Few would argue about the primacy of the clinical learning experience in prelicensure nursing education, and research has demonstrated that many factors influence quality outcomes, including the attitudes of unit nurses toward students and organizational structure issues (Courtney-Pratt, FitzGerald, Ford, Marsden, & Marlow, 2012). Traditional clinical learning models have long been questioned by educators. In response, innovative academic–service partnerships, with precepted learning opportunities such as dedicated education units (DEUs), have become popular, often with demonstrated sustainability (Mulready-Shick & Flanagan, 2014). Understanding the strengths and challenges associated with various clinical models remains an important concern for nurse educators. The current study compares three clinical models that have been in use for years across several sites in multiple agencies, providing an opportunity to consider how the clinical learning model impacts nursing students' clinical education in sustained academic–service partnerships. Are there differences among clinical models regarding standardized test performance, opportunities for practice of skills, and student satisfaction?
The current study examines stakeholder perceptions and student outcomes across three models—the traditional learning model (TLM), the practice–education partnership (PEP) model, and the hybrid learning model (HLM)—used for clinical nursing education at a large public university in the midwestern United States. In the TLM, one faculty member directly supervises between five and 10 students in one or several related clinical nursing units. Although faculty and students work alongside staff nurses, no formal arrangement exists for staff nurses to teach or mentor students.
The PEP model was implemented in 2008 and included a DEU similar to that described by Moscato, Miller, Logsdon, Weinberg, and Chorpenning (2007). This model continues to be used in adult and pediatric settings across multiple health care systems in collaboration with one large school of nursing. In this model, one faculty member mentors a trained staff nurse preceptor, who directly supervises one to two students in the provision of care. The faculty member is directly available for most of the clinical time, but when the individual is not directly in the unit, he or she is quickly available by telephone or pager. The HLM was introduced in one hospital system due to a shortage of qualified preceptors in two of the PEP model units. The HLM incorporates aspects of the TLM and the PEP model. A faculty member directly supervises approximately half of the student groups, while also mentoring staff nurse preceptors, who each work with one to two students. Students self-select into a PEP model, TLM, or HLM unit during two junior-level medical–surgical acute care clinical rotations.
Improving clinical learning is key to preparing graduates who are ready to transition to RN practice and to meet the demands of a challenging practice environment. Because of the primacy of clinical learning for practice, clinical learning models should be carefully evaluated to determine their relative strengths and challenges. In an early review of preceptored learning, Udlis (2008) found that more than half of the studies included in her integrative literature review supported the use of preceptor models in nursing education; however, even today, few studies have attempted to evaluate student learning outcomes and stakeholder perceptions of various long-standing clinical models. Studying these clinical models will inform the ability to transform clinical nursing education and provide direction for future development.
The purpose of the current study was to examine the perceptions of students, faculty, and preceptor stakeholders in three types of clinical learning models. In addition, student learning opportunities and student learning outcomes were studied across the three clinical learning models. The research questions were:
- Is there a difference between the type of clinical learning model and perceptions of students about the clinical learning environment?
- How do student, faculty, and preceptor stakeholders describe the time spent engaged with one another?
- Is there a difference in the amount of student practice opportunities across the three clinical learning models?
- Is there a difference in standardized test scores across the three clinical learning models?
Students in precepted clinical situations, such as DEUs, value their precepted experiences, noting that when they work with staff nurse preceptors over time, they perceive enhanced mentoring, skill development, and readiness for the practice environment, as well as a more welcoming environment (Nishioka, Coe, Hanita, & Moscato, 2014). However, not every analysis of student satisfaction has found DEUs to be superior over time (Hendricks, Wallace, Narwold, Guy, & Wallace, 2013). Precepted clinical rotations are purported to enhance students' knowledge base, clinical skills, clinical judgment, confidence, communication, and role socialization. However, limited evidence exists to support these assertions (Hickey, 2010). Nursing clinical education using precepted models has been found to enhance opportunities for students to practice clinical skills (Hendricks et al., 2013). Theoretically, clinical education models that allow students to engage in realistic situations and roles should positively impact the value of the clinical experience (Rohlfing, Rehm, & Goecke, 2003).
Preceptors in DEUs often report feeling energized and challenged, but they are uncertain about evaluating students and ways to teach critical thinking. Further, preceptors value and desire increased faculty support in challenging student situations (DeMeester, 2012). Orientation to the preceptor role is crucial and should include a focus on adult learning principles, specific student learning outcomes, curricular outcomes, and problem solving (Broadbent, Moxham, Sander, Walker, & Dwyer, 2014). The engagement of preceptors is critical to the sustainability of the DEU and other precepted models.
Among faculty, the establishment of trust, rapport, leadership, and excellent communication with the clinical unit is important in all clinical education models (Glazer, Ives Erickson, Mylott, Mulready-Shick, & Banister, 2011). Faculty report frustration with the constraints of the clinical TLM and the difficulty of overseeing the care of numerous nursing students and their patients, which results in much larger ratios than the typical nurse-to-patient ratios in acute care today. For example, clinical instruction typically uses ratios of six to 10 students per one faculty member, whereas acute care units in hospitals maintain significantly lower nurse-to-patient ratios. The considerations involved in facilitating a precepted clinical experience are also challenging. Faculty teaching in a precepted situation must adapt to an unfamiliar role that includes remaining relevant and engaged when not directly supervising the actions of the students (Rhodes, Meyers, & Underhill, 2012).
Although innovation in clinical education continues to be a critical need in nursing education (Niederhauser, Schoessler, Gubrud-Howe, Magnussen, & Codier, 2012), the creation and evaluation of sustained innovation also remains important. Students, faculty, and preceptors alike may be highly positive about an innovative educational strategy at first, but an important measure is whether the innovative model is sustainable and scalable—that is whether the positive results reported initially are sustained over time.
The current study used a quasi-experimental design to examine the perceptions, opportunities, and learning outcomes of the TLM, the PEP model, and the HLM among stakeholders. Participants included junior baccalaureate nursing students enrolled in a medical–surgical clinical course, RN preceptors for those students, and faculty teaching all sections of the clinical courses. Qualitative methods were also used to describe the perceptions of students, preceptors, and faculty, which are reported elsewhere.
Junior nursing students self-selected into a TLM, PEP model, or HLM at the time of registration into a medical–surgical course. Clinical faculty were assigned by their department chair in a nonrandom manner to teach at the various clinical sites. RN preceptors had 3 years of RN practice experience, preceptor training, and supervisor recommendation and were willing to serve as preceptors in the clinical nursing units.
The student perception of the learning environment was measured using the Student Evaluation of Clinical Education Environment (SECEE) Version 3 tool (Sand-Jecklin, 2009). This instrument measures student perceptions about three subscales—Instructor Facilitation of Learning, Preceptor Facilitation of Learning, and Learning Opportunities. The scale has an overall alpha coefficient of .94, and its subscale reliability coefficients are also strong (Instructor Facilitation of Learning = .94; Preceptor Facilitation of Learning = .89; and Learning Opportunities = .82). The instrument is a forced choice, 32-item questionnaire, scored on a scale of 1 to 5 (the higher numeric values representing desirable scores).
Students, faculty, and preceptor stakeholders described the time spent engaged with one another via a researcher (S.H.)-developed questionnaire that included demographic data and several questions involving estimating time spent in various types of communication. Each stakeholder group was asked similar questions about how often and for how many minutes the students spent working with faculty and preceptors and in observational experiences. In addition, each stakeholder estimated the percentage of overall clinical time in individual or group meetings with one another.
In response to a question on the researcher-developed survey, the number of practice opportunities was estimated by students. Students were asked to estimate the number and type of several common practice opportunities throughout the clinical rotation. Students were asked about documentation in patients' electronic health records, communication with members of the health team, and practice opportunities of several common nursing psychomotor skills. Student learning outcomes were measured using integrated test scores on the Kaplan medical–surgical examinations, which have been nationally normed. After obtaining students' permission, scores on their Kaplan standardized medical–surgical examinations were matched with student clinical learning model groups, allowing the evaluation of differences in performance associated with the clinical model.
The current study was approved by the university's institutional review board as an exempt study. Confidentiality was maintained throughout the study. Students were surveyed at the end of the semester by completing both the SECEE and researcher-developed questionnaires. Faculty members' and preceptors' responses to the researcher-developed questionnaire and qualitative questions were gathered, using either an interview or written format based on the participant's preference.
All of the junior students enrolled in one of two medical–surgical clinical courses were invited to participate (N = 250; 150 participated) at the end of a classroom session, near to the close of the semester course. Because the sample of undergraduate students eligible to participate was finite and also moderately large (N = 150) for what may be expected in a school of nursing course, a power analysis was not conducted. Within a fairly large school of nursing, if significant differences were not found among groups, then the differences among groups are likely be too small to be practically useful to nurse educators, whether or not a larger sample may have identified statistical significance. Seaman, Seaman, and Allen (2015) noted that problems associated with both under- and overpowering a study exist. All students enrolled in the junior medical–surgical courses complete the same number of clinical hours, regardless of the type of clinical learning environment. All 14 faculty of the medical–surgical clinical courses were invited; 12 participated and 11 had full-time teaching responsibilities. Faculty taught one or two sections of the clinical course. The mean years of teaching experience was 10.8, with a range of 1.5 to 35 years.
All of the 64 preceptors working with the students were invited via e-mail to participate, but only seven responded and participated. The seven preceptors were all women; two had associate degrees, one had a diploma in nursing, three had baccalaureate nursing degrees, and one was master's prepared. The participants had precepted students for a mean of 6.4 years, with a range of 1.5 to 15 years.
Student Responses on the SECEE
Students in the TLM, PEP model, and HLM groups completed the SECEE and the researcher-developed questionnaire. On the SECEE, significant differences were found only on the Learning Opportunities subscale, indicating that students in the PEP model clinical rotation were able to practice more skills than the other two groups. Students in the PEP model group did not identify any differences in satisfaction with the site or preceptor (all of the student results were highly positive). No significant differences were noted among models on the Instructor Facilitation of Learning subscale or the Preceptor Facilitation of Learning subscale (Table 1).
ANOVA Results of the Student Evaluation of Clinical Education Environment Tool Subscales for the PEP, HLM, and TLM Clinical Groups
Perceptions of Time in the Clinical Rotation
Faculty, preceptors, and students were asked to provide estimations of the time spent with one another, and students were asked for an estimation of the time they spent in a purely observational role. As expected, participants describing communication in the PEP model group reported that students spent more time with a staff nurse preceptor, compared with students in the other models (analysis of variance [ANOVA]: df[2, 145], F = 42.832, p = .000). Also expected, participants in the TLM group reported that students spent more time communicating with faculty, compared with students in the PEP model group (ANOVA: df[2, 146], F = 6.569, p = .002). Participants in all of the models reported no significant differences in the time students spent observing care (ANOVA: df[2, 144], F = .345, p = .709). Although this was somewhat surprising, it is important because even in the models such as the PEP and HLM, which are designed to improve time on task, a similar amount of observation occurs. The mean estimated time that students spent in observation was 30.27% (SD = 24.88%).
Communication in postconferences was also a focus of the current study. Group postconferences were not held in the PEP model, and faculty met with students individually. Postconferences were held in the HLM group, but they were attended only by students and faculty (not preceptors). Postconferences in the TLM group were attended only by faculty and students.
Preceptor and Faculty Communication
Preceptors and faculty quantitatively characterized their mutual communication, with most citing at least one meeting on each day a student was engaged with the preceptor. Preceptors described the time spent directly with their students as very high (80% of the time or higher) in both the HLM and the PEP model groups. Preceptors in both the TLM and PEP model groups also estimated that the time their students spent observing (but not responsible for acting) was high—approximately 37.5% to 38% of the time.
Faculty reported that they believed the students were directly working with preceptors approximately 78% of the time in the PEP model groups and approximately 55% of the time in the HLM groups. Faculty in the PEP model group reported spending approximately 16% of their time working directly with students in the clinical setting, whereas faculty in the TLM group reported spending approximately 50% of their time working directly with students. In the HLM group, faculty reported spending 38% of their time working directly with students in the clinical setting. These findings would be expected, given the nature of the models. Faculty perception of the percentage of time students were in observational situations was different than preceptor or student perception—faculty reported that they believed students were observing 22% or less of the time in all three models. Because the sample and group size was small, statistical analysis was not conducted.
Student Practice Opportunities
Students estimated the number of practice opportunities experienced for various communication and psychomotor skills. The items for this estimation were derived from prior work in which a team of faculty and health care agency experts constructed a document about student skill performance, given various levels of supervision (Hendricks et al., 2013). One part of this document listed psychomotor and communication skills that could be performed either with or without direct supervision. For the purpose of the current study, the focus was on junior-level skills that could be performed with nurse supervision or checking (as was posited by the authors that differences in student practice experience would occur in this area). Items were previously piloted and then used successfully. Note that skills such as therapeutic communication or hygienic care, although important, were not included, as no direct supervision was required in any setting for students to practice those skill (Hendricks et al., 2013). No significant differences were found in the practice of communication strategies, including teaching (ANOVA: df[2, 146], F = 2.512, p = .085), collaboration (ANOVA: df[2, 146], F = 2.265, p = .108), or documentation in patients' electronic health records (ANOVA: df[2, 146], F = 2.512, p = .085), but there were significant differences in opportunities to practice psychomotor skills. The PEP model groups reported more frequent skill practice opportunities than the TLM and the HLM groups (Table 2).
ANOVA Results With Post-Hoc Comparisons of Differences in Practice Opportunities, by Clinical Group
Student Test Scores
No significant differences were noted among the three student groups in the integrated Kaplan medical–surgical nursing examination scores of fifth-semester students (ANOVA: df[2, 51], F = 0.628, p = .538). Similarly, no differences were noted among sixth-semester students (ANOVA: df[2, 80], F = 0.442, p = .645). The various clinical learning models did not impact standardized test scores, showing that the translation of what may or may not happen in the various ways of organizing clinical learning are not, by themselves, affecting clinical reasoning or knowledge. Study participants' Kaplan scores, compared with the overall class' mean Kaplan scores, also did not demonstrate a significant difference, suggesting that study participants were not different from the class as a whole in this measure of student performance. Because the duration of student experiences in the PEP model and the HLM spanned only one clinical course (with the previous courses using the traditional clinical model), time exposure may not have been adequate for students to demonstrate the changes in thinking or performance that would translate to a markedly different didactic examination grade.
In the current study of stakeholder perceptions, learning opportunities, and student outcomes across three distinct learning environments, the authors found that overall satisfaction was high, and there were only a few areas of distinctly different outcomes. Student perceptions of the clinical learning models indicated high levels of satisfaction across all models, reinforcing the value that students place on learning to practice in real patient care situations, and that all the models were viewed by students as excellent. Students in the PEP model reported more learning opportunities on the SECEE and more practice with several psychomotor skills, including oral medication administration, intravenous therapy, and patient assessment. Anecdotally, it is known that students ascribe value to these types of hands-on learning situations. No differences were noted across groups in terms of patient teaching, collaboration, or documentation in patients' electronic health records, which required some supervision or checking by the nurse, but not necessarily direct over-the-shoulder observation in every case. Thus, preceptored clinical rotations may offer an advantage in this regard.
Students in the PEP model had more time in communication with the staff nurse preceptor and less time with the clinical nursing faculty. Further, students in the PEP model often did not participate in a weekly postconference meeting with faculty, whereas students in the TLM and the HLM did experience a weekly group meeting or postconference. In addition, students in the TLM and the HLM reported more time overall with clinical faculty. Understanding the relative advantages and disadvantages associated with the differences in models should be the focus of a future study; the differences in communication did not impact examination scores or satisfaction overall.
Regardless of the model, students spent a surprising percentage of their clinical time in observation—approximately one third of their clinical hours (according to students and preceptors). Finding out more about this time is crucial—Were students learning a great deal through observation of a critical event, and then effectively debriefing after the fact? Or were students engaged in a considerable amount of time that was relatively low in value in terms of learning to practice as a nurse? McNelis, Ironside, Ebright, Dreifuerst, Zvonar, and Conner (2014) found that clinical learning situations were fraught with missed opportunities for student learning, such as lacking discussion of complex clinical situations and explicit connections to didactic education, often focusing on getting the daily tasks completed as a measure of successful clinical learning and performance, as well as significant time that was not well concentrated on learning. In the current study, across all the learning environments, the significant amount of time spent in observation may provide additional evidence supporting the finding of McNelis et al. (2014) that today's clinical learning environments include time spent in ways that are less valuable in the development of clinical performance capacity. In many ways, this finding was the most surprising and troubling in the current study and should be a focus for future research.
Although the current study included multiple units across more than one agency, one limitation was that students and faculty were associated with a single, large school of nursing. The authors reasoned that an a priori power analysis would not prove useful for this study; however, lacking this sample size data was a limitation of the study. The student sample size was robust, but students self-selected into a clinical group, which could be a potential for selection bias. However, given that the three models have been in existence for multiple years and that wording included in the course selection materials did not include value-laden descriptors that may have indicated one or another section was preferable, the likelihood of bias was low. Second, few preceptors participated. This may have been related to the method used for recruitment—e-mail requests were used to solicit participation—as it was later discovered that staff nurses across several health systems rarely used their institutional e-mail accounts. E-mail had been selected as a means of contacting preceptors to minimize the likelihood of study bias because the authors explicitly wanted to avoid faculty (who were also studied) contacting preceptors directly and encouraging participation. Preceptors who volunteered were from only two of the five health care systems that have PEP model units. In a future study, accessing potential preceptor participants should be completed in a more reliable manner, while maintaining ethical guidelines. Among faculty, although most participated, the total number of faculty assigned to teach the courses was small (faculty often taught more than one section in a semester).
Because the school of nursing has been using precepted models for many years, variations in how the models were implemented over a long period of time across multiple nursing units at different agencies may have yielded some practices that developed uniquely (e.g., the PEP model may have had slight differences across units). In addition, because the PEP model and HLM have been used for years in the school of nursing, the fidelity of implementation of the TLM may have been slightly limited in that aspects of the PEP model may have been used in a casual manner by faculty teaching in the TLM group, as they may have been familiar with either the PEP model or the HLM. The authors believe this may be the case because some TLM students alluded to spending time with preceptors, which technically is not a part of the TLM. Nonetheless, this kind of effect may be expected in a school using innovative clinical models over time. Most of the studies of innovative clinical units has been limited to the period closely following implementation, when little drift in terms of fidelity and methods may have occurred and when excitement and enthusiasm about the new model would be expected to be high. Despite these limitations, the current study adds to the body of knowledge of different clinical education models from multiple perspectives.
For nurse educators looking for evidence of quality in clinical nursing education, student perceptions of quality can be achieved in various clinical learning models. Clinical learning models that extensively use staff nurse preceptors may demonstrate more opportunities for students to complete the psychomotor skills that health care agencies and schools of nursing require to be directly supervised, such as medication administration and intravenous therapy. However, in preceptored models of clinical education, faculty may find fewer opportunities to directly engage with students in their learning. In all of the models studied, a focus on developing clinical reasoning and making a distinct connection to what is being learned concurrently in the didactic setting would be an area for future development. Because the current study found that the varying numbers of practice experiences of psychomotor skills did not yield measurable changes in the testing of clinical knowledge, finding ways to develop nursing students' thinking skills remains crucial.
Due to the significant percentage of time that students reported observing care in all of the models described in this article, future research could focus on further understanding the value of the observational clinical experience in student learning. Also, ways to optimize clinical time for maximum student learning need to be explored.
It was clear in the current study that the various clinical learning models were heavily focused on how clinical time was structured, without a distinct focus on how faculty and preceptors work with students to develop nursing clinical reasoning skills. Methodology to directly impact thinking and other important clinical skills, such as therapeutic communication in the clinical environment, is a key next step in the work associated with clinical learning models. In addition, the students in the current study were in each of these particular clinical learning models for a clinical course. If gains are to be made in clinical reasoning with any model of clinical education, it may be that the length of time a student learns in a particular model may also be important (i.e., it may be that one clinical course in a given model is not an adequate dose to differentiate learning outcomes for any model). Further study is needed to develop methods to help students, faculty, and preceptors draw meaningful connections between the didactic and clinical learning environments so that students can complete their education to be able to think like a nurse after graduation.
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ANOVA Results of the Student Evaluation of Clinical Education Environment Tool Subscales for the PEP, HLM, and TLM Clinical Groups
|Subscale||ANOVA Results||Bonferroni Comparison||Mean|
|Instructor Facilitation of Learning||2, 145||0.185||.831||N/A|
|Preceptor Facilitation of Learning||2, 145||2.454||.09||N/A|
|Learning Opportunities||2, 145||6.95||.001**||PEP/HLM .002**PEP/TLM .025*HLM/TLM ns|
ANOVA Results With Post-Hoc Comparisons of Differences in Practice Opportunities, by Clinical Group
|Practice||ANOVA Results||Bonferroni Comparison||Mean Difference||Significance||Mean Per Group|
|Oral medication administration||2, 146||37.315||.000||PEP/HLM||12.6||.000|
|Patient assessment||2, 146||7.646||.001||PEP/HLM||5.51||.001|
|Intravenous therapy||2, 146||33.262||.000||PEP/HLM||4.33||.000|
|Urinary catheterization||2, 146||0.317||.729||N/A||N/A||N/A||N/A|