Balancing growth in ambulatory settings are workforce constraints and limitations in education. Some ambulatory practices report having “difficulty recruiting registered nurses that possess adequate training in managing acute and chronic conditions in ambulatory care settings” when working to expand the registered nurse role in the primary care environment (Ladden, et al., 2013). Despite available positions in these settings, most nursing students learn clinical practice primarily in acute care settings rather than in ambulatory and community settings. Focusing largely on acute care practice limits both competence and career development for generalist nurses (Fortier, et al., 2015). Wojnar and Whelan (2016), note “it is unclear to what extent nursing schools” have moved to having a greater ambulatory and community emphasis within their curriculums (pg. 223). Workforce preparation and capacity lack alignment with healthcare delivery.
This survey methods study aimed primarily to describe perceived exposure to specialty, primary, and ambulatory care among current undergraduate nursing students in the United States. Describing the extent to which clinical placement affect where these students plan to work was the secondary aim. These student-focused aims are part of a larger project which also survey pre-licensure program directors about the extent to which their curricula include content on ambulatory and other community healthcare delivery settings. An investigator designed survey that included XX demographic questions and YY content questions was the only measure used. After receiving IRB approval, nursing students currently pursuing a baccalaureate or associate degree from accredited nursing schools in the United States were invited to participate. Recruitment strategies for contacting eligible participants includes personal contacts, nursing social media groups, the National Student Nurses Association (NSNA) listserv, and emails to the Deans and Program Directors of nursing schools found on the membership list on the National League for Nursing (NLN) website. Access to the survey was online through Qualtrics which was also used to store data securely and anonymously. Analysis included descriptive measures and evaluation of statistical significance using chi-square goodness of fit test and chi-square test for independence.
A total of 811 nursing students across the country, representing 47 out of the 50 United States and the District of Columbia. Of those participating, 62.75% of students reported having greater than 30 clinical sessions in hospital settings. Only 0.9% of students reported no clinical sessions in the hospital. Conversely, 20 to 58% of students had no clinical sessions in other settings listed including ambulatory and primary care centers. With clinical sessions defined in this survey as approximately 6-8 hours in length, many students experienced over 240 hours of hospital practice while at the same time many are receiving no experience in other settings. Furthermore, 88.8% of students indicated an aim to work in a hospital setting after graduation with 82.5% of students prioritizing that setting as their first choice for work in five to ten years. When compared to the estimated 61% of nurses who work in inpatient acute care settings today, the difference is clinically significant (𝜒²= 261.78; P<0.001), representing dissonance between the realities of healthcare and nursing students’ expectations.
Across nursing programs these expectations varied somewhat with 95.2% of students from 4-year BSN programs want to work in a hospital setting after graduation as compared to 79.4% from 2-year ADN programs (𝜒²= 4.227; P= 0.039) and 71.1% from RN to BSN programs (𝜒²= 1.98; P= 0.159). Additionally, 4-year nursing programs have a higher percentage of students who have greater than 30 clinical sessions in the hospital. Of 4-year BSN nursing students, 69.8% have 30 or more clinical sessions in a hospital as compared to 2-year ADN with 54.8% and RN to BSN programs with 36.1% (𝜒² 9.87; P= 0.007). The number of hospital clinical sessions is related to nursing students expectations of future practice setting via a chi square test for independence, the two variables is significantly associated (𝜒²=13.855, P<0.001).
Clinical rotations and other educational experiences help shape nursing students’ clinical and critical thinking skills, professionalism, and perspectives on their careers. Our findings corroborate a small but growing body of literature that speaks to the demand for nursing students to be educated more broadly, understanding patient education, continuity of care, transitions in care, and chronic disease management as they extend well beyond the walls of the hospital. Additionally, our findings support the American Academy of Ambulatory Care Nursing’s stance on curriculum transformation. As Wojnar and Whelan (2016) assert “new curricula and practice models will be required from nursing schools and colleges across the nation to prepare future nurses to function in primary and/or ambulatory care practice and ultimately serve as change management and transitional care leaders.” Our findings thus inform future curriculum development and clinical placement design to ensure that the future nursing workforce is better prepared to improve the health of the populations they serve.