1. State of Wyoming 2013 Nursing Education Summit
Nancy DeBasio, RN, PhD, FAAN
Susan Fetsch, RN, PhD
Welcome
Overview of Day
Review objectives

2. Academic-Service Partnerships
Learning Objectives
Examine ways to share expertise and education between agencies and education
Improve or begin partnerships using clinical staff as clinical affiliates for nursing education
Minimize time spent in orientating to multiple clinical sites
Improve preceptor orientation and communication to facilitate best outcomes
MORNING—Focus on Partnership Activities

3. Clinical Education Learning Objectives:
Increase availability of clinical sites/areas using creative models
Utilize best practices for conceptual clinical experiences
Maximize student learning through the creation of timely and valuable clinical experiences
Afternoon—focus on clinical education

4. Status of Nursing
Nursing shortage Faculty shortage Technology Aging of society Clinical Sites Insufficient numbers Ineffective use
Nursing shortage in Wyoming: % increase from 2006 to 2014
Faculty shortage: Nationally average age of faculty is 54—typical retirement at 62.5 yrs.
According to survey by NLN and Carnegie ½ nursing faculty will retire in next 10 years.
Ineffective—competition/underuse due to size, prep of nursing staff and location

5. What is Unique in Wyoming?
Remote areas of state
Boom and bust cycle
Shortfall of 222 nurses annually
Predominance of AD education
Wyoming Center for Nursing and Health Care Partnerships
RENEW
Remote areas—supply of providers; access
Boom and bust cycle—caution in making infrastructrue investments including those involving building or expanding health care facilities
RENEW:
Competency-based statewide curriculum
Courses/clinical experiences through distance delivery???
Shared resources

6. RENEW Shared leadership through education and practice partnership:
Using a shared leadership model that encourages mutual and dynamic partnerships between nursing education and clinical facilities
Thinking big…committing to transformation of nursing in Wyoming
Discussing ASP…hope to provide examples that might help to meet RENEW goal of….

7. AACN Initiative on ASP Guiding Principles
Knowledge is shared among partners
Collaborative relationships between academia and practice are established and sustained
Mutual respect and trust are the cornerstones of the practice/academia relationship
AACN/AONE partnership
Toolkit and template

8. AACN Initiative on ASP (cont)
A commitment is shared by partners to maximize the potential of each registered nurse to reach the highest level within his/her individual scope of practice
A commitment is shared by partners to work together to determine an evidence based
transition program for students and new graduates that is both sustainable and cost effective

9. AACN Initiative on ASP (cont)
A commitment is shared by partners to develop, implement, and evaluate organizational processes and structures that support and recognize academic or educational achievements
A commitment is shared by partners to support opportunities for nurses to lead and
develop collaborative models that redesign practice environments to improve health
outcomes

10. AACN Initiative on ASP (cont)
A commitment is shared by partners to establish infrastructures to collect and analyze data on the current and future needs of the RN workforce
The Institute of Medicine (2010) report, The Future of Nursing: Leading Change, Advancing Health frames these guiding principles and serves as a platform for all strategies to build and sustain academic- practice partnerships.: January 2012

11. Do you feel like you’re trying to get here?

12. Hopefully you’ll leave with some ideas to share the burden

13. Evolution of the partnership Lessons Learned Evaluation Process
The KC ASP
Evolution of the partnership
Lessons Learned
Evaluation Process

14. GKCCNE/KCANE Initiatives
Clinical orientation agreement
Common employer survey
Clinical faculty academy/Affiliate faculty
Preceptor academy

15. Clinical Orientation Agreement
Used by:
17 affiliated nursing programs
28 healthcare agencies
Maintained by:
Missouri Hospital Association
Developed in 1997 for nursing education continues to be used—now includes non-nursing students;
Based on The Joint Commission on Accreditation of Healthcare, Occupational Safety and Health Administration, and Medicare regulations as well as recommendations from the Association of Professional Infection Control.
Annual review by clinical staff educators/deans/directors. Changes in immunization requirements are based on Center for Disease Control recommendations.
Why? Often redundant orientation, reduced the number of actual clinical contact hours for students, and was not cost effective—record keeping
What? includes a description of assumptions regarding faculty and staff roles in clinical education, documentation and record keeping requirements for faculty and students, as well as agency specific and faculty orientation expectations
When? Used at the beginning of the clinical education program with review and retesting for competency on an annual basis.
Students and faculty are expected to demonstrate 90% competency annually prior to clinical experiences. Test results are kept on file at the nursing program.

16. Common Employer Survey
Employer Satisfaction
Low Response Rate
Common Process
Outcomes
Employer satisfaction part of accreditation/some SBN expectations
Response rate to annual employer surveys has traditionally been very low.
The surveys are intended to seek employer satisfaction with new graduates and to help schools determine whether or not nursing curricula are meeting workforce needs.
Schools had individually attempted different approaches to improve employer response rates without much success.
Consequently, the Greater Kansas City Area Collegiate Nurse Educators proposed the development of a common employer survey—one that would be familiar to nurses within the agencies thus reducing completion time.
The Common Employer Survey asks employers to compare the school’s graduate as an employee with graduates from other programs at one-year post graduation.
A series of competencies identified by the Institute of Medicine (2003) are listed—needs to be updated.
A Likert scale, completed by the employer, provides an employer satisfaction rating of graduates.
The survey and process were adopted by all schools of nursing in the greater Kansas City area beginning in June 2007 to facilitate consistent evaluation and improved return rates by area hospitals.
Employers returned the survey electronically to the school of nursing.
The process was again revised for December 2009 area graduates. Nurse managers distributed copies of the survey at unit meetings and asked for completion.
Unfortunately, response rates have not increased.
Future discussions will focus on what revisions may need to be implemented in the distribution and/or collection of these important data.

17. Clinical Faculty Academy
Projected shortage of RN’s at the bedside
Inability of area nursing programs to increase enrollments
Lack of sufficient number of qualified faculty to provide clinical supervision
Two day workshop established in 2005
Outcomes
Here’s What Participants Are Saying about the Clinical Faculty Academy
Selected comments from the evaluations completed by nurses attending the CFA
“This is a great program that would help those nurses who really want to be educators and don’t know where to begin.”
“I loved the practical knowledge and pointers; the concrete teaching strategies.”
“This definitely helped me feel more confident going into clinical instruction for the first time.”
"I appreciate the thoroughness of the presentations and the sharing of actual experiences by the presenters – I also like the interactive nature of the academy."
“I liked meeting other new nurse educators.”
“The variety of speakers with their seasoned experience coming from different institutions was wonderful.”
“I liked the activities for post-conference, rubric, and evaluation tools.”
“There were so many things I gained from this. I have come away with so many good, creative ideas to use in my first instructor experiences. Every clinical instructor should come to this. It has made me more comfortable and touched on all the main issues in being a clinical instructor. I also have thought about my responsibilities and think this program really helps to build professionalism in teaching. Awesome!”
Successes
+ Growth in number of graduates
+ Enhanced academic-practice partnerships
+ Growth in number of qualified clinical adjunct faculty
+ Continuation of the two-day academies and post conferences
+ Online opportunities to stay connected post-academy
Challenges and Opportunities
- Inconsistent availability of clinical staff at some hospitals
- Potential for adjunct clinical faculty burnout due to juggling hospital work, adjunct teaching duties, and coursework for MSN degree
Unanticipated Outcomes
One KC WIRED (Workforce Innovation to Regional Economic Development), a 3-year grant to the Kansas City metropolitan area in February 2006, provided funding to sustain the nurse expansion initiative, including formal curriculum development for the Clinical Faculty Academy, the Nurse Preceptor Academy and the Nurse Mentoring Toolkit.
Schools in other locations may use these training materials for a reasonable, one-time fee.
Other communities have successfully replicated and adapted the Clinical Faculty Academy and nurse expansion model. St. Louis was the first site in They have met and exceeded their target increase.
We've had 624 nurses attend the CFA
We've held 17 CFAs in Kansas City - two per year. In August and January before the start of the semester.
The Missouri State Board of Nursing approved the initial waiver in 2004 for 5 years and extended it another 5 years in (Nurses can teach if they are working on their MSN and attend the CFA.)
For the State Board of Nursing we compile an annual report - it shows that student pass rates have not been negatively impacted by the initiative.
In our baseline year, , we had 1,009 new enrollments in ADN and BSN programs in Kansas City.
In , we had 1,547 new enrollments, over a 50 percent increase in enrollments. Our initial goal had been 20 percent. Graduations are increasing at a comparable pace.

18. Preceptor Academy
Lack of consistent approach to preceptor education across greater KC area
Mission: Proactive approach to educate and support nurse preceptors
Vision: Foster a collaborative work environment based on values of professionalism, diversity, compassion and integrity
Outcomes
OneKC Wired grant: supported first PA…
Part of $1.2 million grant from DOL to greater KC area
Project leaders: 2 hospital based educators; one nursing dean
One day workshop: Myers-Briggs completed to increase awareness of individual differences and behaviors that may enhance working relationships they develop with preceptee
Participated in activities which would help them assess learning needs of their preceptees; how to communicate effectively and provide constructive feedback; conflict resolution
Watson’s Theory of Human Caring served as framework for forming caring partnerships between two; legal/ethical issues discussed to provide professional context of responsibilities to self and others
Over 700 nurses from 20 hospitals participated
Mean overall rating post session = 4.75/5.00
Post eval: 6-12 months out
14 question survey on “did they feel better prepared; what content most useful; what ideas/content now using in their role; support from peers, managers, educators?; most stressful about precepting?”
Results indicated that they felt better to precept new nurses [4.56 mean]; had incorporated newly learned strategies
Post 2009: approximately 450 preceptors trained to date; 4 academies offered through MHA; 1 additional for allied health preceptors throughout state

19. Small Group Discussion
What are the greatest needs related to your current academic-practice arrangements?
What are potential solutions to these needs?
What is different and the same in this environment vs. the Kansas City area?
What would be required to implement the solutions identified?
How can you enhance more effective academic-practice relationships?

20. Large Discussion Group
Small group sharing on needs and solutions
Group preference on pursuing any particular solution(s)?
What currently exists that would facilitate accomplishing 1 or 2 of these solutions?
What barriers need to be overcome to effectively implement these solutions?

21. Clinical Education Learning Objectives:
Increase availability of clinical sites/areas using creative models (DEUs, simulation, traditional, immersion, other?)
Utilize best practices for conceptual clinical experiences
Maximize student learning through the creation of timely and valuable clinical experiences

22. RENEW COMMITTEE Charges
Curriculum Committee: Develop course structures (clinical and didactic)
Clinical Education Committee: Develop and oversee statewide plan for clinical transformation

23. Small Group Discussion: Current State of Clinical Education
What is the purpose of clinical in nursing education?
How is clinical experienced in your environment? # Hours? Structure? Setting?
What guides selection of clinical experiences/settings?
What are the “sacred cows” related to clinical education?
What is working? What is not working?
Per RENEW it is to enhance
Clinical judgment
Skill development
Professional nursing practice
Guburd-Howe:
Improve student achievement of course competencies through the creation of structured learning experiences
Ease strain of clinical education on clinical agencies
Ease transition of student role to professional role
Nursing expects:
Lifespan experiences
Prevalent illnesses
Chronicity
End of life
Care for vets
QSEN
IPE
How is clinical experienced in your environment? How many hours? Structure? Setting? (e.g., 2 days/wk)? Inpatient? Outpatient? Specialties? Simulation?

24. Barriers to Optimizing Clinical Learning (NLN)
Lack of quality clinical sites
Lack of qualified faculty
Size of clinical groups (faculty: student)
Restrictions on numbers of students or limitations imposed
Time consuming nature of learning multiple agency systems (including technology)
51% of respondents said they spent % of time supervising skill performance
13% said they spent % time assisting students to synthesize information and
10% said % questioning students to assess grasp of their patient status.

25. Clinical Models Specialty Experiences Dedicated Education Units (DEUs)
Interprofessional Education/Simulation
Conceptual Experiences
Structure
Education Needs in Wyoming
Practices Unique to Wyoming, e.g. telemedicine/telehealth
Search and rescue?
Trauma?

26. ATI Content Mastery and
Clinical Hours Pilot Study
Difficulty of placing students in specialty clinical areas.
Little was known about the number of clinical hours programs required in specialty areas.
The majority of the membership used the Assessment Technology Institute testing package and agreed to implement a project to compare clinical hours in specialty clinical experiences (mental health, obstetrics, and pediatrics) with student content mastery scores on the related assessment.
Results revealed a wide disparity of clinical hours in the three content areas ( hours) and that the number of clinical hours was correlated only to hands-on obstetric experiences.
While this was a small pilot study with limited generalizability, the results provided some evidence for consideration of potential curriculum changes related to these specialty areas.
Impetus for some programs to reduce clinical hours in those areas.
Makes me wonder more and more about impact of clinical hours.

27. Specialty Areas
What does nurse need to know?What is important about these areas of specialty? What is the goal of learning in these environments?
Quickly discuss at tables---specialty area per table
OB—pre, ante, post natal?
Peds—in/outpt? Acute, chronic, wellness care? (example of learn, live, play—inpt challenges/competition vs. community experience—recognize Alverno)
Mental health? Common? Chronic? In/outpatient (example of integrated clinical)
Critical care—is it skills? Clinical reasoning? Other?

28. DEUs
 Dedicated Education Unit - A model of clinical instruction that provides nursing students with a positive learning environment using proven teaching/learning strategies while capitalizing on the expertise of both clinicians and faculty.   

29. DEUs, cont.
Director/Clinical Manager: responsible for the planning, organizing, directing and controlling of patient care unit.
Clinical Faculty Coordinator : faculty representative on the DEU and serves as the bridge between nursing program and healthcare setting.
Roles and Responsibilities
Director/Clinical Managers
Communicate with CFC regarding CI schedules.
Elicit feedback from CIs and students regarding teaching/learning experiences.
Sustain DEU by retaining current CIs and recruiting future CIs.
Clinical Faculty Coordinator
Establish collaborative working relationships with the director/clinical managers and CIs to build the optimal clinical environment for student learning.
Assure that the CIs are informed of the clinical expectations of the students and encourage the use of evidence-based teaching/learning strategies.
Have the final responsibility for evaluation through collaboration with the staff in their evaluation of students’ achievements.
Grade all student paperwork and be available at all times students are on the unit by cell phone or pager.

30. DEUs, cont.
Clinical Instructors: Staff nurse who performs the delegated activities for student learning with direction, supervision, and assistance from the Clinical Faculty Coordinator
Students: Active, reflective participants in the collaborative relationship
Benefits: Academe and Practice
Clinical Instructors
Assume responsibility for student learning in the clinical setting as a role model, teacher, and coach.
Provide ongoing feedback about student performance to both students and CFC.
Communicate with CFC and Director/Clinical Managers about DEU experience.
Students
Actively participate in the collaborative relationship.
Be knowledgeable of the expected outcomes of their clinical experience and work with their CI to develop professional skills and knowledge.
Come prepared for clinical and actively seek learning experiences.
Reflect on their practice, seek feedback and evaluation and grow in skill and knowledge through their experiences.
Benefits for RMC
It is an expectation that all professional nurses, especially those in Magnet facilities, will contribute to the education of the next generation of nurses.
Nurses on the DEU will be prepared and supported in their teaching role by RCN faculty.
The role of preceptor is elevated to that of clinical instructor recognizing the professional development and passion by those staff nurses who most wish to teach.
DEU managers report increased retention, decreased orientation time (new grades who where in DEU).
Benefits for RCN
Schools using the DEU concept require fewer units for clinical instruction.
Schools using the DEU concept require fewer faculty for clinical instruction.
Students have consistent clinical instructors each day
A DEU partnership between RCN and RMC is being developed. A “pilot” is planned for the Fall 2012 semester in the ICU. With this academic-practice partnership, there are many benefits including:
DEUs were developed in Australia and launched in the United States at the University of Portland in Oregon in Since then, the University of Portland has helped at least a dozen other U.S. nursing schools establish DEUs. We plan to utilize U of P for consultation for this program.

31. Interprofessional Education/Simulation
Josiah Macy Foundation: Alignment of IPE with societal needs
IOM report: 2010
Interprofessional Education Collaborative (IPEC) May 2011
IOM initiates Global Forum on Innovations in Health Professions Education
Macy Foundation: 2008
Greater conversation needed about work of health educators and what society needs
Growing body of evidence that health care delivered by high functioning teams produce better results; education occurs in silos
Macy Foundation supported reforming of educational paradigm: grants to healthcare systems; medical & nursing schools: 2008/2009
Focus was on design of curricula for teaching quality, safety, team based approach and patient centered care
Two or more professions learn from, with and about each in order to improve collaborative practice and the quality of health care [CAIPE 2002]
Can use case-based learning scenarios in classroom
Identify times in clinical environment when students, residents, others can have report together as opposed to “standard clinical times”…ask when can participate in “team”—does facility have “high functioning teams”…access to these?
Education on TeamSTEPPS: evidence based teamwork approach which optimizes patient outcomes by improving communication/other teamwork skills among health care professionals
IOM report on nursing notes as one of its 4 major areas: interprofessional collaboration is essential
Interprofessional Education Collaborative [IPEC] Competencies:
Domain 1: values/ethics for interprofessional practice
Domain 2: roles/responsibilities
Domain 3: interprofessional communication
Domain 4: teams & teamwork
Published in 2011
Malcolm Cox, chief academic affiliations officer of VA: “ no student can come into the VA and disrupt high functioning teams—must have education around teamwork”…may be that clinical sites will prohibit students based on lack of competency in IP
Simulation: premise is to enhance critical thinking, communication skills to provide safe, quality care in non threatening environment
Use of simulation especially to engage learners in IPE:
low fidelity simulation: error disclosures
high fidelity simulation: mock codes: team skills and patient outcomes; practice hand offs and other team activities; reverse roles [MD/RN in difficult situations]; difficult conversations in the ICU [nursing, MD, residents in pastoral care program]
Debriefing: key element in learning process for either low or high fidelity simulation

32. Conceptual Experiences
Lourdes University
Challenged by IOM and QSEN reports for easier transition of grads to work place, to provide safe care and create safe systems
Integrated clinical allows students to apply theory concepts holistically
Each semester up to 3 didactic courses; 1 integrated clinical
One clinical site 15 weeks
Early semesters pop focused and community based—senior centers, schools, housing projects, homeless shelters
Once in acute care setting—goal to keep on same unit for 2 consecutive semesters
Focus is QSEN concepts
Found clinical sites that matched the philosophical underpinnings of QSEN based curriculum.
Clinical Integration Partnership—work with practicing nurses and students re: quality and safety
Clinical liaison written into a grant
Educational resource units (purposefully not DEUs), clinical instructor maintains role. Not meant to be a solution to faculty workload issues
Example—while studying oxygenation—round with RTs and assess pts. Before and after—also promotes interprofessional interactions. Review medical records. Faculty to student ratio can be higher than if providing total patient care.

33. Structure
Random or structured Competency or availability Educational program or residency Separation or immersion Specialty or integrated Direct, indirect, or simulated Inpatient or outpatient Day or night Week or weekend Preceptor or faculty
Regulations
Hours
Faculty ratios
Simulations
Traditional clinical education model taxing faculty, facilities, students, and staff—relies on availability of sites.
Analysis of 16 studies—56% supported use of preceptors; 44% found no significant difference. Failed to demonstrate benefits in areas of critical thinking, clinical competence, and NCLEX-RN pass rates.
Oregon BON defined:
Clinical lab teaching assistant—education level at least same as students and 2 yrs experience
Clinical educator associate—RN with BSN no less than 2 yrs. exp
Clinical teaching associate—specific training as a role model, resource, and coach for nursing students

34. Clinical Learning Models (Guburd-Howe & Scholessler)
Focused Direct Client Care Experience
Concept-Based Experience
Case-Based Experience
Intervention Skill-Based Experience
Integrative Experience
Copy definitions from article.

35. Educational Needs in Wyoming
Telemedicine/Telehealth?
Geriatrics?
Other?
What’s different here? -- Ask group
Practices Unique to Wyoming, e.g. telemedicine/telehealth
Call centers?
Search and rescue?
Trauma?
How can you modify clinical experiences for this environment?

36. Large Group Discussion Future State of Clinical Education
What would your preferred future of clinical education look like?
How might your setting begin to think about clinical education differently?
What would have to happen to make such changes in clinical education occur?
Identify and prioritize barriers—consider why you continue to do what is not working?
Consider educational research that might be conducted.

37. Large Group Discussion
Small group sharing
What is the most significant take-away from the meeting today?
What is the first thing you will do when you return to your setting to begin change?

38. THANK YOU and ACKNOWLEDGEMENT!
Past and current participants/members of
Greater Kansas City Collegiate Nurse Educators
Kansas City Area Nurse Executives
Missouri Hospital Association
Bi-State Workforce Innovations Center
Full Employment Council of Kansas City
Colleagues in Caring Project –RWJ
MSBN

39. References
Burman, M.E. and Sholty, M. (2011). Educational transformation in Wyoming master plan: Revolutionizing nursing education in Wyoming (RENEW).
Conference on Interprofessional Education. (2012). Josiah Macy Jr. Foundation. November 2012.
Dedicated Education Units: An Innovation in Clinical Education. University of Portland School of Nursing.
Burman, M.E. and Sholty, M. (2011). Educational transformation in Wyoming master plan: Revolutionizing nursing education in Wyoming (RENEW).
Conference on Interprofessional Education. (2012). Josiah Macy Jr. Foundation. November 2012.
Dedicated Education Units: An Innovation in Clinical Education. University of Portland School of Nursing.
Didion, J., Kozy, M.A., Koffel, C, & Oneail, K. (2013). Academic/clinical partnership and collaboration in quality and safety education for nurses education. Journal of Professional Nursing, 29,
Fetsch, S. H. & DeBasio, N. O. (2012). Academic service partnerships: Organizational efficiency and efficacy between organizations. Journal of Professional Nursing, 27, e82-e89.
Glasgow, MES, Niederhauser, V.P., Dunphy, L.M., & Mainous, R. O. (2010). Supporting innovation in nursing education. Journal of Nursing Regulation, 1,
Guburd-Howe, P. & Schoessler, M. (2008) From random access opportunity to a clinical education curriculum. Journal of Nursing Education, 47, 3-4.
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
Ironside, P. M., & McNelis, A.M. (2010). Clinical education in prelicensure nursing programs: Findings from a national survey. Nursing Education Perspectives, 31,
Jeffries, P. & Battin, J. (2012). Developing successful healthcare education simulation centers: The consortium model. Springer Publishing Company.
Research and Planning—Wyoming Department of Workforce Services (2011). Health care needs in Wyoming: Advancing the study.
Udlis, K.A. (2013). Preceptorship in undergraduate nursing education: An integrative review. Journal of Nursing Education, 47,

40. References, cont.
Didion, J., Kozy, M.A., Koffel, C, & Oneail, K. (2013). Academic/clinical partnership and collaboration in quality and safety education for nurses education. Journal of Professional Nursing, 29,
Fetsch, S. H. & DeBasio, N. O. (2012). Academic service partnerships: Organizational efficiency and efficacy between organizations. Journal of Professional Nursing, 27, e82-e89.

41. References, cont.
Glasgow, MES, Niederhauser, V.P., Dunphy, L.M., & Mainous, R. O. (2010). Supporting innovation in nursing education. Journal of Nursing Regulation, 1,
Guburd-Howe, P. & Schoessler, M. (2008) From random access opportunity to a clinical education curriculum. Journal of Nursing Education, 47, 3-4.

42. References, cont.
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
Ironside, P. M., & McNelis, A.M. (2010). Clinical education in prelicensure nursing programs: Findings from a national survey. Nursing Education Perspectives, 31,

43. References, cont.
Jeffries, P. & Battin, J. (2012). Developing successful healthcare education simulation centers: The consortium model. Springer Publishing Company.
Research and Planning—Wyoming Department of Workforce Services (2011). Health care needs in Wyoming: Advancing the study.

44. Contact Information
Dr. Nancy O. DeBasio Dr. Susan H. Fetsch