INNOVATIVE CLINICAL PLACEMENTS: A NATIONAL PERSPECTIVE

1. INNOVATIVE CLINICAL PLACEMENTS: A NATIONAL PERSPECTIVE Change, Chaos & Courage: Educating for Nursing Excellence University of Calgary August 25 & 26, 2008

2. Innovative Clinical Placements Research Team Sheryl Reimer Kirkham, RN PhD Catherine Hoe Harwood, RN MScN Rick Sawatzky, RN PhD Landa Terblanche, RN PhD Lynn Van Hofwegen, RN, MSN, NP * Less active role due to relocation to California

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

4. Background • pressures nationally on availability of clinical nursing placements • Changed health care environment – fewer inpatient beds, early discharge & cut backs in traditional public health programs • Theory & practice (praxis) come together within the clinical learning settings

5. Background (cont) • TWU Nursing entered placement negotiations on the cusp of growing shortage of clinical placements • Challenges negotiating community clinical placements led, of necessity, to non-traditional community practice placements

6. ICP Research Program • Pilot Study Phase I: 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)

7. ICP Research Program • Phase II: The Use of Innovative Clinical Placements in Nursing Education: National Survey (2005 – 2007) • Pilot Study Phase III: Innovative Clinical Placements in Nursing Education: A Pilot Study with Host Agencies (2008)

8. 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

9. Study Purpose • To determine utilization rate & other factors r.t. learning and clinical education within Innovative Clinical Placements (ICPs) in Canadian Undergraduate Nursing Programs

10. Study Design • Survey • Questions derived from Phase I study findings • Online format • 3 sections: General; Program Information; Teaching/learning perspectives • Focus Group Validate & extend survey findings

11. 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.

12. Survey Sample Convenience sample from 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 (NE) teaching in any of: • Sr level community health course (or equiv) • Other undergrad courses using ICPs • Undergrad preceptorships in ICPs

13. Data CollectionDec 2005 – Nov 2006 Survey Sample 90 programs met inclusion criteria Data were obtained from: 147 eligible respondents 74 nursing programs represented 40 programs represented by 2 or more respondents Nov 06 Focus Group – 10 participants

14. Focus Group • Profile: • 3 administrators of Nsg programs, • 4 Ns educators • 1 CPC • 2 Joint roles (combination of above roles) • Broad representation of national scene

15. Data Analysis Procedures Descriptive Statistical Analyses of Survey Answers Content Analysis of Narrative responses using NVivo™

16. Overview of Findings Findings included: • ICP’s are widely used in Canadian nursing education • Pedagogy: 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

17. Findings: Use of ICPs • 96% of CPCs reported their program(s) used ICPs • 72% report that use of ICPs has ↑over past 5 years • 52% of CPCs indicate that > ½ of community placements were in ICPs • A majority of programs report use of ICPs exceeds > 100 hrs/student over student’s program

21. Findings: Use of ICPs • Size of program • The extent of ICP 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)

22. Overview of Findings • Use of ICPs • Pedagogy: Rich student learning typically occurs in these settings c) ICPs often require additional administrative time & coordination, as compared to TCPs d) Concerns over capacity & sustainability of ICPs

23. Pedagogy: Nature of Student Learning • Nurse Educators agreed or agreed strongly that ICPs are more effective for promoting student learning of: • Community Development (93%) • Social Determinants of Health (92%) • Social Justice & Equity (89%) • Poverty (89%) • Culture & Diversity (84%) * Based on responses from 71 nurse educators that used ICPs.

24. Pedagogy: Nature of Student Learning Nurse educators agreed or strongly agreed that students in ICPs demonstrated: • More initiative toward engaging in clinical learning opportunities (70%) • More creativity in clinical decision-making (77%) • More critical thinking by identifying nursing assessments & interventions (63%) • Stronger professional relationships with the communities of ICPs (82%) * Based on responses from 71 nurse educators that used ICPs.

25. Pedagogical Outcomes in ICPs “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.”

26. Pedagogy 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

27. PedagogyStrategies to Promote Learning Narrative responses – NE described concepts of: • “Right fit” b/w student & ICP • Student attributes for successful learning • Creative approach to learning • Flexible & open minded • Demonstrate initiative in independent learning • Understanding that clinical is not limited to traditional settings

28. PedagogyStrategies to Promote Learning “Students gain a > understanding of the issues of the community at large… promotes a more global way of thinking…forced to examine own strengths & ability to work & communicate on other people’s terms & territory…they gain an appreciation for the diverse factors that affect the health of the population.”

29. 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

30. Administrative Issues • Labour and Time intensive to negotiate & coordinate • Multiple parties involved in each ICP negotiation • Communication issues • Unique needs to be accommodated/communicated all parties • Educational & service agency administrative support seen necessary for creative process in developing ICPs • Existing partnerships facilitate process

31. Administrative Issues: Barriers to Use of ICPs 69% of CPCs & 58% of NE respondents Reported various barriers exist i) Faculty Factors: • Skill level req’d of faculty • ↑Workload • Shortages of suitable faculty – eg. experience, demographic • Resistance – need “buy in”

32. Faculty & Educational Institution Barriers “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”.

33. Administrative Issues: Barriers to Use of ICPs ii) Educational Institution 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

34. Administrative Issues: Barriers to Use of ICPs 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

35. Administrative Issues “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!”

36. Overview of Findings a) Use of ICPs b) Student learning c) ICPs often require additional administrative time and coordination d) Concerns over capacity & sustainability of ICPs

37. Capacity & Sustainability of ICPs • Capacity: • Widespread use by programs • 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

38. Discussion: Capacity & Sustainability of ICPs • Building Capacity: • Underutilized areas • Making the professional practice role understood • Target Population Groups • Maximizing Learning • Ensuring Sustainability • Fostering Partnerships

39. Discussion • Terminology • Since ICP’s widely used > 10 yrs – they’ve become the “mainstream” • Need to adopt consistent terminology

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

41. 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.

42. 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

43. Research Dissemination • 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

44. Research Dissemination • 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. • Reimer Kirkham, S., Hoe Harwood, C., Terblanche, L., Van Hofwegen, L. & Sawatzky, R. (2007) The Use of Clinical Placements in Nursing Education: A National Survey. Trinity Western University, Langley, B.C. Available at: http://www.twunursing.ca/web/Research/survey.html

45. Conclusion “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.”

46. Conclusion “…Life altering experiences for students.” “Students usually have the greatest personal & professional growth in these sites.”