The senior practicum, a clinical immersion experience recommended for baccalaureate nursing students in their final semester of nursing school (American Association of Colleges of Nursing, 2008), is often one-to-one precepted time with a qualified nurse preceptor in a clinical practice setting, with support provided by the student's nursing faculty (Budgen & Gamroth, 2008). This experience offers nursing students the opportunity to build professional nursing competencies, fosters socialization to the professional nursing role (Casey et al., 2011), and addresses the growing gap between classroom and practice as nursing care delivery models continue to evolve (Benner, Sutphen, Leonard, & Day, 2010; Kumm, Godfrey, Richards, Hulen, & Ray, 2016). Nursing leaders in both clinical and academic settings have a professional obligation to partner and to collaborate in preparing nursing students for their future as professional nurses (Coffey, 2013). This partnership is necessary and critical to close the gap between nursing academia and practice, thus improving the training and preparation of clinical nurses (Sharghi, Alami, Khosravan, Mansoorian, & Ekrami, 2015).
As health care reform in the United States evolves health care delivery models, there is an active transformation in the role of the professional nurse in caring for patients across the health care continuum. This active transformation necessitates the need for highly skilled, highly educated clinical nurses (QSEN Institute, 2014). Baccalaureate nursing programs prepare nursing students to enter the profession to “practice safely, accurately, and compassionately” (Benner, Sutphen, Leonard, & Day, 2010, pp. I) as a nonspecialized nurse (Davis & Kimble, 2011). With the increasing complexities of the health care system and as the needs of the patient populations' progress, a fundamental need exists for nurses across the health care spectrum to practice in highly specialized care areas. Nursing professional practice is transitioning away from generalist practice and challenging new graduate nurses with the complexity and acuity that exists within highly specialized care areas. According to Kumm et al. (2016), new nurses are not prepared for professional practice related to these increases in complexity and practice demands. The senior practicum experience exists to close the gap between nursing academia and practice while aiding nursing student's transition into practice. Although clinical placement for senior practicum students is often limited due to the clinical practice setting's inability to accommodate the number of nursing students seeking placement (Coffey, 2013), hiring managers recognize that clinical setting exposure during the senior practicum potentially reduces time required for clinical orientation upon hire (Rebeschi & Aronson, 2009).
In the heart and vascular center (HVC) service line at an academic medical center in northern New England, the nursing leadership team recognizes the benefits offered by the senior practicum experience. They see the opportunity to prepare senior nursing students for practicing within a service line model. The HVC service line encompasses a variety of different settings for nurses including a cardiovascular/cardiac surgery critical care unit, cardiac special care unit (CSCU), intermediate cardiac care unit (ICCU), interventional cardiac laboratory, outpatient cardiac clinic, and outpatient cardiac rehabilitation program. Due to the high volume of placement requests from nursing students for each individual cardiac unit, traditional methods of placing senior practicum students in the cardiac units created limitations in regard to the number of students accepted. As an academic medical center, there is an obligation to assist in preparation of future clinical nurses by meeting clinical placement needs for local schools of nursing.
The Senior Practicum Immersion Experience (SPIE) was developed by HVC nursing leaders to increase the HVC's capacity to host senior practicums students and to provide the students a more comprehensive view of patient care and nursing roles across the HVC service line. By exploring the HVC SPIE, the current authors hope to report the lessons learned by HVC nursing leadership after offering their first immersion experience.
Historically, the senior practicum experience in HVC consisted of one senior practicum student matched with one preceptor in a single clinical setting. The number of senior practicum students the units could accommodate was limited by preceptor availability. In the traditional senior practicum model, the inpatient HVC units were only able to accommodate four senior practicum students in the ICCU and one senior practicum student in the cardiovascular critical care unit (CVCC). With the evolution and development of service lines, our team pro-actively decided to take an innovative approach to introducing senior practicum students to the concept of service lines and the different roles that RNs fulfill within the service line.
With that vision in mind, the partnership of the nurse educator, clinical specialist, and unit nurse manager for the inpatient HVC units created a senior practicum model based around an immersive experience across the HVC service line. Our team identified other departments within the HVC service line to provide senior practicum students with both clinical time and exposure to different aspects of nursing. Many of these other HVC practice areas do not typically host senior practicum students. Our team met with leadership within identified HVC practice areas and departments to engage them in this process. The HVC Leadership was receptive and excited to try a different approach to hosting senior practicum students. The participating departments included our ICCU, CSCU, CVCC, cardiac interventional laboratory, outpatient heart failure team, cardiovascular and cardiac surgery outpatient clinic, and cardiac rehabilitation. A proposed schedule allowed students to rotate through the different HVC clinical areas, although the bulk of the experience was provided on the ICCU, CSCU, and CVCC. This rotation model increased the number of senior practicum students accepted per semester by 50%.
Our team presented our immersion experience to clinical faculty and program directors from the senior practicum students' schools to help understand any potential barriers that would prevent this practicum from being successful. Most initial concerns centered around the students having a difficult time completing required case studies. Alternate plans proposed by the schools of nursing were devised to ensure students completed their required duties while participating in the practicum.
Given that this was a change to the way senior practicum students were hosted, our team identified a core group of 10 preceptors across the inpatient cardiac units. The core group of preceptors, new to the senior practicum program, reviewed their responsibilities and clinical experience tool. This tool outlines learning activities, providing a structure and a place for the student and preceptor to document progress within each clinical area. The clinical experience tool was tailored to work in conjunction with each individual school of nursing's clinical learning objectives and performance outcomes.
Prior to the senior practicum students starting, our team met with all 10 students and their respective clinical faculty members. This provided an opportunity to review the structure of the new clinical immersion experience. After the meeting, a tour was given to show the students where each of their clinical immersion experiences would be located.
The goal of the HVC SPIE was to provide students with a more comprehensive view of patient care and nursing roles across the HVC service line, as well as increase the capacity to host senior practicum students. At the end of the experience, a survey was administered and used to facilitate discussions to better understand successes and opportunities for improvement. The survey consisted of seven questions: five open-ended questions and two questions using a 5-point Likert scale. There was an 80% response rate to the survey. In the first Likert scale question, 88% of the students responded that this experience was very helpful in developing a deeper understanding of the care of a cardiovascular patient across the continuum. In the second Likert scale question, 63% of the students responded that this experience helped them to develop an understanding of the different roles RNs hold across the continuum of care.
The open-ended survey questions were designed to give the students an opportunity to describe their subjective experience. Overall, the students reaffirmed the HVC SPIE enhanced their knowledge of caring for a cardiovascular patient in a service line model. The students had a better understanding of the role of a professional nurse across the care continuum. Insight was gained into the different levels of care provided to cardiac medical and cardiac surgical patients and how these patients transition across the continuum of care. Students gained a better understanding of the patient experience during procedures and in the immediate postoperative period, which assisted them in providing better education to their patients. As one student stated, “I will not only be able to better understand what my patient will experience as they transition through their care, but I will also be able to better help them understand what is going to happen and ease them through the transition of care. I was also able to meet nurses in all departments and build trusting relationships.”
Contrary to an original concern regarding case study completion, students and faculty expressed that the SPIE enhanced the students' ability to complete required case studies. Students and faculty described the firsthand knowledge and experience around care transitions factored in the student's ability to complete case studies.
Focusing on the rotation of the clinical experiences, opportunities were identified to help improve this experience. For many students, schedules and preceptors were changed due to students' class schedule and preceptor schedule changes. This resulted in some students having many preceptors, which retracted from their ability to build strong relationships with one or two preceptors in each clinical area. Other feedback included the length of time allotted for inpatient experiences.
Changes have been made to the HVC SPIE because of feedback from students, program directors, and faculty members. Moving forward, clinical time will be focused in two cardiac units, instead of three, allowing students more focused time with their preceptors. The students will rotate through CSCU and CVCC with one day experiences in the cardiac catheterization laboratory and cardiology clinic. To improve consistency with preceptors, preceptors will be identified and selected after each school schedule is received.
The goal of any senior practicum experience is to develop skills and relationships as the senior demonstrates and refines their abilities to become an independent practitioner. The HVC SPIE offers students the opportunity to firsthand experience the role of the professional nurse across a service line, as well as experience patient care across the continuum. The HVC SPIE offers an innovative solution to increasing the number of hosted senior practicum students while allowing the students the ability to learn and practice in a service line model. This model also engages other departments or care areas that routinely have not had the ability to host senior practicum students. Of the 10 students who participated in the first SPIE, nine accepted new graduate nursing positions, becoming valuable members of the cardiovascular nursing team. As service lines continue to evolve, it is important for new nurses to have a better understanding for how the professional nurse practices in a service line model. It is equally important for professional nurses in clinical and academic environments to continue to work together to close the gap between education and practice.
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