nursing program are commuter students, selection criteria for DEU participation included their willingness to be assigned to clinical learning experiences for one 12-hour shift per week that was dependent on their assigned staff nurses’ schedules. Nine staff nurses serving as clinical instructors were also invited to participate in the formal evaluation study.
Participation in the pilot phase evaluation study was voluntary and anonymous; written consent was obtained for focus group participation and survey and demographic data collection. The external evaluator (L.B.) conducted three separate focus group interviews, one for the staff nurse and two for the student DEU groups, at the end of the spring semester 2008. The evaluator also had the data transcribed and wrote summary analysis reports for the DEU task force. The interview questions centering on the quality and safety competencies are listed in the Table.
Table: Dedicated Education Unit (DEU) Nursing Students and Staff Nurse Clinical Instructors Focus Group Questions
Sixteen of the 18 DEU students (89% of the total sample) participated in the study. Fourteen students were women and 4 students were men. Ages ranged from 19 to 45. Nine students identified themselves as White/Caucasian, two as African American, three as Asian, and two did not indicate.
Nine staff nurses (100% of the total DEU nurse sample) participated in the study. Ages ranged from 28 to 55. Four nurses identified themselves as White/Caucasian, four as African American, and one did not indicate. Staff nurses' practice experience ranged from 5 to 30 years. The number of years employed on a particular unit ranged from <5 years to 30 years. All of the staff nurses indicated previous precepting experiences. The nine participating staff nurses clinically instructed two student nurses each during the semester.
Responses to the questions posed to DEU students and staff nurses in the focus group sessions follow.
Teamwork and Collaboration. Students specifically noted the cooperation and welcoming attitude and teamwork from all of the nurses on students’ assigned patient care unit. Students thought the DEU model afforded them greater responsibility for coordinating patient care with health care team members and developing skills in professional communication. One participant commented that by having her own patients in conjunction with patients’ actual nurse, rather than working with a college faculty clinical instructor, she felt less like an outsider when observing professional consultations with physicians.
Staff nurse clinical instructors also coordinated with other staff nurses and patient care areas to seek out additional student learning opportunities. The only concerns of both staff nurses and students focused on a few scheduling and patient assignment challenges that improved by midsemester.
Safety. Students focused their responses on medication safety and commented that working with a smaller student-to-teacher ratio reduced the potential for errors and supported medication knowledge gains. In addition, students commented on readily learning hospital systems for patient bracelet scans, potential adverse reactions alerts, and medication administration documentation. One nurse noted the most important teaching moments involved patient safety, including medication safety.
Informatics. Students also commented on the availability of numerous resources, including computer access provision. Students stated they easily accessed patient care information, retrieved doctors’ orders, and obtained laboratory results using computer technology, working alongside their clinical instructors. Staff nurses spoke of their ability to teach students about protecting patient confidentiality while retrieving data.
Patient-Centered Care. One student commented that caring for all aspects of patients, not just one particular facet, was practiced in the DEU clinical model. The students witnessed positive nurse role modeling with nurse-patient interactions throughout the 12-hour shift, and students commented they made significant strides in improving their own patient care skills.
Evidence-Based Practice and Quality Improvement. Participants pointed to learning about these competencies via the unit-based teaching-learning projects. One staff nurse commented that the students’ research activities searching the evidence for best practices served the students well. Staff nurses also praised the quality of the student teaching-learning and quality improvement projects and presentations.
Important knowledge, skills, and attitudes associated with quality and safety competencies, particularly in teamwork and collaboration, were illustrated in the pilot phase evaluation. Students fully integrated onto the patient care unit and participated as team members. Greater opportunity for “teachable moments” occurred in the DEU model due to students’ increased “time-on-task” and intensive and extended learning time working alongside practicing nurses.
Students reported exceeding their clinical learning expectations in the DEU model, particularly through the collaborative relationships built on multiple levels. Staff nurses agreed and offered one suggestion for improvement; they recommended students work alongside another team member, the patient care assistant, for one shift at the beginning of the rotation, for review of requisite fundamental skills. Students highly praised the faculty coordinators for their dedication, availability, and promotion of the unit-based teaching learning projects. One student commented that “although this is a pilot program, it runs so smoothly; it feels like it has been in existence for years.”
Recommendations and Conclusion
The pilot phase evaluation demonstrates the DEU clinical education model clearly facilitated teaching and learning of quality and safety competencies. In addition, the education-practice partnership, initially created to implement the clinical education delivery model, was strengthened as a result of performing this preliminary evaluation. This pilot study of a clinical education innovation, which incorporated quality and safety competency development, exemplifies an initial step toward stronger evaluation of learning outcomes (Tanner, Bellack, & Harker, 2009). Ultimately, the DEU model also may better serve patients by improving the delivery of quality patient care.
The partnership is currently proposing the next steps to further enhance clinical education, practice, and professionalism, including an ongoing evaluation under controlled study on both DEU and traditional clinical education units of educational outcomes and transition to practice quality indicators. A more comprehensive selection of quality and safety competency statements, based on leveling for midprogram or junior students as suggested by Barton, Armstrong, Preheim, Gelmon, and Andrus (2009), for focus group interview questions or survey items is planned. This pilot study not only demonstrated early success of an innovative, collaborative clinical education model and academic-service partnership for addressing quality and safety competency development, but also a sound mechanism for sustaining efforts in ongoing evaluation.
- Barton, A., Armstrong, G., Preheim, G., Gelmon, S.B. & Andrus, L.C. (in press). A national Delphi study to determine developmental progression of quality and safety competencies in nursing education. Nursing Outlook.
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Dedicated Education Unit (DEU) Nursing Students and Staff Nurse Clinical Instructors Focus Group Questions
In looking over some of the materials about the DEU, I see frequent mention of the term collaborative working relationship. Can you tell me what this term means to you? How would you characterize a collaborative relationship in the context of this clinical rotation?
One of the important goals of the DEU experience was to help in the development of quality and safety competencies. What are safety competencies? Do you think you were able to implement them during your clinical experience on the DEU?
What are quality competencies? Do you think you were able to implement them during your clinical experience on the DEU?
Probe: Did you get instruction on (or how did you instruct about) patient-centered care (e.g., involving families, effective communication), evidence-based practice (e.g., reading research relevant to practice, integrating new knowledge), quality improvement (e.g., learning about outcomes of care, measurement of quality and outcomes), and informatics (e.g., navigating the electronic health record, documenting care in electronic record, using Internet sources for health care information)?
As the school of nursing considers continuing the development of the DEU concept, what suggestions do you have about changes that might improve the effectiveness of this experience for future students (and nurses)?