Journal of Nursing Education

Major Article 

Outcomes of a Critical Care Hospital-Based Fellowship for Senior Nursing Students

Vicki Moran, PhD, RN, CNE; Rose Hansen, MSN, RN; Deidre Schweiss, DNP, RN, CPNP

Abstract

Background:

A partnership between four academic sites and one practice site was created to address a gap in baccalaureate nursing education resulting from the lack of pediatric and critical clinical experience. Four schools of nursing (SONs) were invited to recruit senior-level nursing students to participate in a critical care fellowship opportunity during their senior synthesis courses.

Method:

In a mixed-method evaluation, data were collected through three questionnaires.

Results:

The findings indicated that the students increased their knowledge and ability in caring for critical pediatric patients. The difference in clinical hours by the SONs did not reveal significant mean differences across measures of self-efficacy, clinical knowledge, or clinical confidence.

Conclusion:

The critical care hospital-based fellowship can be used as a partnership between a hospital and SONs to expose prelicensure students to clinical experiences and education related to pediatric critical care to decrease nursing shortages in these specialty areas. [J Nurs Educ. 2018;57(8):469–475.]

Abstract

Background:

A partnership between four academic sites and one practice site was created to address a gap in baccalaureate nursing education resulting from the lack of pediatric and critical clinical experience. Four schools of nursing (SONs) were invited to recruit senior-level nursing students to participate in a critical care fellowship opportunity during their senior synthesis courses.

Method:

In a mixed-method evaluation, data were collected through three questionnaires.

Results:

The findings indicated that the students increased their knowledge and ability in caring for critical pediatric patients. The difference in clinical hours by the SONs did not reveal significant mean differences across measures of self-efficacy, clinical knowledge, or clinical confidence.

Conclusion:

The critical care hospital-based fellowship can be used as a partnership between a hospital and SONs to expose prelicensure students to clinical experiences and education related to pediatric critical care to decrease nursing shortages in these specialty areas. [J Nurs Educ. 2018;57(8):469–475.]

Pediatric critical care nursing is a highly specialized area of practice. A pediatric critical care nurse must possess astute assessment, critical thinking, and technical skills while understanding the implications of growth and development on physiologic and pathophysiologic processes. Unfortunately, the pool of experienced pediatric critical care nurses is small and with the nursing shortage, the availability of these nurses is shrinking. The hospital identified newly graduated nurses as the target population to help meet the ever-increasing staffing need. However, it is challenging to assimilate the knowledge and skills needed to provide safe, competent care during traditional orientation periods for newly graduated nurses.

Newly graduated nurses enter practice with little pediatric or critical care skills from undergraduate nursing curriculums. Nationally, clinical placements for nursing students are lacking (National League for Nursing [NLN], 2014). Competition for established clinical sites has been attributed to an increase of undergraduate nursing programs (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Many new nurses possess general, adult-focused health care knowledge and have had minimal pediatric clinical experience. There is also a lack of exposure to critical care nursing in nursing school clinicals. Hospitals can help to bridge the knowledge gap and provide opportunities for the student nurse to assimilate to the critical setting while still in school. It is imperative to consider innovative strategies to ease the transition for student nurses to newly licensed professional nurses in pediatric critical care settings.

Purpose

The purpose of the current study was to evaluate a critical care hospital-based fellowship (CCHBF) in pediatric high-acuity settings within an established senior synthesis nursing course with four baccalaureate nursing school partners. Information gained from this study will be used to plan for future fellowship initiatives and curriculum development.

The following research questions that guided the study:

  1. What are the changes in self-efficacy of nursing students who provide patient care while participating in the CCHBF?

  2. What is the relationship between self-efficacy and critical care clinical skills among nursing students who participate in the CCHBF?

  3. What are the changes in pediatric critical care clinical skills experienced by nursing students during the CCHBF?

  4. What “readiness to practice” issues are reported by nursing students in the CCHBF?

Background

Establishing Academic and Service Partnerships

Two important documents, the NLN's 2003 Position Statement on Innovation in Nursing Education: A Call to Reform and the Institute of Medicine's (IOM) 2010 report The Future of Nursing: Leading Change, Advancing Health, recommend the establishment of academic-practice partnerships. There is value in these partnerships that extends beyond the walls of the hospital and the academic institution and affects health care at the local and national level. The intent of these professional mandates is being actualized through the collaboration formed among the hospital and academic institutions focused on support and preparation of nursing students wishing to transition into pediatric critical care.

In addition to benefits described in the NLN and IOM reports, there are other benefits of academic–health partnerships and patient outcomes. It has been postulated that integrated academic partnerships with health systems can improve evidence-based patient care delivery and generating new clinical knowledge, which translates to improved patient outcomes (Granger et al., 2012). Communication and personal interaction are instrumental between the nursing school and clinical agencies (Taylor, Angel, Nyanga, & Dickson, 2017). Developing and maintaining these relationships is labor intensive and develops over time (Taylor et al., 2017).

National Council of State Boards of Nursing (NCSBN) has established a transition to practice (TTP) model to support newly licensed nurses during their critical entry and progression to practice (NCSBN, 2013). The TTP program is a formal program of active learning implemented across all settings designed to support the progression of newly licensed RNs from education to practice (NCSBN, 2013). One of the guiding principles is the collaboration of practice, education, and regulation to transition new nurses to practice. In addition, this collaboration is encouraged across all settings and educational levels. The program promotes the transition program outcomes consistent with the knowledge, skills, and attitudes required for safe and effective provision of nursing care (NCSBN, 2013).

Hospital-Based Preceptorships

Nursing student preceptorships involving a triad relationship of a student, a nurse educator, and bedside nurse have also been studied in which students in their final semester complete a prescribed number of clinical hours with a nurse preceptor. A systematic review reported that the most adopted preceptorship was a fixed preceptor–preceptee model using a one to one model for 1 to 3 months in duration (Ke, Kuo, & Hung, 2017). Educators and preceptors are challenged to guide students in clinical decision making during the preceptorship (Zawaduk, Healey-Ogden, Farrell, Lyall, & Taylor, 2014). The hospital setting, with an increasing acuity of patients and the changing daily workloads, challenges the nurse preceptor to invest in a brief but important clinical experience of the nursing student. Preceptorships have increased new nurses' overall competence in the clinical setting (Ke et al., 2017).

Nursing Student Fellowship Programs

Nursing student preceptorships (NSPs), nursing student externship programs (NSEPs), student nurse fellowship programs (SNFPs), and student nurse internship programs (SNIPs) are not new to nursing education. Established in the early 1980s, these programs have been used to support nurses in providing patient care and increasing student's clinical exposure (Lott, Willis, & Lyttle, 2011; Walker, 1987). These programs have supported the clinical experience by also incorporating clinical concepts relevant to the setting. Walker developed a SNIP program that provided lecture and skills laboratory to augment the clinical experience and found that the program supported socialization of the student to the RN role (Lott et al., 2011; Walker, 1987). Other fellowship programs incorporated simulation exercises and focus groups to clarify nursing students' perceptions, values, and beliefs of the patient care environment (Horst, White, & Lowe, 2012; Ruth-Sahd, Beck, & McCall, 2010). The NSEPs, SNFPs, and SNIPs have been a viable option for acute care settings with impending fiscal constraint. They encourage recruitment and retention of nursing candidates by educating them about necessary and relevant nursing knowledge pertinent to the setting. Nursing students perceived themselves as more confident and more prepared after participating in an 8-week NSEP (Remle, Wittmann-Price, Derrick, McDowell, & Johnson, 2014; Steen, Gould, Raingruber, & Hill, 2011). Another NSEP's goal was to acquaint nursing students to the hospital environment while assessing their ability as potential nursing candidates (Lott et al., 2011).

Critical Care Nursing Environment

The critical care environment can be emotionally and intellectually challenging (Farnell & Dawson, 2006). The shortage of critical care nurses results in a need to train both experienced and new graduate nurses for critical care positions. Strategies to ensure successful transition to these practice settings are not well documented. Results from the NLN national survey suggest that critical clinical experiences are necessary to learn the practice of nursing (Ironside & McNelis, 2010).

New graduate nurses struggle to attain proficiency and competence in all areas of clinical practice. Newly qualified nurses have been described as not ready for independent professional practice, lacking some degree of depth in their knowledge and had difficulties applying knowledge to patient care (Clark & Holmes, 2007). These issues can be intensified in a fast-paced, critical care setting as well. In a Delphi study, Lakanmaa, Suominen, Perttila, Puuka, and Leino-Kilop (2012) surveyed nursing experts to achieve consensus regarding competence requirements of intensive and critical care nursing. The main domains necessary were knowledge, skills, attitudes and values, experiences, and personal base. These domains are applicable to other nursing specialties (Lakanmaa et al., 2012), and their uniqueness to intensive care nursing versus other specialty areas of nursing needs further delineation.

Theoretical Framework

The theoretical framework for this study was based on self-efficacy of the social cognitive theory developed by Bandura (1977). He based his theory on the principle that a relationship exists between an individual's perceived self-efficacy and behavior change (Bandura, 1977). The expectation of a person's degree of self-efficacy directly predicts the amount of time, energy, and effort an individual will put forth to accomplish a behavior in the face of a difficult experience (Bandura, 1995). Two major concepts underpin the theory: efficacy expectations and outcome expectations. Efficacy expectations are the belief that one can successfully perform the behavior required to produce outcomes. Outcome expectations are defined as an individual's appraisal that a given behavior will lead to an assured outcome (Bandura, 1995).

Self-efficacy is important for nursing students. Self-efficacy is the perception of the ability to perform a task or cope with a situation that is new or difficult (Bandura, 1995). This construct is important in clinical behavior. Nursing students are taught skills and assessments in a controlled classroom and then expected to perform the behavior in the clinical setting. Utilization of learned knowledge and skills from the classroom to clinical practice can result in increased self-efficacy in the role of a professional nurse.

Method

Research Design

A pretest–posttest study design was used to answer the research questions and provide an overall evaluation of the CCHBF. Institutional review board was obtained and approved from one academic partner and the pediatric hospital prior to conduction of the research.

Population and Sample

Participants included nursing students from four local baccalaureate nursing schools chosen to participate in a pediatric CCHBF with clinical rotations in two of four different areas: the emergency department, cardiac care unit, pediatric intensive care unit, and the neonatal intensive care unit. Each nursing school identified five students who completed an application with essay. There was not a prescribed selection criteria established by the hospital for the CCHBF. A group consisting of clinical nurse specialists, managers, and the nursing recruiter from the pediatric hospital selected three students from each of the four schools of nursing, for a 12-student cohort. The study was conducted over four semesters with student groups in the fall and spring semesters for a total of 2 years. The total sample size consisted of 48 nursing students. Institutional review board approval was obtained from the hospital and the academic facility of the principal investigator.

After the nursing students were notified of acceptance into the CCHBF, they completed hospital requirements. This included a confidentiality agreement and clinical orientation education modules required by the hospital. Clinical hours varied from the four school of nursing from 80 to 160 hours based on course objectives and were required for graduation from all the baccalaureate nursing programs. The students completed prescribed clinical time from their school of nursing in two of four clinical areas. Each school had a clinical evaluation tool and was followed by a nursing educator from their respective school which documented the clinical as pass or fail.

The CCHBF is a combination of the traditional preceptorship with one nursing student and one preceptor from two of the four critical care areas with the addition of a pediatric critical care curriculum. All students in the CCHBF participated in 24 hours of a didactic course over an 8-week period that focused on acute alterations of the pediatric client. The didactic and simulation instruction was developed by the four SONs and the pediatric hospital Clinical Education Specialist. The Clinical Education Specialist coordinated and taught the curriculum with the assistance of other specialty nurse educators and staff from the hospital.

Before the first clinical shift, the students met with the research specialist from the hospital. The research protocol was explained to the students and consent was obtained. The students were assigned a random number and that number was used on all course paperwork. The students completed the General Self-Efficacy Tool (GSE) and Pediatric Intensive Care Unit Basic Knowledge Assessment Tool version 6 (PICU-BKAT6r) during the first and last didactic day. The Casey Fink Readiness to Practice Survey was also administered on the last didactic day.

Instruments

The GSE. The GSE aims at a broad and stable sense of personal competence to deal efficiently with a variety of stressful situations. The German version of this scale was originally developed by Ralf Schwarzer and Matthias Jerusalem in 1981, first as a 20-item version and later as a reduced 10-item version (Schwarzer & Jerusalem, 1995). The GSE has been translated into other languages and the reliability and validity has remained consistent (Scholz, Dona, Sud, & Schwarzer, 2002). It has been used in numerous research projects, where it typically yielded internal consistencies between alpha = .75 and .90 (“General Self-Efficacy Scale,” n.d.). The GSE is scored on a 4-point Likert scale (1 = not at all true, 2 = barely true, 3 = moderately true, 4 = exactly true). The minimum score that one can receive is a 10, with a maximum score of 40.

Pediatric Intensive Care Unit Basic Knowledge Assessment Tool Version 6 (PICU-BKAT6r). The PICU-BKAT6r is a 75-item pencil-and-paper test that measures basic knowledge in critical care nursing. The PCIU-BKAT4 was the original version developed in 1996 that had a reliability coefficient (Cronbach's coefficient alpha) of .86, with a mean score of 78.7 points and a standard deviation (SD) of 9.8 (Runton & Toth, 1998). The newest version, PICU-BKAT6r, focused on revisions of knowledge from experienced PICU RNs and new graduate nurses. The construct validity was computed on these two groups known to be different in knowledge. Internal consistency reliability was complete with a reported alpha of .81 to .83 (Toth, 2017). Each question answered correctly on the PICU-BKAT6r was scored 1 point. The minimum score was zero and the maximum score was 75.

Casey Fink Readiness to Practice Survey. The Casey Fink Readiness to Practice survey was used as a posttest to assess nursing student perceptions of readiness to practice as an RN. The survey has been used and validated with more than 1,000 graduate nurse residents (Casey, Fink, Krugman, & Propst, 2004). The survey consists of three sections. The first section asks for demographic data and information about the student's senior practicum experience: total hours, clinical setting, preceptor, and course content information. The second section focuses on the student's comfort with both clinical and relational skill performance. Participants are asked to identify the top three skills or procedures they are uncomfortable performing independently. Students are asked about their level of confidence in managing multiple patient assignments. Finally, students are presented with a list of 20 items asking for a self-report about level of comfort or confidence in performing key nursing activities using a Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). This comfort and confidence questionnaire was used to identify the four domains of readiness offered during the senior practicum course in development of readiness for practice. The third section consists of one open-ended question asking respondents' what they think could be done to help them feel more prepared to enter nursing practice.

Results

Data were collected from 48 participants across four cohorts of nursing students. Univariate summary statistics were created for demographic variables of age, grade point average (GPA), hours worked per week, and required clinical practicum hours (Table 1). Reliability analysis using Cronbach's alpha was performed on both pre- and postfellowship GSE scales, and univariate summary statistics were created for each survey instrument to characterize instrument performance in the sample. One-way analysis of variance (ANOVA) was used to check for mean cohort differences in GSE pre- and postfellowship, pre- and postfellowship PICU-BKAT6r, Casey Fink average, and demographic variables. Paired samples t test was used to test for significant pre- and postfellowship PICU-BKAT6r changes. Wilcoxon signed-rank test was used to test for significant pre- and postfellowship GSE changes. Pearson correlations were used to check for significant relationships between Casey Fink Average, pre- and post-GSE, pre- and post-PICU-BKAT6r, change in PICU-BKAT6r and GSE, and the three Casey Fink confidence items (confidence caring for two, three, or four patients).

Demographics of Critical Care Hospital-Based Fellowship

Table 1:

Demographics of Critical Care Hospital-Based Fellowship

The number of required clinical practicum hours was recoded into a binary variable of 0 to 150 hours versus 151 or more hours to improve potential predictive power. Items 1 through 10 of both the pre- and postfellowship GSE were summed into a single total score of self-efficacy. An additional variable was computed by subtracting prefellowship GSE from postfellowship GSE to index the change in total self-efficacy score. Given the small sample size and the large number of items in the measure section of the Casey Fink scale, the mean of all item level responses was calculated as an average measure of comfort in performing key nursing activities. Since only total pre- and postfellowship PICU-BKAT6r scores were provided, a variable was computed by subtracting pre- from postfellowship score as an index of nurse-related content knowledge change.

Alpha was preset to 5% for all significance tests. All analyses were performed using SPSS® version 22.0 for Mac®.

Demographic data of the participants were collected from the Casey Fink Readiness to Practice Survey. The fellowship participants were 8.3% male and 91.6% female. The average age of the students was 23 (M = 22.68, SD = 2.5) with an average GPA of 3.68 (self-reported range of 3.0 to 3.99, SD = 0.24). Sixty-six percent of the students worked in a health care setting. They worked an average of 18 hours per week (M = 17.66, SD = 10.18). Results of the ANOVA indicated no significant effect of cohort on any demographic or prefellowship scale variables. Reliability analysis for pre- and postfellowship GSE revealed marginal to acceptable scale performance in the small sample (Cronbach's α = .69 and .80, respectively).

The analysis of the data was used to determine whether a change occurred in reported GSE for the nursing students participating in the CCHBF. Wilcoxon signed-rank test revealed a significant increase in total self-efficacy between pre- and postfellowship responses (z = −3.336, p < .005), with a mean increase of 1.57 across all participants (Table 2).

Pre- and Postsurvey Critical Care Hospital-Based Fellowship

Table 2:

Pre- and Postsurvey Critical Care Hospital-Based Fellowship

The relationship between self-efficacy and critical care clinical skills of the nursing students participating in the CCHBF was assessed with the GSE and PICU-BKAT6r. There were no significant correlations between pre- to post-GSE and critical care clinical skills, as measured by pre- to postfellowship PICU-BKAT6r. In addition, no significant relationships were found between prefellowship GSE and change in critical care clinical skills. However, prefellowship critical care clinical skills showed a marginal positive correlation with pre- (r = .25, p = .09) and postfellowship GSE (r = .27, p = .07), suggesting that prior clinical knowledge is positively associated with self-reports of self-efficacy. An exploratory linear regression was calculated to predict self-reported confidence in caring for multiple patients by change in total self-efficacy. The regression model was significant [F(1, 47) = 4.96, p < .05]. Change in self-reported self-efficacy positively predicted self-reported confidence in caring for four patients (β = 0.32, p < .05), suggesting that postfellowship boosts to self-efficacy promote nurses' self-perception of being able to manage multiple patients (Table 3).

Changes in Self-Efficacy Predicts Confidence in Patient Care

Table 3:

Changes in Self-Efficacy Predicts Confidence in Patient Care

The PICU-BKAT6r was used to assess changes in the critical care clinical skills of the students participating in the CCHBF. Paired samples t test revealed significant mean change in PICU-BKAT6r score between pre- and postfellowship responses [t(47) = −5.43, p < .001), with a mean increase of 3.92 across all participants (Table 2).

An exploratory analysis was used to find addition relationships from the tools used in the research design. Current GPA was significantly positively correlated with both prefellowship PICU-BKAT6r (r = .45, p < .005) and postfellowship PICU-BKAT6r (r = .43, p < .005), as well as self-reported confidence in caring for four patients (r = .31, p < .05). Number of required clinical practicum hours was significantly correlated with self-reported confidence in caring for three patients (r = .31, p < .05), and marginally correlated with self-reported confidence in caring for two or four patients (r = .28 and r = .24, respectively). A binary variable for required practicum hours (⩽150 hours versus >150 hours) revealed no significant mean differences across any measures of self-efficacy, clinical knowledge, or clinical confidence.

The Casey Fink Readiness to Practice survey revealed additional information of the students participating in the CCHBF. At the end of the precepted clinical, the students identified four skills that the students felt uncomfortable performing: intravenous catheter/central line care, responding to a code or emergency care, chest tube care, and electrocardiogram (Table 4). Twenty three of the 48 (47.9%) stated that intravenous catheter care/insertion or central line care was challenging. Seventeen of the 48 (34.6%) stated that assisting with a code or an emergency was an uncomfortable skill. Fourteen of the 48 (29.1%) stated chest tube care was an area of discomfort, and 12 of the 48 (25%) concluded that electrocardiogram analysis was a challenging skill.

Top Skills and Procedures That Cause Discomfort in Critical Care Hospital-Based Fellowship Students

Table 4:

Top Skills and Procedures That Cause Discomfort in Critical Care Hospital-Based Fellowship Students

The survey also asked the students what they needed to help them feel more prepared to enter the nursing profession. Twenty one of the 48 (43.75%) wanted more clinical, practice, or simulation time. Twenty-one of the 48 (43.75%) stated that nothing else was needed. Of the cohort, 66% of the students worked in a health care setting. Other areas reported included additional time with phone communication with other providers of care, precepting in one area, having more orientation to the unit, passing NCLEX-RN, or reviewing content learned daily.

Discussion

The CCHBF was unique in that it was a collaborative effort involving one practice setting and four separate academic settings. The partnership between the hospital and the SONs demonstrates collaboration consistent with current NLN initiatives. The 24 hours of classroom instruction, coupled with different required clinical hours for each of the SONs, was the groundwork for the research and changed the focus from a nursing preceptorship to a more organized fellowship focused on pediatric critical care. Four clinical areas were used in the CCHBF: emergency department, cardiac care unit, neonatal intensive care unit, and PICU. The students were able to choose two of the four areas to complete their required clinical hours.

The CCHBF focused on the pediatric critical care areas. In the past few years, there has a sharp decline of pediatric clinical hours in the undergraduate nursing education due to safety concerns and pediatric complexity (Hayden et al., 2014). For the study population, the clinical skills of the students in the CCHBF showed a marginal positive correlation with pre- (r = .25, p = .09) and postfellowship GSE (r = .27, p = .07), suggesting that prior clinical knowledge is positively associated with self-reports of self-efficacy.

The students chosen for the CCHBF had an average GPA of 3.68. This indicates a highly motivated group of nursing students from the local SONs although there was not a prescribed selection criterion for the CCHBF. As identified from the statistical analysis, paired samples t test revealed significant mean change in BKAT score between pre- and postfellowship responses (t (47) = −5.43, p < .001), with a mean increase of 3.2 across all participants. Wilcoxon signed-rank test revealed a significant increase in GSE between pre- and postfellowship responses (z = −3.336, p < .005), with a mean increase of 1.55 across all participants. The CCHBF provided a solid didactic and clinical experience to improve knowledge and GSE caring for acute care needs of the pediatric population.

Required precepted clinical time varied from 80 to 156 hours for each of the four SONs. When asked about what was needed for the students to enter the nursing profession, 21 of the 48 students (43.75%) recognized the need for additional clinical hours. Although students' evaluations are helpful to improve clinical and courses, the results add challenges to the CCHBF curriculum and impairs the ability to discern the appropriate amount of clinical time required by each of the SONs. A binary variable for required practicum hours (⩽ 150 hours versus > 150 hours) revealed no significant mean differences across any measures of self-efficacy, clinical knowledge, or clinical confidence. Nursing research identifying the number of clinical hours a nursing student needs to clinically competent is limited. Also, few studies have adequately assessed clinical competence of the student by the preceptor (Ke et al., 2017).

The CCHBF clinical experience exposed student concerns of skill competency. Use of the Casey Fink survey revealed four skills that the students felt uncomfortable performing at the end of the fellowship: intravenous catheter/central line care, responding to a code or emergency care, chest tube care, and electrocardiogram. Goode, Lynn, McElroy, Bednash, and Murray (2013) and Casey et al. (2011), using the Casey Fink survey tool in a 10-year study, identified three clinical skills graduate nurses reported having discomfort with performing: responding to codes and emergencies, ventilator care, and chest tube management. This information obtained from the CCHBF and previous research should be used to build the future initiatives using simulation experiences or other learning methodologies to decrease the concerns and improve skill competency in the areas identified.

The model used in the research design had similar directives consistent with the NCSBN TTP program. The CCHBF was formalized in an institution, used a preceptor–preceptee model, customized to learn the specialty knowledge needed to work in the specialized area, and allowed time for the new graduate to learn and apply the content, obtain feedback on their clinical performance, and share their reflections (Spector et al., 2015). The NCSBN TTP program is used primarily after a nursing student has successfully passed NCLEX-RN and aids the employing agency to transiting the graduated student to the role of the RN. If the model presented is used while students are in a nursing program, it may aid in the transition of the graduate nurse to an RN increasing self-efficacy and clinical competence sooner than expected.

Limitations are inherent to any study. The students were only exposed to two of the four critical care areas. Pre- and post-GSE student reporting was from the student's clinical experience in only two of the four clinical areas. The study design lacked a control group. The Casey Fink Graduate Nurse Experience survey has been used for graduate nurses. The research tool in this study was used on prelicensure undergraduate nursing students prior to graduating from nursing school. The concern is whether students would answer the survey differently after passing the licensure examination. The GPA of the students involved in the study population was 3.68. Those involved in the CCHBF may have been more motivated than their peers. When asked about what was needed for the students to enter the nursing profession, 21 of the 48 students (43.75%) recognized the need for additional clinical hours, whereas the other 21 of the 48 (43.75%) indicated they did not need anything more. In addition, the number of clinical hours required by the four SONs varied. Conflicting information what the students felt they needed and the number of hours does not address the difference in the amount of clinical time as prescribed by the SONs.

Future implications for research should focus on recruitment and retention of the nursing student to a graduate nurse position in a pediatric setting. Pediatric and adult residency programs could use the PICU-BKAT6r and GSE to evaluate the knowledge obtained from residency program and identify the growth of confidence in the nursing student as they transition to practice. Linkage of both tools could address retention issues. A cost analysis should be conducted to determine whether the CCHBF decreased orientation time if the student was hired after graduation and passage of the NCLEX-RN. The cost analysis of those students in the CCHBF compared with those that were not in the CCHBF should be researched to identify retention and transition to practice issues using the PICU-BKAT and GSE. The collaboration between the pediatric hospital and the schools of nursing could attempt to quantify patient care data and patient outcomes with students that participated in the CCHBF compared with those that did not.

Conclusion

The CCHBF was a collaborative effort between one practice setting and four SONs in the care of acute care of pediatric clients. New graduates lack confidence, clinical judgment, critical decision making, and problem-solving skills to respond in crises or life-threatening conditions in critical care areas (Meghani & Sajwahi, 2013). Novice nurses in critical care areas who are provided with mentoring, prolonged preceptorship, time, and guidance can mature them into safe critical care nurses (Meghani & Sajwahi, 2013). The CCHBF provided a solid clinical and didactic experience with prelicensure baccalaureate nursing students in pediatric critical care areas. Self-efficacy improved with the students who participated in the CCHBF. The CCHBF outcomes are consistent with the knowledge and skills necessary for safe and effective provision of pediatric critical care, consistent with the NCSBN TPP program. Other specialty nursing practice areas should consider the implementation of a similar program for the recruitment and retention of potential nursing candidates.

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Demographics of Critical Care Hospital-Based Fellowship

VariableNMean (SD)
Age (years)4823 (2.5)
Current grade point average483.68 (0.24)
Average hours worked4117.66 (10.18)
Clinical practicum hours44145 (69.25)

Pre- and Postsurvey Critical Care Hospital-Based Fellowship

Survey ToolPresurveyPostsurveyChange



nMean ScoreNMean ScoreMean ChangeSignificance
Pediatric Intensive Care Unit Basic Knowledge Assessment Tool4846.694850.63.92< .0
General self-efficacy4734.124835.691.57< .0
Casey Fink survey portionn/an/a483.06n/an/a

Changes in Self-Efficacy Predicts Confidence in Patient Care

Survey ToolBeta Weightt ValueSignificance
Pre- and postsurvey self-efficacy change0.3235.69.03a

Top Skills and Procedures That Cause Discomfort in Critical Care Hospital-Based Fellowship Students

Skill or ProcedureN (%)
Intravenous starts or central line care23 (48)
Codes or emergency situations17 (35)
Chest tube care and maintenance14 (29)
Tracheostomy or endotracheal tube care10 (21)
Verbal report or working with advanced providers8 (17)
Urinary catheter or Foley care or straight catheter5 (10)
Medication administration3 (6)
Wound care3 (6)
Pulse oximetry1 (2)
Authors

Dr. Moran is Assistant Professor, Saint Louis University School of Nursing, Ms. Hansen is Clinical Education Specialist, Critical Care, St. Louis Children's Hospital, and Dr. Schweiss is Assistant Professor, Goldfarb School of Nursing, St. Louis, Missouri.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Funding was received for the statistical analysis of the project from St. Louis Children's Hospital Foundation.

Address correspondence to Vicki Moran, PhD, RN, CNE, Assistant Professor, Saint Louis University School of Nursing, 3525 Caroline Mall, St. Louis, MO 63104; e-mail: Vicki.moran@slu.edu.

Received: November 17, 2017
Accepted: March 27, 2018

10.3928/01484834-20180720-04

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