Building Practice Partnerships: Facilitating Role Development of Novice Clinical Instructors in Dedicated Education Units

In 2010, The Future of Nursing: Leading Change, Advancing Health Report was released by the Institute of Medicine, calling for transformational changes across the nursing profession. In this report, nursing leaders were summoned to address the nursing faculty shortage, the education-practice gap and make improvements in quality and safety (Institute of Medicine, 2010). The implementation of the dedicated education unit (DEU) model for clinical education is an innovative approach to address the nursing faculty shortage and the education-practice gap. In this model, baccalaureate-prepared staff nurses employed by the clinical facility serve as the primary clinical instructor (CI) for one or two nursing students, and the nursing faculty member oversees approximately eight staff nurse CIs. The nursing faculty member serves as a coach to provide clinical supervision, mentoring for the staff nurses in the role of educator, and is responsible for completing the student’s clinical evaluation. The DEU clinical model was originally developed at the Flinder’s University of South Australian School of Nursing in the 1990’s, and was introduced in the United States in 2003 at the University of Portland, School of Nursing (Glynn, McVey, Wendt, & Russell, 2017). Since this time, the DEU model was identified by nursing leaders as one possible solution to the faculty shortage and the anticipated nursing shortage, and has been replicated in multiple schools of nursing and in a variety of clinical settings around the United States (Moscato, Nishioka, & Coe, 2013; Glynn et al., 2017; & Harmon, 2013; Nishioka, Coe, Hanita, & Moscato, 2014).

Collaborative academic-practice partnerships are essential to the development and implementation of a DEU, require a commitment to a shared vision, and are based upon a set of assumptions that identify a shared set of beliefs, expectations, agreements, and tasks (Moscato et al., 2013). Prior to the implementation of the DEU model, an intensive planning period is needed between the academic institution and the clinical practice partner. This often begins with conversations between the dean of the academic institution and the nurse executives within the clinical agencies. Clinical nursing units are selected within the facility, and the nurse managers of these units work together with the DEU project coordinators from the academic institution. During this planning phase of the DEU, experienced staff nurses are encouraged to volunteer to serve as a CI. The DEU project coordinators work closely with the nursing unit managers to develop a vision for the program and to employ the DEU concept. Clarification of roles and responsibilities is essential as part of this process. As part of the initial preparation of the staff nurses for their role as CIs, the CIs are required to attend a comprehensive orientation workshop provided by the partnering school of nursing. Throughout the semester, the CIs are provided with ongoing mentoring opportunities to facilitate role development. Outcomes associated with this model include a strengthened academic practice partnership, improved clinical experience for the students and supported professional development of the CIs (Glynn et al., 2017). CIs have reported gratification in actively facilitating student growth and development and have a heightened sense of job satisfaction (Moscato et al., 2013). New CIs have reported feelings of uncertainty about evaluating performance and critical thinking and requested validation and further development in these areas by expert faculty members (Moscato et al., 2007). ). It was noted that CI’s reported a heightened sense of job satisfaction, enhanced feelings of ownership in the success of future nurses, contributing to increased retention of these nurses in their roles as staff nurses in the DEU units (Harmon, 2013; Moscato et al., 2013). Students who participate in a DEU experience have reported increased opportunities to learn invaluable skills including teamwork, time management, and communication among other necessary skills to facilitate their transition to prosperous nursing careers (Nishioka, 2014).

This quality improvement project seeks to address the following PICOT question: In the novice DEU clinical nurse educators, does training and mentoring prior to the first clinical experience increase attitudes, beliefs, and commitment to role development when evaluated at the end of the first semester of teaching? To address this question, Kanter’s Model of Structural Determinants of Behavior in Organizations was used. This model is a validated methodology to analyze the impact of employees’ perceptions of power and opportunity on commitment to an organization (Wiens, Babenko-Mould, & Iwasiw, 2014). Within this model, power refers to the access to support, information, supplies, and aptitude to activate resources to achieve organizational goals, whereas opportunity signifies possibilities for advancement, the option to enhance skills and competencies, and rewards and acknowledgement of skills (Wiens et al., 2014). This model is applicable to the DEU setting as CIs in the role of the instructor have access to power and opportunity to influence learning in potential future nursing peers. The influence of power and opportunity will support commitment to the CI role. In addition, CIs in the DEU model are positioned to advance, enhance skills and competencies, and receive rewards and acknowledgement of skills. The Evidence-Based Practice Model (Rosswurm & Larrabee, 1999) was also used in support of this project as it provides an outline to guide the user through a systematic, six-step process of creating and integrating an evidence-based change in practice. This process begins with assessing the need for a change in practice. As part of this quality improvement project, the problem was identified. Next, problems, interventions and outcomes were linked. In this step, potential interventions and activities were identified. The third step in this process is to synthesize the best evidence, in which a literature review was performed. In the fourth step, practice changes were designed. In this step, the proposed change was defined, needed resources were identified, outcomes were defined, and the project implementation was planned. In the fifth step of this process, the change in practice is implemented and evaluated. As part of this step, a pilot study was implemented, and the process and outcomes were evaluated. This quality improvement project is currently in this step of the process. The final step in this model is to integrate and maintain the practice change. This includes integrating the change into the standard of practice and monitoring the process and outcomes.

This Doctor of Nursing Practice (DNP) student’s quality improvement project was divided into three phases. During Phase I, all registered nurses (RNs) identified to be new DEU CIs attended an orientation and training program at the educational institution, which was scheduled several weeks prior to the beginning of the fall semester. Continuing education units were provided for attending this training. At the beginning of the orientation program, the RNs serving in the role of CI were invited to participate in this quality improvement project, and informed consent was then obtained from the RN participants who agreed to voluntarily participate in this project. After obtaining informed consent, the RN CI participants were asked to complete the Preceptor Questionnaire (Dibert and Goldenberg, 1995) will assess the attitudes, beliefs, and confidence of these nurses prior to receiving any training on the CI role. This survey was completed using SurveyGizmo. Following survey completion, the RN CIs were provided with evidence based teaching and preceptor focused information and resources on the following topics: the importance of mentoring, monitoring outcomes of student interventions, curriculum development, quality improvement, and incorporating evidence-based practice into the clinical setting over the course of a two-day orientation session. Phase II of the project spanned the duration of fall semester. During this phase on two occasions, the DNP student provided mentoring and support to the CIs as they developed in their new role of instructing undergraduate nursing students. Topics discussed included items such as CI role development, clinical instruction techniques, answered questions, and provided overall guidance as needed. These conversations were brief and were held at a time convenient for each CI, as to not interfere with patient care. The support provided by the DNP student was given in addition to the Course Coordinator/Clinical Faculty member assigned to the course that the CIs are providing clinical instruction. During Phase III, the DNP student visited each CI at the conclusion of the semester for summative mentoring support and for the completion of the Preceptor Questionnaire as a post-experience survey. This survey assessed the attitudes, beliefs, and confidence at the end of the first CI/DEU instructional experience. In addition, the results of the pre- and post-semester Preceptor Questionnaire assessment of attitudes, beliefs and confidence of clinical nursing instructors will be compared to determine if a change has occurred. An evaluation of the need for additional education and support will also be conducted.

It is imperative that the current practice for preparation of CIs must continue to be explored to ensure that the process are sufficiently meeting the needs of the CIs. In addition, these academic-practice partnerships must remain committed to provide the necessary support for both staff nurses serving as CIs and the nursing students participating in a DEU clinical experience.