Dr. Terri McKown is Associate Professor, College of Natural and Health Sciences, Arkansas Tech University, Russellville, Arkansas; Dr. Leslie McKeon is Assistant Dean for Student Affairs and Associate Professor, and Dr. Webb is Assistant Professor, College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Terri McKown, DNP, FNP-BC, Assistant Professor, College of Natural and Health Sciences, Arkansas Tech University, 402 West O Street, Dean Hall 224, Russellville, AR 72801; e-mail: email@example.com.
Building a capable nursing workforce is critical to transform the care environment and create a culture of safety. Exemplary care and learning environments, established through academic-practice partnerships, are examples of innovative strategies to develop essential student competencies required for our increasingly complex delivery system (Herrin et al., 2006). To achieve optimal program outcomes, clinical education models need to support the development of quality and safety competencies among prelicensure nursing students. This article describes the development of a Dedicated Education Unit (DEU) through academic and practice collaboration and use of Quality and Safety Education for Nurses (QSEN) competencies to evaluate nursing students’ quality and safety competencies achieved during the clinical education experience.
The Institute of Medicine (IOM) (2001) report Crossing the Quality Chasm: A New Health System for the 21st Century and the Health Professions Education: A Bridge to Quality (Peterson, 2003) noted myriad system issues contributing to poor quality and wide gaps in how professionals were trained versus the demands of current practice. The IOM charged providers to render care that is safe, timely, efficient, effective, equitable, and patient centered. They also mandated educators to prepare health professionals with competencies in patient-centered care, interdisciplinary teamwork, evidence-based practice, quality improvement methods, and informatics.
In 2007, faculty and advisory board members of QSEN published six domains of nursing quality and safety based on IOM recommendations: patient-centered care, teamwork and collaboration, evidence-based practice, safety, quality improvement, and informatics. Each domain includes specific knowledge, skills, and attitude competencies to be developed during professional entry education. The QSEN competencies were integrated in the American Association of Colleges of Nursing’s (2008) Essentials of Baccalaureate Education for Professional Nursing Practice and are now embedded in nursing curricula across the nation. However, still remaining is the challenge to narrow the preparation-practice gap by developing better ways to teach nursing students essential quality and safety behaviors in clinical practice. The DEU is gaining recognition as an innovative approach for experiential learning.
Dedication Education Unit
The DEU, created in 1999 by the Flinders University of South Australia School of Nursing (Edgecombe, Wotton, Gonda, & Mason, 1999) was readily adopted by the University of Portland and its clinical partners as an exemplary clinical teaching model. The DEU is designed to promote a positive student-learning environment by capitalizing on the intellectual and experiential elements of staff nurse clinicians as teachers. Faculty use their expertise to guide staff nurses in clinical teaching and applying theoretical content in the clinical setting (Moscato, Miller, Logsdon, Weinberg, & Chorpenning, 2007; University of Portland, 2006). Outcomes of the DEU include expanded student enrollment; decreased clinical teaching costs; increased faculty time for individualized student learning; improved faculty, nursing staff, management, and student satisfaction; and enhanced recruitment of staff nurses (Miller, 2005; Moscato et al., 2007; Ranse & Grealish, 2007).
Academic Practice Dedication Education Unit
Nursing faculty from a mid-southern health science university worked with their practice partner to develop a transformational clinical educational model after attending a DEU conference at the University of Portland in the summer of 2008. The advantages for recruitment and reduced orientation time were quickly realized by the practice leaders, and the first DEU opened within 8 months. The second DEU opened in May 2009. Each DEU is a 22-bed adult acute care unit; one unit is focused on neurology and the other is focused on orthopedics. Consultants from the University of Portland assisted the academic practice team during the 8-month planning phase.
The university nursing faculty co-teach with the DEU staff nurses, who are called clinical teachers. Each clinical teacher is assigned two students. During the first 2 weeks of the 10-week course, the clinical teachers’ care assignment decreased to four patients instead of the usual six. In addition, the unit-based patient care coordinators provided extra support for patient care on these days. This allowed the clinical teachers to have time to establish a relationship with their two students and assess their learning needs and to organize daily activities. Nursing faculty are present with clinical teachers and students on the DEUs to assist with problem solving, identifying quality and safety issues, verifying student performance, and helping with other activities as needed. Faculty consult with clinical teachers daily concerning students’ performance and are ultimately responsible for student evaluation.
In addition to their Methodist University Hospital Preceptor Training, clinical teachers attend a 2-day workshop conducted by University of Tennessee Health Science Center faculty on the clinical teacher role; discussion and clarification of QSEN competencies; adult learning; teaching–learning techniques; student evaluation; and personal digital assistant (PDA) use.
In preparation for the transition from BSN to Master’s Entry Clinical Nurse Leader education in 2010, the DEUs were pilot tested with second-degree BSN students in January 2009. This article addresses one of several pilot evaluation questions. Specifically, did this new clinical education model support acquisition of quality and safety competencies among nursing students enrolled in an adult health course?
The primary author (T.M.) of this article conducted this pilot evaluation in partial fulfillment for the degree of Doctor of Nursing Practice at the university. Approval from the academic and hospital institutional review boards were obtained prior to the start of the pilot.
Participants for the evaluation included second-degree BSN students (N = 12) who were randomly assigned to the DEUs for the clinical portion of the 10-week adult health course during the second term of the three-term BSN program. Students were informed about the study purpose, that participation would not affect their course grade, and that data would not be used in the summative evaluation or course grade. In addition to their regular course deliverables, students were asked to voluntarily complete a 7-item daily QSEN log and participate in midpoint and endpoint debriefing sessions.
The author-developed DEU QSEN Log is a 7-item open-ended survey designed for students to document ways their clinical teacher helped them achieve QSEN competencies (Table). Questions focus on interdisciplinary collaboration, use of electronic information for evidence-based practice and patient teaching, patient and family decision making, quality improvement activities, and strategies used to resolve safety issues in the DEU. Two reflective questions were added after the 5-week midpoint evaluation to capture improvement suggestions and comments. The DEU QSEN Log was reviewed and revised by nursing quality, education, and test construction experts.
Table: Dedicated Education Unit (DEU) Student Log Entries by Quality and Safety Education for Nurses (QSEN) Domain (N = 148)
Prior to the start of the clinical portion of the course, students were instructed on completion of the daily DEU QSEN Log. Students were scheduled on the DEU for 2 consecutive days for 8 consecutive weeks. Each student was expected to complete 16 logs during the 8-week period, resulting in 192 logs to review. The DEU QSEN Log was posted on the course Blackboard® site in a separate section. A password was given to DEU students, eliminating data contamination from non-DEU students. Logs were not reviewed or graded by course faculty. Submitted logs were confidential, viewed only by the primary author, and kept in a locked file drawer. De-identified aggregated data were analyzed using Microsoft Excel 2003. Analyses included descriptive statistics. Results were shared with the students, clinical teachers, and clinical faculty at the 5-week midpoint evaluation to facilitate rapid improvement of the DEU clinical teaching model. The endpoint debriefing included data from the entire 10-week evaluation period.
Results showed a completion rate of 87% for the DEU QSEN Log among students. The primary author conducted a midpoint evaluation that exposed emerging trends. Students reported confusion regarding the terminology, such as clinical microsystems and safety initiatives, in the practice setting. Additional clarification on these topics with examples was provided by the primary author both in person and in Blackboard under the DEU section, along with a gentle reminder to students to complete their logs.
Three of the 12 clinical teachers participated in the midpoint debriefing, which included faculty observations, student feedback, and opportunity for clinical teachers to share their experiences. Scheduling and competing patient care priorities prevented most clinical teachers from attending; subsequently, updates were provided individually to clinical teachers by faculty. Feedback from participating clinical teachers was positive; no suggestions for improvement were offered.
For the 10-week period, the student DEU QSEN Log completion rate was 77.1%. Students submitted 148 of a possible 192 clinical log submissions. Again, scheduling conflicts prevented a group debriefing, so faculty met individually with clinical teachers to discuss course outcomes.
Teamwork and Collaboration. Students reported 177 interprofessional encounters to resolve patient problems; several students reported more than one encounter per clinical day. Students consulted physicians most frequently (25%, n = 44), followed by clinical teachers (18%, n = 32), medical social workers (11%, n = 19), physical therapists (10%, n = 17), case managers (9%, n = 14), clinical specialists (9%, n = 13), and speech therapists (8%, n = 11).
Evidence-Based Practice and Informatics. On average, each student reported accessing two or more electronic information sites to facilitate evidence-based practice and patient teaching, for a total of 201 visited sites. Mosby’s RN Drug was accessed most frequently (49%, n = 99), followed by Taber’s Cyclopedic Medical Dictionary (25%, n = 52) and Mosby’s Diagnostic and Lab (21%, n = 42). Students and clinical teachers also accessed the hospital Intranet for patient education and translation materials (4%, n = 8). The most common uses for the PDA included medication administration and safety issues followed by disease pathophysiology and corresponding laboratory values to guide patient care.
Patient-Centered Care. Students reported including patients in decision making for activities centered on scheduling of care 55% of the time (n = 76), followed by providing specific comfort measures, such as pain medication administration or position changes, at a frequency of 37% (n = 51). Other patient decision-making responses, such as discharge transportation options and educational needs, were reported at a frequency of 8% (n = 11).
Quality Improvement. Fall prevention was reported most frequently by students (27%, n = 29) as a DEU quality improvement initiative. Patient protocols, such as stroke protocols, seizure precautions, infection control, universal precautions, and the admission/discharge process, were reported at a frequency of 26% (n = 28). Medication safety administration (e.g., route, dosage, six patient rights, and labeling/mislabeling) was cited 19% of the time (n = 20).
Safety. Fall prevention (32%, n = 30) and medication administration (23%, n = 21) were the two most common safety issues reported by students.
DEU Reflection. Students shared that the DEU was “informative and enlightening” and provided a “rewarding experience…that allowed me to leave with more knowledge about safety and quality, and a clear advantage in the clinical setting versus students in the traditional model.” One student shared that the DEU “has been the best part of my experience…because it is such a more encompassing, educational and collaborative [experience] with efficient use of limited clinical time.” Another student wrote that there was a sense of “integration between us and all of the nurses, enabling them to be part of the team instead of an outsider looking in.” Students did not report any negative statements concerning their DEU experience.
Clinical teachers also reflected on the DEU experience. They defined the students as “our students” and took “pride” in participating in their learning transformation. One clinical teacher stated “it kept me on my toes” and that she “enjoyed” the enthusiasm the students brought each day.
Overall, the DEU QSEN Log completion was 77.1%. Although the rate was better than expected, student adherence declined at the end of the course. During the last 3 days, survey submission decreased by 30%, suggesting survey fatigue.
Findings suggest the DEU was successful in supporting development of quality and safety competencies among intermediate nursing students. Participants self-reported numerous examples of how they were mentored by their clinical teacher, including consulting with the patient care team, using PDAs to access clinical information, including patients in decision making, and ongoing discussions of microsystem quality and safety issues. Implications for further evaluation include measuring students’ ability to initiate these actions and behaviors independently during the final internship clinical experience.
The finding that 25% of interprofessional collaboration was with the physician was a welcome result because it has been mentioned anecdotally in nursing leadership circles that many students graduate without speaking directly to a physician. This assertion is further supported in a recent survey on graduate nurse performance by 5,700 nurse leaders conducted by the Nurse Executive Center (Berkow, Virkstis, Stewart, & Conway, 2009). The authors reported that only 23% of nurse leaders believe that new graduates are competent in communicating with physicians, and only 38% of the respondents believed that new nurses possess the skill to communicate with professional team members. The pilot data suggest that the low student-to-clinical teacher ratio (2:1) may provide more opportunities for interprofessional collaboration and better facilitate achievement of teamwork competencies than the traditional clinical teaching model.
Another significant finding was the high satisfaction of the DEU experience reported by students and clinical teachers, particularly in regard to effective use of time. This is particularly important because in a study of nursing students by Candela and Bowles (2008), most reported wanting more clinical hours to better prepare them for the workforce. In a traditional clinical teaching model, each faculty member is assigned eight to nine students in a health care setting and is responsible for providing theoretical and practical instruction. It is common practice for students to wait for faculty to perform skills that require validation (i.e., giving medications, conducting a patient assessment, performing invasive skills). Conversely, the DEU model increases the amount of productive learning time, providing students with more opportunity to perform assessments, learn safe practice, and collaborate with the interprofessional team without increasing clinical hours.
Although no critical events occurred during these rotations, students did identify several near misses and had the opportunity to report the event to the patient care coordinators, who in turn followed-up to correct the error. Near misses included mislabeled medications (name and dosage), wrong medication in patient drawers, and incorrect documentation of medication on medication administration record when compared with physician’s orders.
Limitations to this pilot study included the small sample size and lack of a control group or historical data for comparison. Reasons for these limitations are two-fold. First, there was an insufficient number of second-degree students for comparison groups. Second, due to a grant-related requirement, survey data of graduating students on QSEN competency achievement were anonymously reported and therefore were unable to be stratified for comparison. Subsequently, comparative studies were postponed until after the start of the Master’s Entry Clinical Nurse Leader program. Lack of psychometric testing of the QSEN Log beyond face validity was another limitation. For example, there were redundancies in the DEU QSEN Log (e.g., fall prevention was listed under both the quality improvement and the safety domains). Subsequently, similar data were often reported in two domains. Recommendations include revision to the DEU QSEN Log to eliminate redundancies and improve reporting uniformity using checkboxes. A second recommendation is to embed the revised Log questions into the course evaluation tool used by all students. These changes will likely improve the student response rate and, more importantly, enable comparison of student outcomes between DEU and non-DEU clinical settings.
Future studies are needed to better understand the role of the clinical teacher in the DEU learning environment for supporting QSEN competency development among prelicensure students. For example, assumptions were made that quality and safety knowledge skills and attitudes were similar for clinical faculty and DEU clinical teachers; however, these assumptions were not tested. Focus groups with clinical teachers and students may also capture additional information regarding the QSEN DEU Clinical Log and DEU experience. In addition, many programs assign students to exemplary learning units used by multiple programs on different days and shifts. These units are known in some regions as designated education units. More needs to be known whether designated education units will support QSEN competency development similarly to a DEU.
This pilot study suggests that the DEU shows potential as an effective teaching model for building a nursing workforce capable of providing safe, quality care for complex patients. Staff nurses functioning as clinical teachers serve an essential role in helping prelicensure nursing students achieve competency in quality and safety early in their professional development. Finally, QSEN competencies provide an excellent framework for teaching clinical teachers how to mentor students in quality and safety and evaluating learning outcomes.
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/Education/pdf/BaccEssentials08.pdf
- Berkow, S., Virkstis, K., Stewart, J. & Conway, L. (2009). Assessing new graduate nurse performance. Nurse Educator, 34, 17–22.
- Candela, L. & Bowles, C. (2008). Recent RN graduate perceptions of educational preparation. Nursing Education Perspectives, 29, 266–271.
- Edgecombe, K., Wotton, K., Gonda, J. & Mason, P. (1999). Dedicated education units: 1. A new concept for clinical teaching and learning. Contemporary Nurse, 8, 166–171.
- Herrin, D., Hathaway, D., Jacob, S., McKeon, L., Norris, T. & Spears, P. et al. (2006). A model academic-practice partnership. Journal of Nursing Administration, 36, 547–550.
- Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
- Miller, T.W. (2005). The dedicated education unit: A practice and education partnership. Nursing Leadership Forum, 9, 169–173.
- Moscato, S.R., Miller, J., Logsdon, K., Weinberg, S. & Chorpenning, L. (2007). Dedicated education unit: An innovative clinical partner education model. Nursing Outlook, 55, 31–37.
- Peterson, C. (2003). Institute of Medicine report—Health professions education: A bridge to quality. Retrieved from http://findarticles.com/p/articles/mi_qa4102/is_200308/ai_n9262559
- Ranse, K. & Grealish, L. (2007). Nursing students’ perceptions of learning in the clinical setting of the dedicated education unit. Journal of Advanced Nursing: Original Research, 58, 171–179.
- University of Portland. (2006). Dedicated education unit: Purpose, features & roles. Retrieved from http://nursing.up.edu/showimage/show.aspx?file=8189
Dedicated Education Unit (DEU) Student Log Entries by Quality and Safety Education for Nurses (QSEN) Domain (N = 148)
|QSEN Domain||Activity||Log Entries||Rate % (n)|
|Teamwork and collaborationa||Briefly describe a patient-focused problem that you or your clinical teacher discussed with another licensed professional on the health care team; include the title of the professional and key aspects discussed.||Physician||25 (44)|
|Clinical teachers||18 (32)|
|Medical social workers||11 (19)|
|Physical therapist||10 (17)|
|Case manager||9 (14)|
|Clinical specialist||9 (13)|
|Speech therapist||8 (11)|
|Evidence-based practicea||List the electronic sites that you or your clinical teacher accessed with your personal digital assistant or through the Intranet or Internet to facilitate evidence-based practice and patient teaching (excluding electronic medical records).||Mosby’s RN Drug||49 (99)|
|Taber’s Cyclopedic Medical Dictionary||25 (52)|
|Mosby’s Diagnostic & Lab||21 (42)|
|Hospital Intranet or Internet||4 (8)|
|Patient-centered care||Briefly describe how you or your clinical teacher included the patient or patient’s family in clinical decision making.||Scheduling of care||55 (76)|
|Comfort measures||37 (51)|
|Quality improvement||Briefly describe a microsystem quality improvement initiative that you and your clinical teacher discussed today.||Fall prevention||27 (29)|
|Patient protocols||26 (28)|
|Medication safety||19 (20)|
|Safety||Briefly describe a safety issue that you and your clinical teacher identified on the DEU. Include your plan for communicating the information to the microsystem process owner.||Fall prevention||32 (30)|
|Medication administration||23 (21)|