Nursing programs include three components of learning: didactic (classroom), laboratory, and clinical. Clinical learning provides an opportunity for students to apply knowledge gained from the classroom and laboratory. The clinical experience can include nursing care provided within hospitals, nursing homes, clinics, schools, and other community-based settings. The variety of clinical experiences help to develop clinical judgment, decision-making, and the holistic delivery of care to patients of associate degree nursing students. Therefore, absences from clinical experiences threaten the application of critical elements of learning to the real-world environment in health care.
Faculty acknowledged a significant increase in nursing student enrollment and increased number of student clinical absences. Patterns of absences were noted as illnesses (for the students themselves or a family member), child care issues, transportation issues, inadequate preparation for the clinical assignment, family or social commitments, and inclement weather. This led to the development of an innovative method to assign clinical points to recognize student completion of the clinical component of the course. The clinical component of learning is essential within nursing education, as faculty observation ensures student performance of safe, competent care (Oermann, Yarbrough, Saewert, Ard, & Charasika, 2009), development of clinical judgment (Benner, Sutphen, Leonard, & Day, 2010), and fulfillment of student learning outcomes. A paucity of literature exists relating to the recognition of nursing clinical completion, with point assignment credit and the effect on absences for nursing courses.
Identification of the Problem
Historically, the associate degree nursing program acknowledged the lack of attendance at any normally scheduled clinical day and attempted to rectify it. Doyle et al. (2008) and Kosta (2012) suggested that faculty must preserve the integrity of the program and hold all students accountable equally and fairly. The practice used by the associate degree nursing program was to reconcile an absence with a make-up clinical day. The makeup day was scheduled as an additional clinical day, typically occurring at the end of the semester to replace the one missed by the student. However, the scheduling of additional make-up clinical days created an overscheduling problem, as other schools of nursing were already scheduled for the same clinical day or unit. Students also had an overscheduling problem, with conflicts of other classes, examinations, or work that is scheduled for the day of the clinical make-up.
A growing problem arose over the past several years of students not having appropriate electronic patient chart access at the assigned clinical site scheduled as a make-up. Every clinical agency requires students to orient to the facility, and requests must be made for student computer accesses to electronic medical records many weeks to months in advance of the student’s arrival at a clinical site. As a result of clinical make-up days being added to students’ schedules at the end of the semester, students were unable to access electronic medical and medication records or to enter chart notes electronically, resulting in reduced clinical learning opportunities.
A final problem that was identified with the method of student absence reconciliation was the need to hire additional faculty to work the make-up day. Therefore, the additional clinical make-up day had a financial impact for the department. After discussion about these recurrent issues, faculty agreed that make-up days were no longer supportive of student learning, nor were they cost effective.
Review of Options
Alternative measures were considered for reconciling student absences, including allowing a particular number of absences without penalty, make-up assignments, and a proposed innovative idea to assign points to the clinical component of the course.
The lack of any reconciliation of incurred absences was considered as an option. However, according to Doyle et al. (2008), faculty are responsible to monitor absences, hold students accountable, and maintain the standards of the profession. When considering this option, there would be no penalty for absence from a scheduled clinical experience. It was concerning that lack of reconciliation may further reinforce the lack of attendance and potentially contribute to a reduction in student learning, sense of responsibility, and reliability. In addition, as a practice profession, nurses must develop competencies in the clinical area. The competencies are supported by student learning outcomes, measured by clinical performance in the clinical environment under the direction of a qualified nurse faculty.
Make-up assignments were considered as another option to remedy student absences by requiring the student to complete a paper or online assignment. However, faculty was concerned about the loss of clinical experiences and attainment of organization and student learning outcomes when actual patient contact is replaced with a paper or online assignment.
A strategy was proposed to assign a point value to the clinical component of the course for student attendance. The suggestion was developed by faculty to remedy the identified problems and was based on feedback from students on course evaluations requesting that credit be awarded for clinical work. The nurse faculty developed a scale to allot a point assignment to the clinical component in the sophomore-level nursing clinical courses. On a pilot basis, it was decided to assign 9 clinical points (or 3% of the total points earned for the course) to the clinical component of the course. It was also decided that if a student missed 1 clinical day, they would lose three of the points assigned, resulting in six points tallied for the clinical component. If the student missed 2 clinical days, he or she would lose six of the points assigned, resulting in three points tallied for the clinical component. If a student missed 3 clinical days, they would earn zero points for the clinical component. The maximum number of absences allotted for the clinical component of this course remained at three. An absence of a fourth clinical day constituted failure of the course. Every absence from a clinical rotation was counted, regardless of the reason.
Challenges and Opportunities
Challenges for this new clinical point assignment included the ethical aspect of students potentially attending the clinical experience when ill, in conflict with military orders, or in extremely stressful personal situations. The challenges were discussed at length, and a decision was made that a student would not be allowed to practice at clinical site if faculty determined that the student was ill. If a student attended the clinical day and was determined to be ill, the student would be sent home to maintain patient and student safety, despite the loss of clinical points. Absences in relation to military service orders, death in the family, or extreme situations/circumstances would be handled on a case-by-case basis by the faculty.
Opportunities were identified as a direct result of this new clinical point assignment. Faculty hoped that recognition and acknowledgment of the importance of reporting to the clinical site on the days assigned would transpose to increased responsibility and reliability for the nursing student and fulfillment of the student learning outcomes. Within the health care arena, absenteeism is noted to impact the budget and presents a serious problem for health care agencies to provide safe patient care (Gaudine, Saks, Dawe, & Beaton, 2013). Therefore, the importance of students attending the clinical experience as assigned reinforces responsibility, reliability, and dedication of students to their patients and health care agency. Attributes of dependability and responsibility built while attending nursing school are anticipated to carry into the work environment well after graduation. Another benefit of this implementation was the elimination of all make-up days and the financial burden associated with make-up days. As a result of this innovative measure, it was no longer necessary to hire additional faculty to complete make-up clinical days.
Evaluation of Clinical Point Assignment
An evaluation plan for the success of the initiation of the new clinical point assignment system is multifold. Comparing the number of clinical absences before the point system with the number of absences noted after implementation of this system would be a simple measure—if the number of absences decreases, the point system would be considered a success. Prior to the initiation of this pilot project, 98 make-up clinical days were scheduled. After the initiation of the clinical point assignment system, the number of clinical absences noted within the same course was 25. A reduction of nearly 75% of absences led faculty to determine that the clinical point assignment was successful. Faculty opinion supported that students were more careful about taking a clinical day off and were more cognizant about reporting to the clinical agency as assigned.
Budgetary costs were easily identified as a success by the elimination of hiring additional faculty to complete the makeup days. In an economy of budget-tightening times, the cost savings of faculty salaries for the make-up days can easily be measured as a savings.
The clinical point assignment initiative has been considered a success by nurse faculty and is anticipated that other schools of nursing could also use a similar system to the one described in this article, with an anticipation of success with these measures. Clinical point assignment is effective in promoting attendance, reinforcing commitment to patient care, and developing professional nurse characteristics.
- Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
- Doyle, L., O’Brien, F., Timmins, F., Tobin, G., O’Rourke, F. & Doherty, L. (2008). An evaluation of an attendance monitoring system for undergraduate nursing students. Nurse Education in Practice, 8, 129–139. doi:10.1016/j.nepr.2007.09.007 [CrossRef]
- Gaudine, A., Saks, A.M., Dawe, D. & Beaton, M. (2013). Effects of absenteeism feedback and goal-setting interventions on nurses’ fairness perceptions, discomfort feelings and absenteeism. Journal of Nursing Management, 21, 591–602. doi:10.1111/j.1365-2834.2011.01337.x [CrossRef]
- Kosta, J. (2012). Monitoring student attendance, participation, and performance improvement: An instrument and forms. Nurse Educator, 37, 115–120. doi:10.1097/NNE.0b013e3182504171 [CrossRef]
- Oermann, M.H., Yarbrough, S.S., Saewert, K.J., Ard, N. & Charasika, M. (2009). Clinical evaluation and grading practices in schools of nursing: National survey findings. Part II. Nursing Education Perspectives, 30, 352–357.