INNOVATIVE CLINICAL INNOVATIVE CLINICAL PLACEMENTS: PLACEMENTS:

A NATIONAL PERSPECTIVEA NATIONAL PERSPECTIVE

CASN National Research ConferenceCASN National Research Conference

Victoria, BCVictoria, BC

November 16, 2006November 16, 2006

Innovative Clinical Placements Innovative Clinical Placements Research TeamResearch Team

Sheryl Reimer Kirkham, RN PhDSheryl Reimer Kirkham, RN PhD

Catherine Hoe Harwood, RN MScNCatherine Hoe Harwood, RN MScN

Lynn Van Hofwegen, RN, MSN, NPLynn Van Hofwegen, RN, MSN, NP

Landa Terblanche, RN PhDLanda Terblanche, RN PhD

Rick Sawatzky, RN PhD(c)Rick Sawatzky, RN PhD(c)

FundingFunding

• Western Region Canadian Association Western Region Canadian Association Schools of Nursing (WRCASN) Schools of Nursing (WRCASN) 2005 - 20072005 - 2007

BackgroundBackground

Over past five years there has been increasing Over past five years there has been increasing pressures nationally on availability of pressures nationally on availability of clinical nursing placementsclinical nursing placements

Theory & practice (praxis) come together Theory & practice (praxis) come together within the clinical learning settingswithin the clinical learning settings

BackgroundBackground

• New program coming into placement New program coming into placement negotiation on the cusp of growing shortage negotiation on the cusp of growing shortage of clinical placementsof clinical placements

• Challenges negotiating community clinical Challenges negotiating community clinical placements led, of necessity, to non-placements led, of necessity, to non-traditional community practice placementstraditional community practice placements

Research ProgramResearch Program

• Pilot Study:Pilot Study: Parish and Rural Settings as Parish and Rural Settings as Clinical Placements Clinical Placements (2001)(2001)

• Phase I:Phase I: Innovative Clinical Placements: A Innovative Clinical Placements: A Descriptive Study Descriptive Study (2002 – 2004)(2002 – 2004)

• ““Keeping the Vision”: Sustaining Social Keeping the Vision”: Sustaining Social Consciousness following International Learning Consciousness following International Learning Experiences Experiences (2004 – 2006)(2004 – 2006)

• Phase IIPhase II:: A National Survey A National Survey

of the Use of Innovative Clinical of the Use of Innovative Clinical Placements Placements (2005 – 2007)(2005 – 2007)

Definitions:Definitions:• Innovative Clinical PlacementsInnovative Clinical Placements Less structured clinical environments, often Less structured clinical environments, often

multidisciplinary; typically outside or multidisciplinary; typically outside or varying from the main health care delivery varying from the main health care delivery systemsystem

• Traditional Clinical PlacementsTraditional Clinical Placements Structured clinical environments, typically Structured clinical environments, typically

within the main health care systemwithin the main health care system

MethodologyMethodologyA survey was designed to elicit the A survey was designed to elicit the

utilization rate & numerous factors r.t. utilization rate & numerous factors r.t. student learning and clinical education student learning and clinical education

within Innovative Clinical Placements (ICPs) within Innovative Clinical Placements (ICPs) in in Undergraduate Nursing ProgramsUndergraduate Nursing Programs

throughout Canadathroughout Canada

ObjectivesObjectivesa)a) describe the describe the useuse of innovative clinical settings in of innovative clinical settings in

Canada (prevalence, type).Canada (prevalence, type).b) elicit the perspectives of nurse educators b) elicit the perspectives of nurse educators

regarding the regarding the nature of student learningnature of student learning in in these sites; these sites;

c) describe variables related to c) describe variables related to administrative administrative mattersmatters regarding the use of ICPs; regarding the use of ICPs;

d) describe d) describe strengths and weaknessesstrengths and weaknesses of clinical of clinical placements in these sites; andplacements in these sites; and

e) identify ethical, legal, and academic e) identify ethical, legal, and academic issuesissues associated with the utilization of these settings. associated with the utilization of these settings.

Survey DesignSurvey DesignSurvey QuestionsSurvey Questions

Derived from Phase I findingsDerived from Phase I findings

Survey FormatSurvey FormatOnline format (utilizing Survey Monkey)Distributed via email and telephone follow up

Survey featured 3 sectionsSurvey featured 3 sections::a)a) General section – all respondentsGeneral section – all respondentsb)b) Program information – Clinical Placement Coordinators (CPC)Program information – Clinical Placement Coordinators (CPC)c)c) Teaching & learning perspectives – Nurse Educators (NE) Teaching & learning perspectives – Nurse Educators (NE)

teaching in ICPs, including some CPC who are NEteaching in ICPs, including some CPC who are NE

Data CollectionData CollectionNovember 2005 – January 2006November 2005 – January 2006

National Perspective elicited:National Perspective elicited:151 eligible respondents 151 eligible respondents

76 nursing programs represented 76 nursing programs represented 41 programs represented by 2 or more respondents41 programs represented by 2 or more respondents

Data Analysis ProceduresData Analysis ProceduresDescriptive Statistical Analyses of Survey AnswersDescriptive Statistical Analyses of Survey AnswersContent Analysis of open-ended written responses Content Analysis of open-ended written responses

using NVivousing NVivo™™

LimitationsLimitations

• Administrator, student & agency Administrator, student & agency stakeholder perspectives not soughtstakeholder perspectives not sought

• Impact of Nursing program collaborations Impact of Nursing program collaborations on dataon data

• Language constraints Language constraints → Incomplete data re: → Incomplete data re: French language based programsFrench language based programs

SampleSampleConvenience sample from among all Canadian baccalaureate Convenience sample from among all Canadian baccalaureate

undergraduate nursing programsundergraduate nursing programs

Potential respondents nominated by deans/directors of Potential respondents nominated by deans/directors of nursing programsnursing programs

Inclusion Criteria:Inclusion Criteria:• Clinical Placement Coordinator (CPC) for program &/orClinical Placement Coordinator (CPC) for program &/or• Nurse Educator teaching in any of following:Nurse Educator teaching in any of following:

• Sr level community health course (or equiv)Sr level community health course (or equiv)• Other undergrad courses using ICPsOther undergrad courses using ICPs• Undergrad preceptorships in ICPsUndergrad preceptorships in ICPs

Describing the Sample: Describing the Sample: Profile of Respondents by Role in Profile of Respondents by Role in

Nursing Program Nursing Program Role in ProgramRole in Program FrequencyFrequency PercentPercent

CPC onlyCPC only 5757 3838

Role as CPC Role as CPC andand NE NE who used ICPswho used ICPs

3636 2424

NE who used ICPsNE who used ICPs 4747 3131

NE who did not use NE who did not use ICPsICPs

1111 77

n = 151n = 151 100100

Overview of FindingsOverview of Findings

Corroborate Phase I findingsCorroborate Phase I findings, including: , including:

a)a) ICP’s are widely utilized in Canadian nursing ICP’s are widely utilized in Canadian nursing educationeducation

b)b) Rich student learning typically occurs in these Rich student learning typically occurs in these settings settings

c)c) ICP’s often require additional administrative time ICP’s often require additional administrative time and coordination, as compared to traditional settingsand coordination, as compared to traditional settings

d)d) Concerns over capacity & sustainability of ICPsConcerns over capacity & sustainability of ICPs

Findings:Findings: Use of ICPs Use of ICPs

• 96% of respondents report their 96% of respondents report their program use ICPsprogram use ICPs

• 72% report that use of ICPs has 72% report that use of ICPs has ↑↑over over past 5 yearspast 5 years

• 52% of CPC respondents indicate that 52% of CPC respondents indicate that > ½> ½ of community placements were in of community placements were in ICPsICPs

• A majority of programs report use of A majority of programs report use of ICPs ICPs > 100 hrs/student> 100 hrs/student throughout throughout their entire programtheir entire program

Most Common Sites for ICPs

81%

80%

66%

60%

57%

50%

38%

20%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Schools

Community Support Groups

Aboriginal Communities

Rural Settings

Corrections/ forensics

Impoverished/ Inner city settings

International placements

Parish/Faith Communities

% reported by CPCs(N = 74, no response = 10)

Average # of hrs that Nursing Students Spent in ICPs in Undergraduate Program

29%

1%

9%

8%

17%

16%

19%

0% 5% 10% 15% 20% 25% 30% 35%

Don't Know

< 10 hours

10 – 50 hours

51 – 100 hours

101 – 150 hours

151 – 200 hours

> 200 hours

as reported by CPCs(N = 75, no response = 9)

Courses that use ICPs

80%

58%

54%

29%

25%

18%

13%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Community Health

Mental Health / Psychiatric Nursing

Preceptorships

Pediatrics

Maternal-child / Perinatal

Gerontological Nursing

Palliative Care

as reported by CPCs(N = 76, no response = 8)

Findings: Use of ICPsFindings: Use of ICPs

• Size of programSize of program • The extent of ICPs use in undergraduate programs was similar for programs The extent of ICPs use in undergraduate programs was similar for programs

of difference sizes.of difference sizes.• Graduate ProgramsGraduate Programs

• Nursing programs offering graduate degree(s) used ICPs more extensively in Nursing programs offering graduate degree(s) used ICPs more extensively in undergrad programs than programs without graduate degrees.undergrad programs than programs without graduate degrees.

• PartnershipsPartnerships • Nursing programs that had more partnerships with community agencies Nursing programs that had more partnerships with community agencies

reported more extensive use ICPs.reported more extensive use ICPs.• Level of student Level of student

• 32% of CPCs reported that their programs used ICPs for entry level students 32% of CPCs reported that their programs used ICPs for entry level students (N=75, 9 = no response)(N=75, 9 = no response)

(Above conclusions are based on chi-square analyses of contingency tables)(Above conclusions are based on chi-square analyses of contingency tables)

Overview of FindingsOverview of Findings

a)a) Use of ICPsUse of ICPs

b)b) Student learningStudent learningc) ICP’s often require additional administrative

time and coordination, as compared to traditional settings

d) Capacity & sustainability of ICPs

Findings:Findings: Nature of Student Nature of Student LearningLearning

• Majority of Ns Educator respondents Majority of Ns Educator respondents agreed agreed stronglystrongly that ICPs are that ICPs are moremore effective effective for for promoting student learning of:promoting student learning of:• Community DevelopmentCommunity Development• Social Determinants of HealthSocial Determinants of Health• Social Justice & Equity (Health Care Social Justice & Equity (Health Care

Access)Access)• Issues r.t. PovertyIssues r.t. Poverty• Culture & DiversityCulture & Diversity

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

Findings:Findings: Nature of Student Nature of Student LearningLearning

• Majority of Ns Educator respondents agreed that Majority of Ns Educator respondents agreed that students in ICPs demonstrated:students in ICPs demonstrated:• More More initiativeinitiative toward engaging in clinical learning toward engaging in clinical learning

opportunitiesopportunities• More More creativitycreativity in clinical decision-making in clinical decision-making• More More critical thinkingcritical thinking by identifying nursing by identifying nursing

assessments & interventionsassessments & interventions• Students in ICPs develop Students in ICPs develop stronger professional stronger professional

relationships with the communitiesrelationships with the communities of ICPs (34% = of ICPs (34% = agree strongly, 49% = agree somewhat)agree strongly, 49% = agree somewhat)

Findings:Findings: Strategies to Promote Strategies to Promote LearningLearning

• Structure of the learning activitiesStructure of the learning activities• NE unanimous re: importance of clarity of course & clinical NE unanimous re: importance of clarity of course & clinical

placement objectives placement objectives

• Links to existing curriculum importantLinks to existing curriculum important

• Models of Clinical SupervisionModels of Clinical Supervision• Most common approach reported by CPC (50%) & NE (43%) Most common approach reported by CPC (50%) & NE (43%)

is is some supervisionsome supervision with contact q 2 – 3 days via email, with contact q 2 – 3 days via email, phone or on-campus contact, limited on-site visitsphone or on-campus contact, limited on-site visits

Overview of FindingsOverview of Findings

a)a) Use of ICPsUse of ICPs

b)b) Student learningStudent learning

c)c) ICP’s often require additional ICP’s often require additional administrative time and coordination, as administrative time and coordination, as compared to traditional settingscompared to traditional settings

d)d) Capacity & sustainability of ICPsCapacity & sustainability of ICPs

Findings:Findings: Administrative Issues Administrative Issues

• Negotiation of ICPNegotiation of ICP• Majority of CPCs agree strongly (57%) or Majority of CPCs agree strongly (57%) or

somewhat (20%) that time for coordination & set-up somewhat (20%) that time for coordination & set-up for ICPs is for ICPs is greatly increasedgreatly increased compared to TCPs. compared to TCPs.

• Most often ICPs are Most often ICPs are negotiated by CPCsnegotiated by CPCs, although , although involvement of nursing faculty & existing involvement of nursing faculty & existing partnerships also commonpartnerships also common

• Administrative support for creative process in Administrative support for creative process in developing ICP’sdeveloping ICP’s

Findings:Findings: Administrative Issues Administrative Issues

Barriers to Use of ICP’s69% of CPCs & 58% of NE respondents 69% of CPCs & 58% of NE respondents

indicate barriers existindicate barriers existi) Faculty Factors:i) Faculty Factors:

• Skill level req’d of facultySkill level req’d of faculty

•↑↑WorkloadWorkload • Shortages of suitable faculty – eg. experience, Shortages of suitable faculty – eg. experience,

demographicdemographic• Resistance – need “buy in”Resistance – need “buy in”

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

Findings:Findings: Administrative Issues Administrative IssuesBarriers …..Barriers …..

ii) Educational Institutional factorsii) Educational Institutional factors• Competition b/w different professions/programs for spacesCompetition b/w different professions/programs for spaces

• Costs of clinical faculty supervising students/site or covering Costs of clinical faculty supervising students/site or covering multiple placementsmultiple placements

• Geographic factors – keep some students closer to home Geographic factors – keep some students closer to home

iii) Student related factors (as reported by NE)iii) Student related factors (as reported by NE)

• Typically additional costs/scheduling impactTypically additional costs/scheduling impact

• Access to technology, transportation, accommodationAccess to technology, transportation, accommodation

• Impact on family or work commitmentsImpact on family or work commitments

Findings: Findings: Administrative IssuesAdministrative Issues Barriers ….. Barriers …..

iv) Agency factorsiv) Agency factors & constraints & constraints• Staff issues – shortages/schedules impact placements, Staff issues – shortages/schedules impact placements,

downsizing, retirement of most experienced staffdownsizing, retirement of most experienced staff

• Space/equipment limitationsSpace/equipment limitations

• Consistency of strong clinical instructor keyConsistency of strong clinical instructor key

• Protectiveness of staff re: clientele, confidentiality issuesProtectiveness of staff re: clientele, confidentiality issues

• Agency criteria Agency criteria ↑↑constraints on student assignments to setting eg. desire strong students only, criminal record desire strong students only, criminal record checks, refusal of junior studentschecks, refusal of junior students

““The numbers of agencies and individual The numbers of agencies and individual students can be overwhelming to the CPC when students can be overwhelming to the CPC when

we are looking at the numbers of agencies, we are looking at the numbers of agencies, students, preceptors and faculty persons students, preceptors and faculty persons

involved. Each one involves different players, involved. Each one involves different players, policies, procedures and communication policies, procedures and communication

factors……..factors……..

A challenge indeed!”A challenge indeed!”

Overview of FindingsOverview of Findings

a)a) Use of ICPsUse of ICPs

b)b) Student learningStudent learning

c) ICP’s often require additional administrative time and coordination, as compared to traditional settings

dd)) Capacity & sustainability of ICPsCapacity & sustainability of ICPs

Discussion:Discussion: Capacity & Capacity & Sustainability of ICPsSustainability of ICPs

• Capacity: Widespread use by programsCapacity: Widespread use by programs• Underutilized areasUnderutilized areas• Making the RN role understoodMaking the RN role understood

• Sustainability: Burn-out FactorSustainability: Burn-out Factor• Can’t expect CPC & NE to negotiate & utilize ICPs Can’t expect CPC & NE to negotiate & utilize ICPs

under the same formula as used in traditional sitesunder the same formula as used in traditional sites• Agency fatigueAgency fatigue

• Importance of partnerships to success Importance of partnerships to success

Challenges using ICPs:Challenges using ICPs:

““Gleaning the role of the Gleaning the role of the nurse within agencies that do nurse within agencies that do

not have a nursing not have a nursing presence.”presence.”

RecommendationsRecommendations1. Nursing programs should continue to 1. Nursing programs should continue to

develop the use of ICPs develop the use of ICPs 2. Strategies be developed to 2. Strategies be developed to ↑ ↑ capacity & to capacity & to

facilitate sustainability of ICPs.facilitate sustainability of ICPs.3. Administrative support (such as funding, 3. Administrative support (such as funding,

release time) should account for the extra release time) should account for the extra time req’d to negotiate ICPs. Includes: time req’d to negotiate ICPs. Includes:

• encouraging innovation to develop new encouraging innovation to develop new clinical sites, & the clinical sites, & the

• purposeful building of understanding among purposeful building of understanding among faculty regarding the value of ICPs. faculty regarding the value of ICPs.

Recommendations (cont’d)Recommendations (cont’d)

4. Partnerships b/w academic & host agencies 4. Partnerships b/w academic & host agencies should be established to facilitate administration should be established to facilitate administration of ICPs & foster student learning.of ICPs & foster student learning.

5. The role of the nurse in non-traditional sites 5. The role of the nurse in non-traditional sites should be articulated. should be articulated.

6. Research should be conducted with agency 6. Research should be conducted with agency stakeholders to gain insight into the issues they stakeholders to gain insight into the issues they face hosting students face hosting students

Follow-up Focus GroupFollow-up Focus Group

• Seek to validate and extend the survey findingsSeek to validate and extend the survey findings• Incorporate some administrative viewpoints – the Incorporate some administrative viewpoints – the

Deans & Directors invited participationDeans & Directors invited participation

• Scheduled for November 16, 2006Scheduled for November 16, 2006

1600 hrs Esquimalt Room, 1600 hrs Esquimalt Room,

Victoria Conference CenterVictoria Conference Center

(thanks to the Conference Planning Committee for (thanks to the Conference Planning Committee for scheduling this event )scheduling this event )

PublicationsPublications• Reimer Kirkham, S., Van Hofwegen, L., & Hoe Harwood, C. Reimer Kirkham, S., Van Hofwegen, L., & Hoe Harwood, C.

(2005). Narratives of Social Justice: Student Learning in (2005). Narratives of Social Justice: Student Learning in Innovative Clinical Placements. Innovative Clinical Placements. International Journal of International Journal of Nursing Education Scholarship.Nursing Education Scholarship. 2(1), article 28. Available: 2(1), article 28. Available:

http://www.bepress.com/ijnes/vol2/iss1/art28

• Van Hofwegen, L., Reimer Kirkham, S., & Hoe Harwood, C. Van Hofwegen, L., Reimer Kirkham, S., & Hoe Harwood, C. (2005). Accessing the strength of rural health settings: (2005). Accessing the strength of rural health settings: Implications for undergraduate nursing education. Implications for undergraduate nursing education. International International Journal of Nursing Education Scholarship.Journal of Nursing Education Scholarship. 2(1), article 27. 2(1), article 27. Available: Available: http://www.bepress.com/ijnes/vol2/iss1/art27

• Reimer Kirkham, S., Hoe Harwood, C., & Van Hofwegen, L. Reimer Kirkham, S., Hoe Harwood, C., & Van Hofwegen, L. (2005). Capturing the vision: Undergraduate nursing students in (2005). Capturing the vision: Undergraduate nursing students in innovative clinical settings. innovative clinical settings. Nurse Educator,Nurse Educator, 3030(6):263-270.(6):263-270.

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