An academic-practice partnership achieves student and staff nurse success.
- Developing and sustaining a dedicated education unit (DEU) academic-practice partnership requires collaboration, commitment, and careful planning.
- The benefits of DEUs include positive student learning outcomes, fulfillment and professional advancement of front line staff nurses, increased new graduate retention rates, and increased identification and application of evidence-based practices to improve patient outcomes.
By Kimberly Dimino, MSN, RN, CCRN
Can we continue to prepare new nurses for practice in the same way we did in the 20th century? In 2010, the Institutes of Medicine reported that “the ways in which nurses were educated in the 20th century are no longer adequate for dealing with realities of healthcare in the 21st century.” And in 2016, the American Association of Colleges of Nursing (AACN) issued a report, Advancing Healthcare Transformation: A New Era for Academic Nursing, creating a new vision for nursing leaders to work collaboratively to better integrate nursing education, research, and practice. The collective wisdom and collaborative efforts of academic and practice leaders can serve as a powerful voice for much-needed change in the preparation of new nurses.
In this article, we’ll look at a collaboration between a nursing program and an academic medical center that put the AACN’s vision into action to create a dedicated education unit (DEU).
Building a partnership
In 2011, the faculty of the baccalaureate nursing program at William Paterson University in Wayne, NJ (where I work as a clinical instructor), sought to align a newly adopted innovative concept-based curriculum with an equally innovative senior student clinical learning experience. At the same time, St. Joseph’s Regional Medical Center in Paterson, NJ, a large academic regional medical center, with a longstanding clinical affiliation with the university, began exploring how to increase recruitment and retention and ease the transition for new nurses.
Recognizing the need for change at the academic and practice levels, nurse leaders from both organizations collaborated to identify the evidence-based DEU as an innovative clinical teaching model that could potentially meet the needs of both organizations and better prepare tomorrow’s nurses for this challenging and rewarding profession.
Understanding the DEU model
New graduate nurses’ responsibilities have changed dramatically over the past 30 years, but clinical teaching models haven’t kept pace. Most new nurses lack competence in essential clinical skills such as assessment, critical thinking, problem-solving, and independent work. So it should come as no surprise that new nurses are at increased risk of near-misses, adverse events, and errors. In addition, inadequately prepared nurses experience increased stress and decreased confidence during the transition from student to practicing professional. And the lack of preparation can result in a lack of professional development and commitment to the profession. Poor retention and high attrition rates of new nurses reflect this issue.
The original DEU model was identified in the 1990s by nursing faculty from Flinders University in Australia. Then, in 2003, in an effort to increase faculty teaching capacity and improve the clinical teaching environment, the University of Portland in Oregon adapted Australia’s DEU model. Since then, many nursing schools across the United States have successfully implemented DEUs. The model continues to show satisfaction among students, staff, and faculty and promise in addressing nurse faculty shortages, strengthening academic practice relationships, and enhancing clinical teaching and learning experiences, but identifying measurable academic/quantitative outcomes has been slow.
The Joint Commission and several nursing bodies, including the AACN and the New Jersey Board of Nursing (NJSBN), support academic practice partnerships and a DEU model. Growing evidence demonstrates the effectiveness of DEUs for narrowing theory practice gaps and transforming the clinical experience of the student from an observer to a participant. In addition, recent research identifies DEUs as empowering frontline staff nurses and providing them with opportunities for professional growth and leadership.
Finally, the DEU affords practice organizations with opportunities to recruit motivated new nurses who are familiar with the organization’s culture, are up-to-date with the most current electronic health records (EHRs) and other technology, and have been exposed to real-world nursing practice.
Challenges to DEU implementation include undergraduate nursing students’ inability to commit to shift/work schedules; clinical instructor absences because of sickness, vacation, or low census; the dynamic and unpredictable clinical environment; and difficulties associated with student evaluations. Committed academic-practice partnerships can address these challenges by collaborating to identify shared visions and goals, carefully planning the program, and thoughtfully tailoring the model to meet the partnership’s unique cultures and needs. In addition, establishing long-term goals and measuring outcomes are crucial to implementing and sustaining a DEU.
Building a DEU
Leaders in our academic-practice partnership had a lot to learn before establishing our DEU. They visited the University of Massachusetts Amherst School of Nursing DEU, modeled after the University of Portland and Flinders University DEUs, for instruction and guidance in funding, identifying participants, establishing responsibilities, and pinpointing shared goals and visions. (See Consider this.)
The partners applied for a New Jersey Nursing Initiative Innovations in Clinical Education grant based on a demonstrated partnership between an accredited school of nursing and a practice organization. This grant was part of a multi-year, $30 million project of the Robert Wood Johnson Foundation (RWJF) and the New Jersey Chamber of Commerce Foundation. In September 2011, the partnership was awarded a $10,000 grant to develop and implement the state’s first medical/surgical and pediatric DEUs.
Identifying active participants
After securing funding, we identified participants from both the academic and practice sides of our partnership. Academic participants included the dean of the Health and Sciences Department, the director of the nursing program, faculty members, the faculty curriculum committee, the upper-division curriculum-level coordinator, clinical instructors (CIs), and senior nursing students. From the practice side, participants included the chief nursing officer, a clinical educator, a nurse manager, staff nurses, and ancillary/supportive unit staff.
The dean of the Health and Sciences Department, the director of the nursing program, and the chief nursing officer of St. Joseph’s Regional Medical Center collaborated along with other senior faculty and administrators.
Both institutions committed to sharing responsibility for the DEU and recognized and compensated their employees accordingly. For example, the academic organization presented CIs with certificates of appreciation, certificates for Board of Nursing–approved continuing education hours for time spent teaching, and invitations to on-campus workshops and conferences. The hospital increased CIs’ preceptor pay $2.00 per hour, provided leadership role recognition, and encouraged CIs to submit documents for the RNStars program, which awards nurses a yearly monetary bonus and recognition.
The partnership also agreed that all former DEU students who passed their boards would be invited to apply and interview for open positions at the hospital.
Pinpointing shared goals and visions
Before identifying shared goals and visions for the academic-practice partnership, each institution presented their individual goals and visions.
Academic goals and vision: The leaders from the university’s nursing department presented and discussed the Commission on Collegiate Nursing Education (CCNE) accreditation report, curriculum, and syllabi describing undergraduate students’ academic and clinical expectations. They also described the university nursing department’s overarching goal: to optimize student learning in the clinical practice environment; foster growth and collaboration between academia, practice, and students; enhance students’ ability to apply learned theory to real-world practice; and increase new graduate nurses’ competence and confidence.
The university’s nursing program vision states that it’s committed to preparing nurses to be accountable for the delivery of culturally sensitive, caring, and competent nursing care to diverse clients in a variety of settings. Graduates of the baccalaureate, master’s, and doctor of nursing practice degree programs are encouraged to pursue lifelong learning to affect and enhance self-development, professional growth, critical thinking, and leadership.
Practice goals and vision: Leaders from the practice organization explained their accrediting body’s goals and their organization’s overarching goal of addressing the growing nursing shortage, improving recruitment and retention of new graduate nurses, and addressing the perceived education practice gap and lack of student readiness for professional practice.
The practice organization’s vision is to be recognized as a leading healthcare provider of choice in New Jersey. It will be characterized by the excellence of its healthcare services, its focus on compassionate care of its patients, and by a culture of continuous quality improvement.
Shared vision: At the end of these discussions, the two partners settled on a shared vision: To collaborate to advance nursing practice, education, research, and informatics.
Identifying and preparing units
The next step to establishing our DEU was to select appropriate nursing units based on the level of student preparation, current curriculum requirements, and interest and availability of unit staff. A medical-surgical neurologic unit was chosen for the adult rotation, and the general pediatric unit was chosen for the pediatric rotation. These units were chosen because of their nurse managers’ enthusiasm and belief in the benefits of the DEU and the availability and interest of staff nurses for the CI role.
Building the pediatric DEU
As the current clinical faculty coordinator (CFC) on the pediatric unit, I was challenged with the task of transforming it from a traditional model of clinical teaching to a DEU. The first step to initiating this process required clearly identifying and defining roles and responsibilities of the academic course coordinator, nurse manager, CIs, clinical and nonclinical staff, and students. The success of the program depended on non-CI staff nurses and unlicensed assistive personnel understanding how DEU students would differ from traditional students in the clinical environment. The motto “it takes a village” was used to articulate the DEU’s philosophy and to help all members of the unit recognize themselves as stakeholders with an important role in educating nursing students.
Identifying goals, training CIs
Next, we established short-term goals, which included identifying and preparing staff nurses who met the criteria to train as CIs (We re-evaluate the CIs each semester and replace any who move on). We were looking for baccalaureate-prepared RNs with at least 2 years of clinical experience and an interest in teaching nursing students. CI training, created and implemented by CFCs, included a 4-hour workshop that clearly described the clinical course learning objectives and provided specific teaching/learning strategies to support nurses in their new roles as teachers and mentors. (Med-surg and pediatric nurses were trained together because the roles and responsibilities are the same.) CIs were provided with simple and specific guidelines, including discussing 1:2 ratio of CI to students, patient assignments, daily and weekly plans, and student evaluation tools. On DEU days, the CI’s assignments are limited to five patients and two students.
Because CIs must evaluate students daily (in additional to providing feedback during the shift), the evaluation tool was created to be simple and specific to avoid unnecessary paperwork. It consisted of a brief Likert scale for rating students from 0-5 (0 = needs total assistance to perform activities; 5 = independently performs activities with minimal supervision) on specific activities and a comment section. Evaluated activities included assessment skills, technical skills (for example, vital signs, blood glucose sampling, medications, and wound care), following a plan of care, prioritization, time management, clinical decision-making, family and patient–centered communication, interprofessional collaboration, delegation, EHR documentation.
Weekly informal and biannually formal meetings with all participating members of the DEU serve to address the DEU’s goals and evaluate outcomes. Additionally, CIs and students complete end-of-semester evaluations.
Long-term unit goals for the DEU include continued collaborative support for preparing senior nursing students for real-world practice and empowering nurses and all staff through continuing education and encouragement. We want staff to recognize the value of their expertise and the integral role they play in preparing future generations of professional nurses. Academic and practice advisors meet yearly to review evaluations and revise accordingly.
Rolling out the pediatric DEU
The course coordinator and the CFC selected eight senior nursing students based on their letters of intent, grade point averages above 3.0, and faculty recommendations. On the first day of the clinical rotation, students received 4 hours of training on the hospital’s EHR system and unit orientation, which included introductions to all unit members and participation in a scavenger hunt. During the scavenger hunt, the students interacted with staff to locate items and areas of the unit they would need to be familiar with.
This first day, students spent 8 hours on the unit; after that, their schedules mirrored their CI’s—two back-to-back 12-hour shifts 2 days a week. After the students became acclimated to the unit, the CI assigned them to one patient each. Students progressed from one patient each to two or three patients by the end of the 8-week rotation. (Semesters at this university are 16 weeks, so in the second half of the semester, students switched to the med-surg unit.)
As the CFC, I’m responsible for formative and summative student evaluations, which are based on CI feedback (verbal and written) and student performance during one-on-one meetings with the CFC and in group conferences.
Quality indicator project
During the 8-week pediatric DEU rotation, students work in groups of four and collaborate with staff, including nurse educators, the child life team, respiratory therapists, the nurse manager, CIs, staff nurses, and ancillary staff to develop a quality indicator project that examines contributing processes and procedures of a representative healthcare quality indicator specific to the unit. The project supports the development of leadership skills through interprofessional communication and collaboration, analysis of national patient safety goals, application of performance improvement principles in the practice setting, and implementation of proposed plans. Additionally, students identify and implement evidence-based teaching and learning strategies for the selected indicator to be presented to staff and faculty.
The CFC remains in the hospital during clinical hours and is available to students and staff at all times. As the groups work on their projects, they’re encouraged and coached to identify and value their interconnectedness and to recognize themselves and their team members as partners in the ongoing process of change. These strategies support the group’s sense of ownership of the DEU and motivate them to continue to eagerly participate in the process.
All staff and students are encouraged and invited to “coach upward” and provide the CFC with feedback. This process creates transparency and is essential to complete the circle of communication and advance the project. I encourage coaching upward by clearly communicating that all staff members play an integral role in the change process and that I welcome any questions, comments, or concerns. Additionally, I provide up-to-date information about the process of the project and keep everyone aware of the progress and measurable outcomes of our DEU.
The med-surg/pediatric DEU has been in effect since 2012 and faculty, students, clinical instructors, unit staff, and leaders in both academic and practice settings report high levels of satisfaction.
The university continues to have two tracks for senior clinical experiences (DEU and traditional). Nursing students in the DEU rotation consistently report higher quality educational and learning experiences than students in the traditional rotation. Nurses who serve as CIs report satisfaction with their DEU experiences. Positive statements and evaluations from CIs center on the sense of accomplishment they experience in observing their students’ growth during the semester. CIs also indicate that the DEU has improved their morale and interest in researching evidence-based practice to enhance and improve care. Additionally, many of our CIs have continued to develop their practice by advancing their degrees and obtaining advanced certifications; two CIs have begun careers as nurse faculty at our institution.
Nurse managers on the DEU units have noted that staff nurses and nursing assistants assume a more active teaching role, embracing the “it takes a village” philosophy. One pediatric staff nurse who’s pursuing her BSN requested information about how she can become a CI after graduation.
As of May 2018, our program has graduated 195 DEU students. To date, 69 of those students (35%) have been successfully hired by the practice organization, with a reported retention rate of 84%. Furthermore, because of the success of this academic practice partnership, in 2014 the partners strengthened their ties by collaborating to establish a critical care elective.
Nurse managers who have hired former DEU students report that they assimilate into the unit at a faster pace than traditional new graduates. Additionally, two former DEU students are now serving as CIs for current DEU students and others are members of their unit-based councils. Another notable outcome is that many former students have been hired to the units on which they trained. One of the CIs who’s precepting a new graduate who was in her DEU said, “This is so rewarding. I am so proud of my student. I trained her as a student and now I get to continue to train her as a nurse.”
Since 2015, students have been invited by the hospital’s nursing leadership to present their quality indicator projects at nursing practice council meetings. And in 2016 and 2018, the students’ projects were accepted for presentations at Sigma Theta Tau’s International Research Congress. (See DEU outcomes.)
Collective wisdom, collaborative practice
According to Tim Porter-O’Grady, EdD, PhD, RN, FAAN, “Innovation never occurs in isolation or by a single individual—it requires a team of dedicated individuals passionately committed to making a difference.” The collective wisdom and collaborative efforts of academic and practice leaders can serve as a powerful voice for much-needed change in the preparation of nurses for practice. Nurse leaders in both education and practice must work together and commit themselves to making a difference and improving the way tomorrow’s nurses are educated and prepared for clinical practice.
Kimberly Dimino is a nursing clinical faculty member at William Paterson University in Wayne, New Jersey.
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