INNOVATIVE CLINICAL
PLACEMENTS:
A NATIONAL PERSPECTIVE
CASN National Research Conference
Victoria, BC
November 16, 2006
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)
Funding
• Western Region Canadian Association
Schools of Nursing (WRCASN)
2005 - 2007
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
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 nontraditional community practice placements
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)
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
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
Objectives
a) describe the use of 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.
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:
a)
b)
c)
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
Data Collection
November 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™
Limitations
• Administrator, student & agency
stakeholder perspectives not sought
• Impact of Nursing program collaborations
on data
• Language constraints → Incomplete data re:
French language based programs
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
Describing the Sample:
Profile of Respondents by Role in
Nursing Program
Role in Program
Frequency
Percent
CPC only
57
38
Role as CPC and NE
who used ICPs
NE who used ICPs
36
24
47
31
NE who did not use
ICPs
11
7
n = 151
100
Overview of Findings
Corroborate Phase I findings, including:
a) ICP’s are widely utilized in Canadian nursing
education
b) Rich student learning typically occurs in these
settings
c) ICP’s often require additional administrative time
and coordination, as compared to traditional settings
d) Concerns over capacity & sustainability of ICPs
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
Most Common Sites for ICPs
Parish/Faith Communities
20%
International placements
38%
Impoverished/ Inner city settings
50%
Corrections/ forensics
57%
Rural Settings
60%
Aboriginal Communities
66%
Community Support Groups
80%
Schools
81%
0%
10% 20% 30% 40% 50% 60% 70% 80% 90%
% reported by CPCs
(N = 74, no response = 10)
Average # of hrs that Nursing Students
Spent in ICPs in Undergraduate Program
> 200 hours
19%
151 – 200 hours
16%
101 – 150 hours
17%
51 – 100 hours
8%
10 – 50 hours
9%
< 10 hours
1%
Don't Know
29%
0%
5%
10%
15%
20%
25%
as reported by CPCs
(N = 75, no response = 9)
30%
35%
Courses that use ICPs
Palliative Care
13%
Gerontological Nursing
18%
Maternal-child / Perinatal
25%
Pediatrics
29%
Preceptorships
54%
58%
Mental Health / Psychiatric Nursing
Community Health
80%
0%
10%
20%
30%
40%
50%
60%
70%
as reported by CPCs
(N = 76, no response = 8)
80%
90%
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)
Overview of Findings
a) Use of ICPs
b) Student learning
c) ICP’s often require additional administrative
time and coordination, as compared to
traditional settings
d) Capacity & sustainability of ICPs
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
“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.”
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)
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
Overview of Findings
a) Use of ICPs
b) Student learning
c) ICP’s often require additional
administrative time and coordination, as
compared to traditional settings
d) Capacity & sustainability of ICPs
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
Findings: Administrative Issues
Barriers 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”
“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”.
Findings: Administrative Issues
Barriers …..
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
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
“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!”
Overview of Findings
a) Use of ICPs
b) Student learning
c) ICP’s often require additional administrative
time and coordination, as compared to
traditional settings
d) Capacity & sustainability of ICPs
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
Challenges using ICPs:
“Gleaning the role of the
nurse within agencies that do
not have a nursing
presence.”
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.
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
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 )
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.
“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.”