Faculty leaders are challenged to transform prelicensure nursing education to increase enrollment capacity and ensure that graduates have developed the clinical reasoning ability and clinical competencies needed for current practice. Although enrollment has increased nationally, the American Association of Colleges of Nursing's (2015) most recent annual report revealed that in 2014, 50,681 qualified applicants were denied admission to U.S. baccalaureate nursing programs. In addition, the National League for Nursing's (2014) biennial survey of schools of nursing revealed that a lack of clinical placements and insufficient numbers of faculty were among the main obstacles to baccalaureate program expansion.
The search for solutions to capacity issues must be considered concurrently with the quest for ongoing nursing program quality improvement. The Carnegie Foundation for the Advancement of Teaching report, Educating Nurses: A Call for Radical Transformation, asserts that new graduate nurses are unprepared for the complexity of current nursing practice (Benner, Sutphen, Leonard, & Day, 2010). This report calls for shifts in thinking and approaches to nursing education that include a focus on salience and situated cognition, an integration of didactic and practicum teaching, a shift to clinical reasoning and multiple ways of thinking, and an emphasis on formation.
The dedicated education unit (DEU) clinical education model was developed as an innovation to increase enrollment capacity and secure stable clinical placement sites in units that provide an optimal learning environment (Moscato, Miller, Logsdon, Weinberg, & Chorpenning, 2007). A DEU is reserved for the exclusive use by one school of nursing whose nursing students learn in a consistent dyadic partnership with a qualified staff nurse clinical instructor (CI), who is, in turn, mentored as a teacher by a faculty member from the affiliating school. The CIs foster students' acquisition of the knowledge, skills, and judgment that are requisite for practice (Moscato et al., 2007). Evidence to support the effectiveness of the DEU model has only recently begun to emerge. Preliminary evaluations suggest that enrollment capacity can be increased (Moscato, Nishoka, & Coe, 2013) and staff and student satisfaction are higher in the DEU clinical learning environment (Moscato et al., 2007; Rhodes, Meyers, & Underhill, 2012; Saxton, Warmbrodt, Mahley, Reberry, & McNeece, 2015). Several studies have explored the perceptions of CIs, students, managers, administrators, and faculty (Nishioka, Coe, Hanita, & Moscato, 2014a; Nishioka, Coe, Hanita, & Moscato, 2014b); however, faculty participants have been recruited only from a single site. Jeffries et al. (2013) suggested that a significant faculty responsibility shift is inherent in clinical experiences that are based on the DEU model. Similarly, Moscato, Nishioka, and Coe (2013) emphasized the need for purposeful reframing and dialogue about the faculty member's transition to teaching in a DEU. Studies of other faculty role transition experiences reveal that a period of adjustment can be expected for faculty who are either new to teaching or new to a different learning environment. Faculty may go through a period of working through identity formation until they achieve fulfillment in the role (Clark, 2013; Schoening, 2013). It is imprudent to assume that teaching expertise in one learning context will transfer to immediate adaptation into a new teaching and learning environment.
The faculty experience of teaching or transitioning to teach in this clinical model has not been studied across multiple programs. The purpose of this study was to describe, interpret, and offer insight into the meanings of the lived experiences of nursing faculty in DEUs across seven prelicensure baccalaureate programs in the United States.
A growing body of evidence is emerging that demonstrates that students who learn in DEUs perform as well on standardized tests, classroom tests, or simulations compared with students learning in the traditional faculty-led model (Hendricks, DeMeester, Stephenson, & Welch, 2016; Smyer, Gatlin, Tan, Tajeda, & Feng, 2015). Polvado, Sportsman, and Bradshaw (2015) compared several outcome measures for DEU and traditional students, including Survey of Student Engagement scores, HESI examinations, course grades, course failures, and self-reports of quality and safety competency. Although DEU students perceived greater progress in development as a nurse than students learning in a traditional clinical environment, no statistical differences in any other outcome measure were reported.
Mulready-Shick and Flanagan (2014) interviewed 12 CIs working in DEUs, 12 staff nurses, three faculty, and seven DEU partners. Using a hermeneutic approach to theme identification, seven themes emerged: Engaging in Recurring Communication, Problem Solving, Working Together, Recognizing Unfamiliarity With Changing Roles and Responsibilities, Valuing Interdependence, Complementary Competence, and Equalizing Power Balance, Witnessing Teamwork, and Advocating for a DEU Future. Unfamiliarity, anticipation, uncertainty, and letting go were among the sentiments expressed by participants in the various roles.
In a study of 473 nursing students, Nishioka, Coe, Hanita, and Moscato (2014a) found that DEU students were more likely than students in the traditional model to agree that the learning atmosphere, unit manager's leadership style, patient care, and the nature of the clinical supervisory relationship were of high quality. However, DEU students rated both the cooperation between staff and faculty and the clinical faculty's ability to integrate theory and practice lower than students in a traditional model of clinical teaching. DEU students were less likely than traditional students to perceive that the faculty members were part of the nursing team.
In addition, Nishioka, Coe, Hanita, and Moscato (2014b) used the Clinical Nurse Teacher Survey to examine the perceptions of 69 staff nurses from DEUs and traditional model units. DEU CIs had significantly higher mean scores on sub-scales of unit atmosphere, nature of relationships, professional development and faculty support, and student benefits and learning. The DEU CIs reported being equal partners who communicated with faculty about evaluation, goals, and student concerns. The importance of faculty in-person check-ins was appreciated, and faculty feedback was welcomed. Irregular communication from faculty contributed to CI dissatisfaction. Nurses in the traditional model expressed dismay that teamwork was not emphasized and that faculty expected students to know all the answers, rather than encouraging them to use decision support resources.
Although the emerging evidence indicates that stakeholders view student learning and participation in the DEU model positively, measurable cognitive performance indicators do not reveal significant differences. The current review suggests that the DEU faculty role may need to be refined to ensure that CIs perceive adequate support and that students view the faculty as a member of the team who contributes to their learning.
Van Manen (1990, p. 101) offered four lifeworld “existentials” as guides to reflection: (a) lived space (spatiality), (b) lived body (corporeality), (c) lived time (temporality), and (d) lived human relations (relationality or communality). These four existentials are considered to be the fundamental structures of the lifeworld in phenomenological human science.
The researcher used hermeneutic interviews for data generation. The research question that guided the study was: What is the meaning and significance of the lived experience of being a faculty member in a DEU used for prelicensure baccalaureate nursing education? Institutional review board (IRB) approval was obtained, and all IRB protocols were adhered to related to confidentiality and signed informed consent. The hour-long audiotaped interviews were conducted during a 4-month time frame. Each participant chose a private setting for the interview. The researcher asked open-ended questions and probes to explore the meanings and feelings associated with the experience of becoming and being a DEU faculty member. Immediately after the interview, the researcher recorded observations and reflections in the form of written field notes.
Purposive sampling using electronic participation invitations yielded a total of eight full-time nursing faculty member participants from five different states across the United States. The participants taught in the DEU model in seven prelicensure baccalaureate nursing programs. There was representation from public and private, urban and suburban, and large and small universities or colleges. All participants were women, with an age range of 30 to 69 years. Nursing experience ranged from 10 to 45 years, with an average of 26.9 years in nursing. Years of experience in academia ranged from 2 to 30 years. Four had earned doctorates and four were prepared at the master's level. All participants had previously taught using the traditional faculty-supervised clinical model, with this experience ranging from one semester to 27 years.
Colaizzi's (1978) method of phenomenological analysis was used in tandem with van Manen's (1990) philosophical approach to formulate meanings and theme clusters. In preparation for this method of analysis, verbatim transcriptions of the interview audio recordings were completed by the researcher during the data collection process. Phenomenological data collection and data analysis occurred simultaneously to identify when saturation had been achieved. A written audit trail was maintained and audio-recordings were kept as password-protected digital files. The researcher used prolonged engagement with the interview transcripts through multiple readings and engaged in member checking with the interviewees. Two nurse researchers periodically dialogued about the unfolding analysis. To bolster authenticity, the list of interview probes included an invitation for participants to share stories of both successes and challenges in the faculty experience in the DEU.
Three major themes, with a total of nine subthemes, emerged that elucidated the overall essence of what faculty may experience during the journey to prepare for, adapt to, and ultimately sustain, embrace, and become the guardian of the synergy of learning that underlies the learning environment inherent in the DEU clinical model. The faculty participants often described how they learned to adapt to DEU clinical teaching as a process that evolved over time. The Figure depicts this evolution.
Overall essence of the dedicated education unit (DEU) faculty lived experience.
A DEU capitalizes on both the teaching expertise of the education partner and the clinical practice proficiency of the hospital partner in the creation of a new learning environment that is synergistic in nature. The term becoming was chosen to portray the passage to a new faculty role experience and guardian of synergy to capture the essence of the faculty narratives about how they perceive their responsibilities in supporting the model and its stakeholders. One participant explained, “I'll give you an analogy. It's like when you're cooking something on the stove. You're constantly checking it and it's simmering just like it should be.”
Preparing for a New Synergy of Learning
The participants had varying degrees of involvement in the development of their DEU as a learning site, and all emphasized that a united vision and shared governance among the partners must underlie the formation of a successful DEU. Most participants indicated that contractual agreements between the leadership of the school of nursing and the health care organization were established prior to their involvement. They stressed the importance of the alliances of upper management. One participant stated, “You need the leadership buy-in to make this work”; however, this was viewed more as an antecedent to their own lived experience, which began with personal preparation at the unit level.
Am I Ready? The participants explained preparatory approaches that included reading current literature, attending conferences, spending time in the unit, shadowing, and dialoguing with other experienced DEU faculty members. Most emphasized that they designed modifications deemed suitable for the learning environments of their own DEU and ultimately assumed ownership. As one put it, “You can read until you're blue in the face, but until you've lived it, you cannot appreciate those nuances.” Another explained, “Once I got familiar with that unit, I've really taken it on as mine and have developed all kinds of things.”
Are They Ready? Participants addressed the importance of the orientation and staff nurse preparation for the CI role prior to the implementation of the model or as new CIs join the teaching team over time. Several described formal orientation events held at the university that included explaining course outcomes, role-playing, using evaluation tools, and delineating expectations for students and CIs. Several were involved as an organizer or a presenter for the workshops.
Are We Ready? The participants explained how they experienced working collaboratively with managers, staff educators, or other nurse leaders at the unit level to become a cohesive team of “we,” with shared expectations and mutual respect. Scheduling logistics were mentioned as a critical, yet very time-consuming and frustrating element in developing an infrastructure. One participant described the dialogue during a meeting with the unit leadership as, “We sat down, the three of us, and talked about how we wanted to set it up. We wanted these students to feel part of the staff.”
In addition, the participants emphasized the importance of all stakeholders “being on the same page.” Several participants emphasized that each DEU has a unique culture and that no DEU will operate exactly like another; therefore, the faculty must work with the appropriate parties within the school of nursing and the agency to create the framework that will both fulfill the needs of all stakeholders in the DEU and fit with the missions of the two partners and the curriculum.
Adapting to a New Synergy of Learning
Participants shared how they had experienced the process of learning to adapt as a faculty member in this new clinical model. Two subthemes emerged: gaining and awarding trust, and reframing their faculty lifeworlds.
Gaining and Awarding Trust. The participants talked about trust as a reciprocal phenomenon. They described how they came to earn the trust of the CIs and their own feelings about trusting the CIs and the students. Although they emphasized the importance of being open and earning others' trust, they experienced trust in different ways. Two participants described initial feelings of being a guest or an outsider and the proactive, yet gentle approach they used to gain acceptance. Several shared how they developed trust in CIs' ability to teach the students as they reflected on their own limitations when trying to be “all things to students.” One participant summarized joint trust acquisition as, “They could see that I knew what I was talking about…and I appreciated them for what they had to offer.”
Reframing the DEU Faculty Lifeworlds. The participants' stories revealed transformations in the meanings of their faculty lifeworlds as they ventured into teaching within the DEU clinical model. Through their narratives, their perceptions of van Manen's (1990) dimensions of lived body, lived time, lived relationships, and lived space emerged.
Lived Body. In response to the question, “What is the meaning of faculty presence?” in the DEU model, several participants described initial feelings of grief or doubt as they realized that their sense of embodiment in the DEU was different from that in the traditional model. One participant explained, “There was definitely a transition in my role in how I felt because I used to be indispensable to the students. They would need me.” Another participant with many years of teaching experience described what she perceived as a loss in this way:
What's my role? Who am I? What am I supposed to be doing? And it was awkward, because typically in the past I'm going to the room with the students, helping them get their medications out. Well, they were with their nurses doing that now. The biggest thing that I've given up is the actual ability to stand back and see the learning that's taking place in my students and since I had been a clinical instructor for so many years, I derived a great deal of pleasure from that.
The theme that had the greatest variation was how the participants perceived the meaning and importance of their physical embodiment on the DEU. They spoke of the frequency and timing of visits, when or if they chose to leave, and their actions. The participants' accounts of embodiment fell along a continuum, with continual physical presence during student experiences at one end of the spectrum and rare physical presence on an as-needed basis at the other. One participant explained, “I need to be able to have a presence so that I'm there enough, but not where I'm annoying.” Some participants purposefully planned a periodic physical presence at varying, yet regular intervals. The participants described making decisions about presence within the context of their personal insights into the culture of their specific DEU and their perception of the needs of the CIs and students.
Participants discussed specific situations in which their physical embodiment might include performing nursing actions during busy times. Several described situations involving more intentional engagement in nursing actions with students either because a learning opportunity had arisen or as a deliberate component of student evaluation.
Lived Time. Van Manen (1990) considered lived time to be more of a time orientation to past, present, or future, rather than actual clock time. Most faculty participants spoke of the frustration they encountered in the past when teaching in the traditional model and collectively spoke of how the present experience spawned their hopes for the future of the DEU students who would enter the profession more prepared. It was this sense of optimism for the futures of the students, the profession, and the blossoming nurse educators that highlighted the essence of the participants' lived time. One participant shared excitement that “being embedded with the nurse from the very beginning really gives the student a sense of how they're going to have to figure out how to organize their day, how to prioritize their day.”
Lived Relationships. The participants disclosed how they experienced changes in the meaning of their relationships with agency leaders, students, and CIs. Several participants imparted a sense that the nature of relationality with students had changed. One explained, “The relationship is different, but I also have more time to speak with the student. I'm able to gauge their challenges and areas of need.” Others commented on the strong bonds that can develop between the CIs and students without them, and one shared that it was hard to walk away when the CI and student were starting their day together. The participants characterized their communication with CIs as intentional and frequent as they interacted outside of scheduled clinical time via telephone or e-mail.
Several participants included their faculty colleagues when discussing changes in lived relationships as a DEU faculty member. Some participants perceived a sense of curiosity, or even skepticism or “raised eyebrows,” from their faculty peers. Two of the participants alluded to feelings of needing to collect evidence or explain the model to garner more support from faculty colleagues. As one explained:
We've had some pushback. There are a few faculty members, they don't really understand it. They don't know that the outcomes and standards are upheld like they would be in a traditional clinical unit. But there are questions about it. “What is it that you do? Do you just sit there?” We have to prove ourselves. I think I sort of expected it, but you know atfirstit hurt my feelings a little, but then I got over it.
Lived Space. The most common overall space of learning for the DEU faculty was primarily the confines of the DEU itself; however, the participants described an expanded sense of their lived space of clinical teaching that included their office, their home, or cyberspace. They spoke of communicating electronically with students through e-mail, discussion forum reflections, or virtual postconferences. When present in the DEU, they positioned themselves centrally or made walking rounds. Several described using a classroom at the school or the agency for group learning conferences.
Sustaining a New Synergy of Learning
The participants described the supportive essence of being a DEU faculty member as making sure things are going well. The four subthemes that emerged were Supporting CIs as Teachers, Supporting Student Learning and Evaluation, Supporting DEU Processes, and Supporting Evidence-Based Nursing Practice.
Supporting CIs as Teachers. The participants embraced the responsibility of providing ongoing mentoring and support for the CIs. One participant described the essence of this as, “making sure they don't think they know everything, but yet reinforcing what they do know.” Participants discerned the importance of facilitating the CIs' understanding of appropriate expectations for the various levels of students who were on the DEU each semester. Participants explained how they supported the CIs' ability to foster students' critical thinking, clinical reasoning, and giving both positive and constructive feedback.
Supporting Student Learning and Evaluation. Wide variations were reported in how much time the faculty participants spent on the DEU interacting with students; however, several discussed their perception that the DEU enhanced their ability to spend quality time with nursing students, bridging the academic–practice gap. One explained, “The CIs still don't have a lot of time to really sit down and analyze, and tear apart and think about process, and think about development. I can do that.”
Participants discussed the benefits and ramifications of having the DEU staff members take part in the evaluation of students. One commented, “Everyone's sort of watching and the students know that. And I would say that they raise the bar in terms of professionalism because of it,” whereas another explained, “They can't fly under the radar.”
Participants explained they had approached some difficult teaching and learning situations that had arisen with students in their DEU. Their narratives included stories of how they intervened to support learning when difficulties in professionalism or engagement arose or when cultural factors were impeding student learning.
Supporting DEU Processes. The DEU faculty members described being integrally involved in day-to-day problem solving, global ongoing evaluation of the DEU as a learning environment, and the continuous quality improvement needed for the success and sustainability of the DEU. Some elaborated on facilitative interventions such as being a matchmaker of CI and student personalities. Other unanticipated situations that required action included exposures and CI unavailability.
Supporting Evidence-Based Nursing Practice. Participants related stories in which they were involved in supporting safe, evidence-based nursing practice for students and CIs, typically in response to students' concerns. They perceived that students may have had unrealistic expectations and experienced cognitive dissonance between what they had learned and what they observed in practice. One respondent recounted listening to the students and explaining that some acceptable variations in practice may be witnessed. However, legitimate concerns about safe practice occasionally surfaced and the respondents felt compelled to have conversations with students, CIs, or managers. One respondent described the delicate nature of these interactions in this way, “You walk a fine line between you're not their friend and you are not their boss. I tread kind of lightly.”
Gaining insight into the meanings of the experiences of faculty in a DEU has several implications for nursing education. Participants found value in preparing themselves for engagement in the DEU model and emphasized the importance of collaborating with managers and staff at the unit level to develop relationships and an infrastructure to facilitate success within the unique culture of the chosen unit. Although the participants generally expressed an overall optimistic perspective, their stories of their experiences inform current and prospective faculty about challenges they may encounter and how they can best prepare for success.
Faculty members who are new to the DEU clinical model may face decisions about their own physical presence and the nature of their interactions with CIs and students. The faculty role in the DEU model is focused primarily on mentoring CIs; however, only two of participants in this study elected to minimize their contact with students during clinical experiences. Both expressed deep initial feelings of loss of their identity as a teacher, yet high perceptions of trust in the CIs. Although others might speculate that faculty who venture into teaching in a DEU have difficulty relinquishing control over student learning, it is important to consider that faculty may need to feel a sense of purpose in their teaching role, regardless of the model. The participants who chose to be regularly present in the DEU often described fostering students' clinical reasoning or wanting to be helpful to the busy CIs.
Several participants utilized individual or group debriefing to maintain a learning connection with their students. Faculty may consider holding office hours or telephone time with DEU students for dialogue and feedback regarding their individual reflections about their experiences. To engage students in learning from each other, in-person group meetings either at the agency or on campus, online asynchronous discussion forums, or synchronous online chat sessions may be arranged at times that fit into the unique clinical schedule of each DEU.
In light of the emerging evidence that no significant difference has been found in students' standardized test performance between traditional and DEU clinical models, it is important that the potential benefits of faculty presence and faculty engagement with students in a DEU be more deeply considered. Much of the evidence about students' clinical performance in a DEU is anecdotal, and it remains unknown whether differences exist in measurable clinical learning outcomes for students who learn from only a CI and those who learn from both a CI and an engaged and present faculty member who fosters clinical reasoning skills.
One of the most frequently reported issues encountered by the participants was students' questioning whether the care they observed while working with the CIs was consistent with evidence-based nursing practice. Although some variations were deemed acceptable, at times the participants had to bring unit practice issues to the forefront. Faculty who are considering a DEU faculty role may anticipate that students will likely require assistance in thinking through practice issues. It is also possible that they may uncover actual unsafe CI practice habits that must be handled with tact and framed as an opportunity for improvement and support of evidence-based practice. Faculty should be aware that boundary issues may potentially arise.
Faculty members play a pivotal role in evaluating and sustaining a DEU through supporting CIs, students, DEU processes, and nursing practice. As the guardians of the synergy of learning that is the foundation for this model, faculty members nurture the CIs as teachers; facilitate authentic, deep student clinical learning; and elevate evidence-based nursing practice through openness, reciprocal trust, and a mutual sharing of knowledge and expertise that each brings to the partnership. Viewing these complementary abilities in a positive light with a focus on making new contributions to nursing may facilitate a positive adaptation experience for the faculty. Each DEU has a unique culture, and the processes and logistics must be tailored to meet the needs of all partners to the fullest extent possible.
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