INNOVATIVE CLINICAL PLACEMENTS: A NATIONAL PERSPECTIVE

1. INNOVATIVE CLINICAL PLACEMENTS: A NATIONAL PERSPECTIVE CASN National Research Conference Victoria, BC November 16, 2006

2. Innovative Clinical Placements Research Team Sheryl Reimer Kirkham, RN PhD Catherine Hoe Harwood, RN MScN Lynn Van Hofwegen, RN, MSN, NP Landa Terblanche, RN PhD Rick Sawatzky, RN PhD(c)

3. Funding • Western Region Canadian Association Schools of Nursing (WRCASN) 2005 - 2007

4. Background Over past five years there has been increasing pressures nationally on availability of clinical nursing placements Theory & practice (praxis) come together within the clinical learning settings

5. Background • New program coming into placement negotiation on the cusp of growing shortage of clinical placements • Challenges negotiating community clinical placements led, of necessity, to non-traditional community practice placements

6. Research Program • Pilot Study: Parish and Rural Settings as Clinical Placements (2001) • Phase I: Innovative Clinical Placements: A Descriptive Study (2002 – 2004) • “Keeping the Vision”: Sustaining Social Consciousness following International Learning Experiences (2004 – 2006) • Phase II:A National Survey of the Use of Innovative Clinical Placements (2005 – 2007)

7. Definitions: • Innovative Clinical Placements Less structured clinical environments, often multidisciplinary; typically outside or varying from the main health care delivery system • Traditional Clinical Placements Structured clinical environments, typically within the main health care system

8. Methodology A survey was designed to elicit the utilization rate & numerous factors r.t. student learning and clinical education within Innovative Clinical Placements (ICPs) in Undergraduate Nursing Programs throughout Canada

9. Objectives a)describe the useof innovative clinical settings in Canada (prevalence, type). b) elicit the perspectives of nurse educators regarding the nature of student learning in these sites; c) describe variables related to administrative matters regarding the use of ICPs; d) describe strengths and weaknesses of clinical placements in these sites; and e) identify ethical, legal, and academic issues associated with the utilization of these settings.

10. Survey Design Survey Questions Derived from Phase I findings Survey Format Online format (utilizing Survey Monkey) Distributed via email and telephone follow up Survey featured 3 sections: • General section – all respondents • Program information – Clinical Placement Coordinators (CPC) • Teaching & learning perspectives – Nurse Educators (NE) teaching in ICPs, including some CPC who are NE

11. Data CollectionNovember 2005 – January 2006 National Perspective elicited: 151 eligible respondents 76 nursing programs represented 41 programs represented by 2 or more respondents Data Analysis Procedures Descriptive Statistical Analyses of Survey Answers Content Analysis of open-ended written responses using NVivo™

12. Limitations • Administrator, student & agency stakeholder perspectives not sought • Impact of Nursing program collaborations on data • Language constraints → Incomplete data re: French language based programs

13. Sample Convenience sample from among all Canadian baccalaureate undergraduate nursing programs Potential respondents nominated by deans/directors of nursing programs Inclusion Criteria: • Clinical Placement Coordinator (CPC) for program &/or • Nurse Educator teaching in any of following: • Sr level community health course (or equiv) • Other undergrad courses using ICPs • Undergrad preceptorships in ICPs

14. Describing the Sample: Profile of Respondents by Role in Nursing Program Table 1: Profile of Participants by Re in Nursing Program

15. Overview of Findings Corroborate Phase I findings, including: • ICP’s are widely utilized in Canadian nursing education • Rich student learning typically occurs in these settings • ICP’s often require additional administrative time and coordination, as compared to traditional settings • Concerns over capacity & sustainability of ICPs

16. Findings: Use of ICPs • 96% of respondents report their program use ICPs • 72% report that use of ICPs has ↑over past 5 years • 52% of CPC respondents indicate that > ½ of community placements were in ICPs • A majority of programs report use of ICPs > 100 hrs/student throughout their entire program

20. Findings: Use of ICPs • Size of program • The extent of ICPs use in undergraduate programs was similar for programs of difference sizes. • Graduate Programs • Nursing programs offering graduate degree(s) used ICPs more extensively in undergrad programs than programs without graduate degrees. • Partnerships • Nursing programs that had more partnerships with community agencies reported more extensive use ICPs. • Level of student • 32% of CPCs reported that their programs used ICPs for entry level students (N=75, 9 = no response) (Above conclusions are based on chi-square analyses of contingency tables)

21. Overview of Findings • Use of ICPs • Student learning • ICP’s often require additional administrative time and coordination, as compared to traditional settings d) Capacity & sustainability of ICPs

22. Findings: Nature of Student Learning • Majority of Ns Educator respondents agreed strongly that ICPs are more effective for promoting student learning of: • Community Development • Social Determinants of Health • Social Justice & Equity (Health Care Access) • Issues r.t. Poverty • Culture & Diversity

23. “ICPs have a huge effect on students, often opening their eyes to a part of society unknown to them. ICPs sensitize students to the health needs of marginalized populations.”

24. Findings: Nature of Student Learning • Majority of Ns Educator respondents agreed that students in ICPs demonstrated: • More initiative toward engaging in clinical learning opportunities • More creativity in clinical decision-making • More critical thinking by identifying nursing assessments & interventions • Students in ICPs develop stronger professional relationships with the communities of ICPs (34% = agree strongly, 49% = agree somewhat)

25. Findings: Strategies to Promote Learning • Structure of the learning activities • NE unanimous re: importance of clarity of course & clinical placement objectives • Links to existing curriculum important • Models of Clinical Supervision • Most common approach reported by CPC (50%) & NE (43%) is some supervision with contact q 2 – 3 days via email, phone or on-campus contact, limited on-site visits

26. Overview of Findings • Use of ICPs • Student learning • ICP’s often require additional administrative time and coordination, as compared to traditional settings d) Capacity & sustainability of ICPs

27. Findings: Administrative Issues • Negotiation of ICP • Majority of CPCs agree strongly (57%) or somewhat (20%) that time for coordination & set-up for ICPs is greatly increased compared to TCPs. • Most often ICPs are negotiated by CPCs, although involvement of nursing faculty & existing partnerships also common • Administrative support for creative process in developing ICP’s

28. Findings: Administrative IssuesBarriers to Use of ICP’s 69% of CPCs & 58% of NE respondents indicate barriers exist i) Faculty Factors: • Skill level req’d of faculty • ↑Workload • Shortages of suitable faculty – eg. experience, demographic • Resistance – need “buy in”

29. “There is a perception that a community based experience is ‘less than’ an acute care experience. This is propagated by some faculty, as well as nurses, in acute care settings”.

30. Findings: Administrative IssuesBarriers ….. ii) Educational Institutional factors • Competition b/w different professions/programs for spaces • Costs of clinical faculty supervising students/site or covering multiple placements • Geographic factors – keep some students closer to home iii) Student related factors (as reported by NE) • Typically additional costs/scheduling impact • Access to technology, transportation, accommodation • Impact on family or work commitments

31. Findings: Administrative Issues Barriers ….. iv) Agency factors & constraints • Staff issues – shortages/schedules impact placements, downsizing, retirement of most experienced staff • Space/equipment limitations • Consistency of strong clinical instructor key • Protectiveness of staff re: clientele, confidentiality issues • Agency criteria ↑constraints on student assignments to setting eg. desire strong students only, criminal record checks, refusal of junior students

32. “The numbers of agencies and individual students can be overwhelming to the CPC when we are looking at the numbers of agencies, students, preceptors and faculty persons involved. Each one involves different players, policies, procedures and communication factors…….. A challenge indeed!”

33. Overview of Findings • Use of ICPs • Student learning • ICP’s often require additional administrative time and coordination, as compared to traditional settings d) Capacity & sustainability of ICPs

34. Discussion: Capacity & Sustainability of ICPs • Capacity: Widespread use by programs • Underutilized areas • Making the RN role understood • Sustainability: Burn-out Factor • Can’t expect CPC & NE to negotiate & utilize ICPs under the same formula as used in traditional sites • Agency fatigue • Importance of partnerships to success

35. Challenges using ICPs: “Gleaning the role of the nurse within agencies that do not have a nursing presence.”

36. Recommendations 1. Nursing programs should continue to develop the use of ICPs 2. Strategies be developed to ↑ capacity & to facilitate sustainability of ICPs. 3. Administrative support (such as funding, release time) should account for the extra time req’d to negotiate ICPs. Includes: • encouraging innovation to develop new clinical sites, & the • purposeful building of understanding among faculty regarding the value of ICPs.

37. Recommendations (cont’d) 4. Partnerships b/w academic & host agencies should be established to facilitate administration of ICPs & foster student learning. 5. The role of the nurse in non-traditional sites should be articulated. 6. Research should be conducted with agency stakeholders to gain insight into the issues they face hosting students

38. Follow-up Focus Group • Seek to validate and extend the survey findings • Incorporate some administrative viewpoints – the Deans & Directors invited participation • Scheduled for November 16, 2006 1600 hrs Esquimalt Room, Victoria Conference Center (thanks to the Conference Planning Committee for scheduling this event )

39. Publications • Reimer Kirkham, S., Van Hofwegen, L., & Hoe Harwood, C. (2005). Narratives of Social Justice: Student Learning in Innovative Clinical Placements. International Journal of Nursing Education Scholarship. 2(1), article 28. Available: http://www.bepress.com/ijnes/vol2/iss1/art28 • Van Hofwegen, L., Reimer Kirkham, S., & Hoe Harwood, C. (2005). Accessing the strength of rural health settings: Implications for undergraduate nursing education. International Journal of Nursing Education Scholarship. 2(1), article 27. Available: http://www.bepress.com/ijnes/vol2/iss1/art27 • Reimer Kirkham, S., Hoe Harwood, C., & Van Hofwegen, L. (2005). Capturing the vision: Undergraduate nursing students in innovative clinical settings. Nurse Educator,30(6):263-270.

40. “Using non-traditional settings enables the student to perceive nursing as it truly should be – reaching across the continuum to nurse people at all stages of their life, not only in an illness setting.”