Clinical rotations, in which nursing students practice their skills in health care settings with real patients, is an indispensable part of their education. No one disputes that, but nurses at Children’s Healthcare of Atlanta and the WellStar School of Nursing at Kennesaw State University are challenging the status quo of how that training is delivered.
Traditionally, nursing students enter a clinical rotation with a faculty member who serves as their clinical instructor. The ratio is one instructor for every six students.
“Each student will work with one patient and interact with the nurse assigned to that patient. But in order for the student to perform any procedures, the clinical instructor must be present,” said Becky Shabo, RN, Ph.D., associate professor at Kennesaw State’s nursing school. “Since six students are sharing the same instructor, their one-on-one instruction is limited.”
Often times, a student and a nurse are ready to perform a procedure, but must wait for the instructor to arrive. “If too much time elapses, the nurse ends up having to do it,” said Christina Ryan, MSN, RN, senior nurse researcher/education coordinator at Children’s.
Following research from New Zealand and the University of Portland, Ryan believed that Children’s and Kennesaw State could improve on the traditional clinical rotation model. She designed a dedicated education unit (DEU) research study project that put working pediatric nurses in the role of clinical instructors. Each nurse would work one-on-one with a student, just like a preceptor does.
Other hospitals and universities had tried the method using a small sample of students, often ones selected for their top academic achievement. It had never been tried in pediatrics, so Children’s initially proposed to start with 75 percent of KSU’s nursing students, with the rest trained traditionally as a control.
“The other 25 percent complained so much that we soon extended the study to 100 percent of Kennesaw students and 75 percent of the students at West Georgia University for a semester,” Ryan said. In all, 250 students participated during three semesters and one summer.
Kennesaw State nursing faculty conducted an education unit with Children’s nurses to make sure their practical instruction would directly support classroom theory, and to teach them how to evaluate students.
Shabo believes the success of the DEU model depends on the preparation and characteristics of the nurse instructors.
“CHOA has wonderful nurses and they turned out to be natural teachers. They were great role models for our students,” Shabo said. “Overall, the DEU gave our students more hands-on experience and a realistic view of the role of nursing. They got to see what a nurse’s day is really like and to see how nurses prioritize and work through problems.”
Students in the DEU study were placed with nurses who had responsibility for three to five patients, and worked with them through 12-hour shifts for four days.
“It was the most amazing clinical experience I’ve ever had, and it had a profound influence on my life,” said Gary Harris, a senior nursing student at KSU.
A nontraditional student, Harris came to nursing from a background in marketing and massage therapy. He wanted a career in which he could make a good living and give back to the community.
“I had planned to practice in orthopedics, but the more time I spent in pediatrics, the more I knew that’s where I wanted to stay,” he said.
Harris worked in a neurology unit at Children’s and was amazed by the various patients and conditions.
“The nurses made each of them feel like they were the most important patient there,” Harris said. “Seeing how they worked with one another, the patients and their families, I can’t say enough about their professionalism.
“From the early-morning report and [shift] hand-off, they made me feel a part of the team and treatment plans. They enabled me to do so much.”
Instead of caring for one patient, Harris helped care for four, each with different conditions. “I got to see four different ways to do things right, instead of just one,” he said.
Throughout the study, Ryan gathered weekly student emails, surveys and evaluation forms, and measured benchmarks. She said the difference between the outcomes of the two methods was striking. “The DEU study provided students with more experience.”
Students in the study administered five times the amount of medication, learned four times as many technical skills, and got to interact with more hospital staff. One hundred percent of DEU students said their clinical objectives had been met, compared to 82 percent of traditional clinical students. There were no missed medications, no delays to care and only one medication error during the study.
Because students were on the floor for 46 hours in four days, compared to 36 hours in six days, the one-on-one model provided more training in less time.
The model saves colleges the cost of hiring adjunct clinical instructors and also helps hospitals’ bottom lines, Ryan said.
“We have hired some graduates who were in the study, and managers say they are more confident and could come off orientation two to three weeks earlier. With individual orientation costs at about $1,500 a week, that translates to dollars,” she said.
Ryan has presented the results at nursing conferences and published the pilot study results in Nurse Educator (July/August 2011) journal. The hospital and university are seeking funding sources to be able to implement the model as their standard delivery method.
“If we can get more people on board, we’ll be launching a major transformation in nursing education,” Ryan said.
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