Many factors influence clinical nursing education, specifically the availability of clinical placements. The overall nursing shortage as reported by the American Association of Colleges of Nursing (AACN, 2019) also affects nursing clinical education. According to Fang and Kesten (2017), one third of nursing faculty are projected to retire by 2025. A lack of qualified nursing faculty influences clinical education and is becoming critical in many schools of nursing nationwide. Facilities that are understaffed may have difficulty providing adequate training for both their nurse and nursing student cohorts. Limited clinical capacity also is impacting the ability to develop nursing student clinical placements. In a recent systematic review, Jayasekara et al. (2018) reported a lack of research related to clinical placement models.
Many large schools of nursing in metropolitan areas are not affiliated with a medical center and therefore find themselves in competition with other schools of nursing to place students in clinical experiences. Student placement availability also is affected by ongoing health care restructuring and increased enrollments in health care programs (Smith et al., 2010). Schools of nursing with students in multiple sites face the additional challenge of fulfilling multiple on-boarding requirements of various hospitals. This quality improvement project examined the complexities experienced by one nursing program in placing students in clinical practica and explored an alternative strategy using a Home Hospital option.
The AACN (2016) identified the importance of schools of nursing aligning with hospital partners in rethinking innovative models to meet future health care priorities. A meta-analysis of academic-clinical partnerships recognized a need for mutual and shared goals of health care systems and academia (Bvumbwe, 2016), and Papathanasiou et al. (2014) discussed the importance of closely linking real working environments to nursing education. Schools of nursing attempting to meet the challenges of limited faculty, increasing competition for clinical placements, and increasing on-boarding requirements have sought support from agencies through academic service partnerships (Maneval et al., 2019) and dedicated education unit models (Hunt et al., 2015). In an integrative review by Sadeghnezhad et al. (2018), academic partnerships were noted to be supportive of student learning environments.
Other schools have opted for the Home Hospital option for student clinical placements. The Home Hospital option originally was introduced by Yucha et al. (2009) as a potential solution to budgetary cuts and faculty shortages. The authors used a quasi-experimental design assigning students to one hospital for the majority of clinical experiences. Their tools measured anxiety, stress, and academic data (Yucha et al., 2009, 2014), and the authors implied a potential decrease in students' stress related to reducing the number of hospital rotations. In a national study of almost 1,300 students by Grobecker (2016), the vast majority of students expressed less stress in their clinical placements if they felt supported in the agency.
Clinical placements became more challenging as hospitals adjusted to rapid retirements and a parallel influx of new graduates. As a response to competition for clinical placements, schools of nursing participated in a focus group to develop a California statewide software program for assisting schools with a centralized clinical placement system (Waneka et al., 2009). Nonetheless, there is scarce literature addressing Home Hospitals as an approach to the complexities of clinical placements for nursing students.
Home Hospital Option
Several years ago, a northern California metropolitan-based baccalaureate nursing program (N = 350) was faced with multiple dilemmas regarding maximizing students' clinical experiences, including limited clinical site availability. In addition, clinical sites were progressively increasing student orientation requirements, in some cases using up to 2 clinical days. This resulted in decreased overall clinical time for student learning. Agency on-boarding requirements also were increasing, with earlier documentation submission dates. For the purpose of this article, on-boarding was identified as an administrative function involving the completion of agencies' compliance requirements for students to begin their clinical rotations (e.g., safety, HIPAA, health clearances, and computer orientation). Prior to implementing the Home Hospital option, students rotating to multiple agencies reported concerns with the time needed to on-board at various sites. These concerns included learning new computer systems at up to six different agencies over the duration of the nursing program; learning different guidelines for safety, confidentiality, infection control, and workflow; and duplication of health documentation at a different site each semester.
Having clinical rotations in multiple facilities also impacted faculty who were required to spend a significant amount of time gathering students' documentation (Table 1). Agency documentation typically involved approximately 20 hours of administrative faculty time for each cohort. In a 3-year program, excluding preceptorships and mental and community health cohorts, the school of nursing provided 28 acute care clinical rotations per semester for approximately 280 students. As students moved through their semesters, individual clinical faculty were expected to re-review documentation for the students who had rotated to a different hospital the previous semester. Moreover, each agency required their own orientation, adding more time to on-boarding. Students returning to a clinical setting they had previously been enrolled in were required to take the orientation again. In addition, HIPAA confidentiality requirements and personal health information regulations were being enforced more strictly.
Estimated Time Saving for Home Hospital Options
Based on these concerns, alternative models to existing clinical placements were explored. The school of nursing presented the Home Hospital option as a solution to these challenges. The faculty defined Home Hospital as a continual placement experience for the same group of students in a single agency for the majority of their clinical rotations. Using a similar approach as Yucha et al. (2009), the school of nursing provided a voluntary continual placement experience for approximately 50% of the students. This pilot project allowed students to complete the majority of their clinical practica at that same hospital, versus rotating to different agencies. The intentions of implementing this model for students were to: 1) shorten the student on-boarding process and reduce administrative tasks, 2) decrease orientation times and increase students' direct patient care time, 3) build continuity within the agency, and 4) increase students' understanding of policies and procedures. For the school of nursing, eliminating a significant portion of the on-boarding documentation and reducing orientation time for faculty was needed. These intentions were seen as benefits for both the students and the agencies. Table 1 summarizes the estimated time saved by using the Home Hospital option. These data showed a decrease from approximately 20 hours to 8 hours per cohort per semester for both faculty and students (i.e., 60% time saving).
At its onset, this academic-practice partnership (i.e., Home Hospital option) was presented to a variety of existing hospital staff developers and directors of nursing. Four historical hospital sites (both public and private) agreed to act as Home Hospitals. These Home Hospitals included beginning and advanced medical-surgical, pediatrics, obstetrics, and mental health units. In the case of an agency lacking a specific specialty such as pediatrics, students would rotate out of their Home Hospital with their clinical group for the specialty rotation and then return the following semester to their designated Home Hospital. Experienced faculty initially were selected to staff Home Hospital options, but due to high faculty turnover, this was not consistent throughout the data collection period.
Method and Results
A convenience sample of a highly diverse ethnic student population included men and women between the ages of 20 and 45 years. They were informed of the benefits and possible limitations of the new option. During the first clinical registration, approximately half of the students from each cohort group (n = 60) selected the Home Hospital option for their clinical rotation. For the most part, students who selected this option remained with their Home Hospital clinical groups throughout the nursing program. In a few situations, students having medical or personal issues were removed from their Home Hospital group and went back to rotating agencies. The school of nursing provided clinical experiences with a traditional clinical faculty supervision model using a 1:10 or lower ratio. Faculty were responsible for the total clinical experience (i.e., including direct supervision, training, and evaluation). Comparison data from faculty were not available for this study due to high faculty turnover of instructors who had taught in both the Non-Home Hospital and Home Hospital options. Traditionally, clinical faculty have at least 6 to 10 years of nursing experience.
This study was a quality improvement project. Data were gathered biannually during a period of 3.5 years from 2016 to 2019. Data were extrapolated from the exit portion of the school's total program evaluation. The program's exit surveys were administered to students at the end of a six-semester program and included five questions related to the Home Hospital option using a Likert-type scale. The exit survey was reviewed by a panel of faculty experts and the nursing department's evaluation and research committee. Descriptive data were gathered from write-in questions on the same survey. Data were collected via an anonymous Qualtrics® online exit survey for seven graduating cohorts (approximately 60 students in each cohort). Students voluntarily participated in the surveys.
A total of 109 participants of approximately 280 Home Hospital students responded to the survey. The response rates for each year including both spring and fall semesters were as follows: 2016, 36 of 79 students (46%); 2017, 36 of 70 students (51%); 2018, 23 of 53 students (43%); and 2019 Spring only, 14 of 34 students (41%). Cohort numbers varied slightly due to students moving in and out of Home Hospital options for medical or academic reasons. Due to the unpredictability of non-Home Hospital sites, data were not collected from these participants. The survey questions focused on the following:
- Ease of the on-boarding experience.
- Opportunity to learn the culture of the agency.
- Appreciation by staff at the agency.
- Indication that they would choose to repeat the Home Hospital option.
- Whether they would recommend the Home Hospital option for future students.
Data represented a 90% overall student favorability of the Home Hospital option (Figure 1). The majority of respondents (89%) indicated they would choose the Home Hospital option if offered, and the majority of respondents (89%) also indicated they would recommend the Home Hospital option to future students. The majority (86%) of Home Hospital students reported being at ease with the on-boarding process. Both the opportunity to “learn the agency culture” and “staff appreciation” received 94% and 86% agreement, respectively.
Home Hospital (HH) satisfaction data for 2016 to 2019 (N = 109). Note. SPR = spring.
Students reported an increased comfort in “knowing the facility and staff,” which allowed students to concentrate on their learning. Anecdotally, students responded that they were able to “better focus on hands-on skills” and that there was a “consistency of protocols and policies…within the hospital.” Students also thought the “experience better paved the way…for future employment.”
The Home Hospital option for clinical placements proved to have many benefits. Several researchers (Dobrowolska et al., 2015; Grobecker, 2016; Yucha et al., 2009) explored aspects of students' perceived stress and sense of belonging in clinical placements. The authors highlighted the importance of creating a supportive environment to increase students' confidence. Similar to these findings, students in this Home Hospital option may have indirectly perceived less stress based on responses regarding staff appreciation and the ease of orienting and on-boarding during this experience.
The participating Home Hospital academic partners in this study had the advantage of having the same students return every semester. This approach provided an opportunity for agency personnel to familiarize themselves with the students and for students to align themselves with corporate culture and values. The advantages for agencies were the ability to observe students over time and to better assess skill acquisition and critical thinking. Presumably, the agency's administrative responsibilities also were reduced because computer training and orientation times were lessened.
Faculty in this study commented anecdotally that a shorter time frame was needed for the students to begin direct patient care. This option eliminated repetitive on-boarding requirements that reduced faculty administrative tasks. As a result, students at Home Hospital agencies had an earlier start date for direct patient care. A significant amount of faculty time was required to review clinical documentation of students who were from a different agency than the previous semester but had no changes to their documentation (Table 1). This process occurred semester after semester. Both faculty and students were frustrated with the process but needed to comply with agency affiliate agreements.
There also were some challenges with the Home Hospital approach. Students with health issues or an academic failure could no longer participate in their Home Hospital cohort and were placed in a non-Home Hospital rotation. Furthermore, Home Hospital students had limited exposure to different health care environments, agency cultures, and staff. Subsequently, there was a possibility for a difficult transition into practice if students were not hired at their own Home Hospital agency.
In addition, the school of nursing had to deal with the potential issue of inequity. The non-Home Hospital students had varied experiences at multiple hospitals, allowing for more exposure to different socioeconomic and cultural groups. Some Home Hospital students placed in a single private hospital had less overall exposure to a variety of clients. Home Hospital students had the opportunity to learn one agency's culture and workflow, while reducing initial stressors and building their confidence.
Moving forward, there is a continual need to evaluate this option from both the students' and the agencies' perspectives. Schools of nursing are still challenged to work with all agencies to decrease on-boarding requirements. Students should not lose up to 2 days in a 15-week semester completing orientation nor should they be asked to repeat orientation modules and computer training. Competition for placements in large metropolitan areas continues to be a logistical challenge. In the past, students were frustrated with the repetitiveness of on-boarding as well as reorienting themselves to a variety of agencies every semester. This Home Hospital quality improvement option has proved to address students' concerns.
Student satisfaction has been examined by several researchers (Lloyd-Penza et al., 2019; Papastavrou et al., 2016; Yucha et al., 2014) and has been found to be a critical factor in planning for clinical placements. Although satisfaction is based on multiple factors, students tend to evaluate their overall experience based largely on their relationships with staff and peers, as well as their sense of belonging. In this study, more than 89% of the students reported they would repeat using a Home Hospital option for clinical placements. There are likely other schools of nursing that may be facing similar dilemmas for maximizing their clinical opportunities while decreasing administrative challenges. Surveys of the Home Hospital sites should include pre- and postimplementation data, and faculty data also should be explored. The value of further investigation on using this option on a larger scale is warranted. These findings have significant implications for future student placements using the Home Hospital option.
- American Association of Colleges of Nursing. (2016). Advancing healthcare transformation: A new era for academic nursing. http://www.aacnnursing.org/portals/42/publications/aacn-new-era-report.pdf
- American Association of Colleges of Nursing. (2019). Fact sheet: Nursing shortage. https://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-Factsheet.pdf?ver=2019-04-02-160719-987
- Bvumbwe, T. (2016). Enhancing nursing education via academic-clinical partnership: An integrative review. International Journal of Nursing Sciences, 3(3), 314–322.
- Dobrowolska, B., McGonagle, I., Jackson, C., Kane, R., Cabrera, E., Cooney-Miner, D., Di Cara, V., Pajnkihar, M., Pril, N., Sigurdardottir, A.K., Kekus, D., Wells, J. & Palese, A. (2015). Clinical practice models in nursing education: Implication for students' mobility. International Nursing Review, 62(1), 36–46.
- Fang, D. & Kesten, K. (2017). Retirements and succession of nursing faculty in 2016–2025. Nursing Outlook, 65(5), 633–642.
- Grobecker, P.A. (2016). A sense of belonging and perceived stress among baccalaureate nursing students in clinical placements. Nurse Education Today, 36, 178–183 doi:10.1016/j.nedt.2015.09.015 [CrossRef]
- Hunt, D.A., Milano, M.F. & Wilson, S. (2015). Dedicated education units: An innovative model for clinical education. American Nurse Today, 10(5), 46, 48–49.
- Jayasekara, R., Smith, C., Hall, C., Rankin, E., Smith, M., Visvanathan, V. & Friebe, T.R. (2018). The effectiveness of clinical education models for undergraduate nursing programs: A systematic review. Journal of Nursing Education in Practice, 29, 116–126 doi:10.1016/j.nepr.2017.12.006 [CrossRef]
- Lloyd-Penza, M., Rose, A. & Roach, A. (2019). Using feedback to improve clinical education of nursing students in an academic-practice partnership. Teaching and Learning in Nursing, 14(2), 125–127 doi:10.1016/j.teln.2018.12.007 [CrossRef]
- Maneval, R., Browne, K.P., Feldman, H.R., Brooks, C., Scuderi, D., Henderson, J. & Epstein, C. (2019). A collaborative academic practice approach to meeting educational and workforce needs. Journal of Nursing Administration, 49(10), 463–465.
- Papastavrou, E., Dimitriadou, M., Tsangari, H. & Andreou, C. (2016). Nursing students' satisfaction of the clinical learning environment: A research study. BMC Nursing, 15(44), 1–10 doi:10.1186/s12912-016-0164-4 [CrossRef]
- Papathanasiou, I.V., Tsaras, K. & Sarafis, P. (2014). Views and perceptions of nursing students on their clinical learning environments: Teaching and learning. Nurse Education Today, 34(1), 57–60 doi:10.1016/j.nedt.2013.02.007 [CrossRef]
- Sadeghnezhad, M., Nabavi, F.H., Najafi, F., Kareshki, H. & Esmaily, H. (2018). Mutual benefits in academic-service partnership: An integrative review. Nurse Education Today, 68, 78–85.
- Smith, P.M., Corso, L.N. & Cobb, N. (2010). The perennial struggle to find clinical placement opportunities: A Canadian national survey. Nurse Education Today, 30(8), 798–803.
- Waneka, R., Spetz, J. & Kaiser, J. (2009). Evaluation of the centralized clinical placement system (CCPS) and the centralized faculty resource center (CFRC). Center for the Health Professions, University of California, San Francisco. https://healthforce.ucsf.edu/sites/healthforce.ucsf.edu/files/publication-pdf/1.%202009_08_Evaluation_of_the_Centralized_Clinical_Placement_System_and_the_Centralized_Faculty_Resource_Center.pdf
- Yucha, C., Smyer, T. & Strano-Perry, S. (2014). Sustaining nursing programs in the face of budget cuts and faculty shortages. Journal of Professional Nursing, 30(1) 5–9. doi:10.1016/j.profnurs.2013.07.002 [CrossRef]
- Yucha, C.B., Kowalski, S. & Cross, C. (2009). Student stress and academic performance: Home hospital program. Journal of Nursing Education, 48(11), 631–637 doi:10.3928/01484834-20090828-05 [CrossRef]
Estimated Time Saving for Home Hospital Options
|Option||Students||Faculty||Agencies||Clinical Cohorts||Orientation and On-Boarding Requirementsa|
|Pre-Home Hospital||280||28||7–9||28||Faculty: 20 hours per cohort/semester; students: 20 hours/semester|
|Home Hospital||160||16||4||16||Faculty: 8 hours per cohort/semester; students: 8 hours/semester|
|Non-Home Hospital||120||12||3||12||Faculty: 20 hours per cohort/semester; students: 20 hours/semester|