Education Unit. A Dedicated. for Maternal Newborn Nursing Clinical Education. Deborah A. Raines

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2 A Dedicated Education Unit for Maternal Newborn Nursing Clinical Education Deborah A. Raines The dedicated education unit (DEU) model of clinical nursing education is rapidly gaining popularity. I conducted a keyword search in the CINAHL database (EBSCO Information Services, Ipswich, MA) and found 23 articles and one dissertation focused on the concept from the last 3 years. However, these articles primarily focused on general adult inpatient units in acute-care settings. I also found a few articles focused on other settings, such as long-term care, oncology, and school nursing, but I found no articles about the use of the DEU model of clinical education on maternal newborn units. In the curricula of many nursing schools, students clinical learning experience in maternal newborn nursing is limited to a single course. Therefore, providing a rich and practicedense learning environment is critical. The DEU model of clinical education is a potential solution to the limited duration of clinical placements in this area of practice and is a strategy to enrich the quality of students learning opportunities. Abstract: Designing a quality maternal newborn clinical practice experience for undergraduate nursing students is often challenging. A dedicated education unit (DEU) is a partnership model of clinical education in which students partner with a designated unit-based nurse in providing nursing care within a typical patient care assignment. This article describes the experience of implementing a DEU in a junior level (third year) nursing practice course in a bachelor of science in nursing program curriculum. A DEU model is a perfect fit for maternal newborn clinical learning experiences and provides a win win outcome for academic and clinical partners as well as safe patient care. Keywords: clinical education dedicated education unit maternal newborn nursing self-directed learning

3 In a DEU experience, learners are exposed to a greater range and diversity of patients, resulting in a more dense learning experience. Reports by the Carnegie Foundation (Benner, Sutphen, Leonard, & Day, 2010), Institute of Medicine (IOM, 2010), and the Robert Wood Johnson Foundation (Goldman, 2014) call for nurse leaders to improve how nurses are prepared and educated by reducing the gap between classroom and clinical teaching. In addition, the IOM s Future of Nursing report (IOM, 2011) encourages collaboration among organizations to better prepare nurses to deliver high-quality care (IOM, 2011). The DEU model is a strategy to fulfill these objectives. This article discusses the process of initiating a DEU experience for students in the maternal newborn course. A concept map (see Supplementary Figure 1) illustrates the collaborative planning and accountability of the partners and the responsibilities and interrelationships of the participants in the successful implementation of the DEU model. What Is the DEU Model? The DEU model of clinical education was developed at Flinders University in Australia and is grounded in a strong academic clinical partnership (Edgecombe, Wotton, Gonda, & Mason, 1999). A DEU model changes the traditional role of the faculty and the unit staff in their provision of clinical education to students. In a traditional model, a school of nursing faculty member has primary responsibility for a group of 8 to 12 students, and each student is assigned to specific care delivery activities by the faculty member who also supervises the delivery of care (Raines, 2006). The involvement of unit-based staff in a student s provision of nursing varies based on the relationships established by the faculty member. In some settings unit-based staff may have limited awareness of students clinical expectations, their designated learning objectives, or their prior knowledge (see Supplementary Figure 2). In the traditional model, students are often providing care focused on the completion of skills, with little knowledge of a woman s or family s unique situation. The learning environment is primarily between the students and the faculty member, and the faculty member lacks the continuity of relationships with patients over time. The involvement of unit-based nursing staff varies by the attitude of each individual nurse or the clinical setting. Given that a number of different schools of nursing may be bringing students to the same maternal newborn unit, there are the risks of fragmented care and of exposing women to unnecessary or repetitive procedures, such as when different students each collect a complete health history or a family genetic history from the same woman on multiple occasions. Deborah A. Raines, PhD, EdS, RN, ANEF, is an associate professor at the University at Buffalo: State University of New York in Buffalo, NY. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: draines@buffalo.edu. In the DEU model, the learning environment is expanded to include the unit s nursing staff and nurse manager, in addition to the students and faculty. Staff nurses are selected to fulfill the role of clinical instructor or DEU nurse based on strong clinical, interpersonal, and teaching skills. The DEU nurse assumes responsibility for the on-unit clinical instruction of students. Students are assigned to a DEU nurse and not to an individual patient. A student works with the DEU nurse to provide care for the group of patients assigned to that nurse. As a result, a student is integrated into the unit s workflow and, therefore, experiences the multidimensional role of the nurse (Glazer, Ives Erickson, Mylott, Mulready-Shick, & Banister, 2011; Jeffries et al., 2013). In this collaborative learning experience students engage in firsthand, real-time learning experiences over an 8- or 12-hour shift and are exposed to the management of a multiple-patient assignment. The involvement of the unit-based DEU nurse provides better continuity In this collaborative learning experience students engage in firsthand, real-time learning experiences over an 8- or 12-hour shift and are exposed to the management of a multiple-patient assignment with a woman s plan of care as well as compliance with unit guidelines and standards of care. Because DEU nurses are working directly with students in care provision, the role of the school of nursing faculty member evolves to being a coach and resource provider. As the coach, the faculty member guides DEU nurses in the development of teaching strategies and providing on-the-spot feedback to students. The faculty member is also a resource to DEU nurses and to the unit in general to promote professional development. Examples of these activities include sharing articles of interest with the unit, presenting in-service education activities, and organizing grand rounds for the facility. This is further evidence of the enlarged learning environment, because the school of nursing faculty member engages in the professional development of the nursing staff and in the education of the nursing students. Conceptual Model The DEU model uses a problem-based and collaborative approach to clinical learning. This is consistent with Knowles s self-directed learning model (Knowles, 1975). Self-directed learning increases students confidence and their ability to Opening photos: Left top Blend Images, Left bottom istock Collection; Right top Jose Luis Pelaez Inc., Right middle Kati Molin, Right bottom Wavebreak Media / All from thinkstockphotos.com , AWHONN nwhjournal.org

4 the provision of nursing care and not just observers of DEU nurses. The synergy of the DEU model and self-directed learning fulfills the American Association of Colleges of Nursing s statement that learning to perform as a nurse is predicated on engaging in experiential learning with actual patients (American Association of Colleges of Nursing, 1999, p. 31). Photo Comstock / thinkstockphotos.com Getting Started learn in dynamic and challenging educational and work environments. Self-directed learning allows learning to progress beyond gaining knowledge to motivating through experience (Levett-Jones, 2005). These experiences provide a structure for students to continue to problem-solve and to learn in future new or unexpected situations. Through self-directed learning students develop independent learning skills and strategies to seek knowledge as needed. The DEU model of clinical education provides an ideal setting for self-directed learning. While working collaboratively with DEU nurses, nursing students are accountable for identifying and engaging in opportunities to meet their learning needs. In addition to their course expectations, students develop daily goals and learning aims to be achieved during the clinical day. Students must be able to advocate for themselves to obtain experience with the tasks of nursing care, such as performing a complete assessment, administering intravenous medications, or inserting a Foley catheter, and in seeking clarification or assistance to expand their knowledge and nursing practice skills. This requires students to be active participants in February March 2016 The birth of a DEU begins with the formation of an academic clinical partnership. Creating a DEU requires a high level of collaboration, planning, and organization among the clinical agency and the school of nursing. A commitment from both partners is needed, as is adequate time for integration of faculty, selection of DEU nurses, and all the education, planning, and preparation necessary before a student s first day on the nursing unit. A partnership based on trust, respect, and commitment is critical to a DEU s success. Early planning and recognizing the roles of leadership at the clinical and academic agencies are the foundations of a successful DEU. Leaders at the clinical agency are responsible for identifying a cohort of nurses to designate as the DEU nurses or the clinical instructors and for planning unit staffing to maintain the continuity of the DEU experience. The school of nursing faculty member is responsible for educating and preparing The birth of a DEU begins with the formation of an academic clinical partnership nurses on the nursing unit. Education and preparation for becoming a DEU involve the designated DEU nurses and others involved in the daily activity of the nursing unit, including information about what they each bring to a DEU experience. The goal is to create a learning environment in which students learn, nurses grow professionally, and women receive highquality, patient-centered care. The key elements of the concept Nursing for Women s Health 23

5 map of the DEU model (see Supplementary Figure 1) are discussed in the following section. Roles and Responsibilities Once the academic clinical partnership is established, the designated academic faculty member and the nurse manager establish the vision and objectives of the DEU. The nurse manager must communicate and maintain the vision for the unit and establish a culture open to teaching and learning. She must emphasize with all participants the focus on patient- and familycentered care as well as the safety and security issues unique to the maternal newborn setting. The nurse manager selects the DEU nurses from the unit staff and is responsible for scheduling these nurses to work on the students clinical days. The DEU nurses also need to be scheduled for an orientation to the DEU model and to their responsibilities and accountability. It is important to recognize that a DEU is not a preceptor model of clinical nursing education. In a preceptor model, a during the antepartum, intrapartum, and postpartum periods and also caring for newborns. In some hospitals this involves different geographic locations for each population and an associated set of unique practices and expectations. It is helpful for the faculty member to prepare a handbook with an overview of the focus of nursing practice as well as the policies, procedures, and routines unique to each population. In addition, students need to be prepared for the experience of providing care for a group of patients and for addressing common nursing care issues and questions in the maternal newborn setting. During their orientation session, which occurs before the first day of clinical experience, students participate in a simulated experience of receiving a hand-off report from a nurse and identifying nursing care priorities based on the hand-off information. Students also participate in a think like a nurse activity in which they randomly choose and problem-solve typical obstetric and neonatal situations. To prepare for certain specific skills, such as The goal is to create a learning environment in which students learn, nurses grow professionally, and women receive high-quality, patient-centered care student usually follows the preceptor s work schedule, including night or weekend shifts. As a result, the presence of the school of nursing faculty member may not be consistent. In the DEU model, there are designated clinical days and times. As a result, students, a faculty member, and DEU nurses are all present at the same time to promote and participate in collaborative learning. The school of nursing faculty member provides orientation to the DEU nurses. Topics covered include philosophy of the DEU model, role of the DEU nurse with the student, strategies to be an effective instructor, techniques to give feedback to students, and how to balance the learning needs of students with the nursing care needs of women. The faculty member also shares course objectives and clinical learning outcomes with DEU nurses. It is helpful for the faculty member to give the DEU nurses an overview of where the course fits within the curriculum, the students previous experiences, and any skills associated with the course. The goal of the orientation setting is to create a partnership between the faculty member and the DEU nurses. The DEU nurses functioning as clinical instructors become part of the team and provide feedback to the academic faculty about the students achievements of course objectives and behaviors as nurses in the clinical environment. The faculty member must also prepare students for the DEU experience. The maternal newborn clinical rotation is unique because students need to gain experience caring for women fetal monitoring, students complete an online introductory fetal monitoring package and a competency test on basic fetal monitoring before being on the clinical unit. Finally it is time for the students to arrive on the unit. The faculty member introduces the students and the designated DEU nurses before morning report. At that point the DEU nurses take over teaching the students about the direct nursing care activities. The learning experience begins as the student takes report with the DEU nurse. After report with their DEU nurses, students check laboratory test result values, check for new physician orders, and complete other tasks to identify women s care needs and to organize plans of care for the women on their assignment. Under the watchful eyes of DEU nurses, students perform assessments, implement new orders, provide medications and treatments, and deliver health education consistent with the plan of care and unit-based standards of practice. To emphasize self-directed learning, students are responsible for bringing their individual goals and learning objectives to each clinical experience. Students complete the What I Know and What I Want to Know portions of a Know, Want to Know, and Learned chart before morning report. While students and DEU nurses are getting report, the faculty member is reviewing students accounts of their existing knowledge and their learning goals. The faculty member rounds on each student within the first 2 hours of the clinical day to discuss the goals and to 24 Nursing for Women s Health Volume 20 Issue 1

6 Photo Creatas / thinkstockphotos.com have them begin applying their knowledge to different patient situations. The faculty member also huddles with the DEU nurse to identify opportunities to meet the student s Want to Know objectives. At the end of the clinical day, students complete the Learned section of their Know, Want to Know, and Learned chart to provide evidence of their learning. Whereas the DEU nurses work directly with students in the implementation of nursing care, the school of nursing faculty member meets with each student a minimum of three times during the clinical day. The first meeting is focused on the learning goals written by the student. The second meeting occurs after initial patient assessments are completed, and a verbal concept map is initiated to prompt the student to understand the relationship between the collected data, interventions, and desired outcomes and unique needs of each woman. Students identify the priority physiologic and psychosocial needs of their patients and their plans of care to meet the identified needs. The third meeting occurs near the end of the day, when the students evaluate if nursing interventions were successful in attaining the desired outcomes or what modifications to the plan of care were needed. This provides the faculty member with an opportunity to facilitate the development of critical thinking skills and to do an ongoing evaluation of a student s achievement of the course objectives. Although the faculty member has ultimate responsibility for each student s course grade, input from students (in the form of a daily reflection and self-evaluation) and DEU nurses is a valued component of the evaluation process. Each DEU nurse completes a daily progress sheet on the student, indicating assessments and skills performed, and rates the day as satisfactory or needs improvement. The DEU nurse shares the completed daily progress sheet with the student, and the student gives it to the faculty member, who uses this input as a component of the final course evaluation summary. At the end of each student rotation, the director of professional practice at the clinical agency, nurse manager, school of nursing faculty member, students, and DEU nurses meet to debrief about the experience. These debriefings identify positive aspects of the experience and areas for improvement and growth. Outcomes and Implications for Practice At our facility, the response of students and DEU nurses has been overwhelmingly positive. During the first student rotation minor problems, such as students not knowing how to take report on a group of women, were identified. Students had mini notepads in their pockets and were trying to write down everything said about every patient. This is a common behavior in our traditional model of clinical rotation, in which students have responsibility for a single patient. With a multipatient assignment, however, they had to page through their notepads and frequently were unable to verify which information corresponded to which patient. As a result of this observation by the DEU nurses, the simulated experience of a patient hand-off and taking report on the unit s report sheet was added to the student orientation session. This is an example of how feedback from the unit nurses was used to better prepare the students and enhance the overall experience. February March 2016 Nursing for Women s Health 25

7 The DEU model of clinical education engages students in planning and providing nursing care for groups of women. Caring for a complete assignment of several women and newborns enables students to experience how a nursing intervention such as fetal monitoring, fundal assessment, or assessment of neonatal jaundice, although grounded in fundamental principles, is unique to the individuality of each woman or newborn. clinical learning, where students have one or two patients and spend long portions of the day waiting for the faculty member to complete an activity with another student before they can perform nursing care. In terms of the professional development of DEU nurses, there has been demonstrated growth in the types of teaching strategies used and the feedback provided to students. As DEU Caring for a complete assignment of several women and newborns enables students to experience how a nursing intervention such as fetal monitoring, fundal assessment, or assessment of neonatal jaundice, although grounded in fundamental principles, is unique to the individuality of each woman or newborn For example, fundal assessment of a first-time mother versus a mother of four, or after a vaginal birth versus a cesarean birth, requires cognitive processing of data within the context of the unique situation. Another advantage of this model of education is that students recognize the need to be organized and to continually be reprioritizing competing needs as a shift progresses. The most frequent comments of students who are experiencing a DEU for the first time is how busy the nurse is and wondering how the nurse can keep everything organized. This is an important contrast to the student experience in the traditional model of nurses are teaching students, other nurses often join the conversation, and comments such as I didn t know that, or That s such a good way to explain that, are often heard. This level of collegial sharing is enhancing the knowledge base of all staff on the unit. Members of the nursing staff have begun to identify their own learning needs, sharing these with the faculty member who can provide in-service sessions focused on the needs of the nursing staff. Clinical scholarship has also emerged from this partnership. Some of the DEU nurses on our unit co-published an article with faculty related to a health education program developed by Photo Arne Pastoor / thinkstockphotos.com 26 Nursing for Women s Health Volume 20 Issue 1

8 nursery staff. In addition, a group of nursing students and DEU nurses collaborated in the analysis and synthesis of evidence on a topic of interest to the unit. They presented their project at a local Sigma Theta Tau research event. Currently, a group of nurses are working with a nursing student on the evaluation of a new unit-based health education program. The potential for collaboration in the development of health education materials is also in the planning process. These collaborative projects between clinical and academic partners promote professionalism of DEU nurses and provide a model to students showing that the role of a professional nurse encompasses much more than just completing patient care tasks. Conclusion The DEU model of clinical nursing education is an excellent strategy to address the quality of students maternal newborn learning experiences, especially given the short duration of this clinical experience in many nursing curricula. When a school of nursing and a maternal newborn clinical setting partner thoughtfully to implement and support a DEU model, advantages include the professional growth of the unit s nursing staff and the preparation of the next generation of nurses for the realities of practice in maternal newborn settings. Academicpractice partnerships are essential to improve nursing education, to nurture the professional growth of practicing nurses, and to promote safe, high-quality care. With the anticipated shortage of nurses and changes in the health care delivery systems, educating nurses with skills in patient care, self-directed learning, and problem-solving is important to the future of the nursing workforce. In our experience, the DEU experience in the maternal newborn setting has been a win win situation for the school of nursing and the clinical partner. NWH Supplementary Material Note: To access the supplementary material that accompanies this article, visit the online version of Nursing for Women s Health at and at /j.nwh References American Association of Colleges of Nursing. (1999). The essential clinical resources for nursing s academic mission. Washington, DC: Author. Retrieved from -resources/clinicalessentials99.pdf Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. Stanford, CA: The Carnegie Foundation for the Advancement of Teaching. Edgecombe, K., Wotton, K., Gonda, J., & Mason, P. (1999). Dedicated education units: 1. A new concept for clinical teaching and learning. Contemporary Nurse, 8(4), Glazer, G., Ives Erickson, J., Mylott, L., Mulready-Shick, J., & Banister, G. (2011). Partnering and leadership core requirements for developing a dedicated education unit. Journal of Nursing Administration, 41(10), doi: /nna.0b013e31822edd79 Goldman, T. R. (2014). Innovation in clinical nursing education: Retooling the old model for a 21st-century workforce. Charting Nursing s Future, 23, 1 8. Retrieved from dam/farm/reports/issue_briefs/2014/rwjf Jeffries, P. R., Rose, L., Belcher, A. E., Dang, D., Fava Hochuli, J., Fleischmann, D.,... Walrath, J. M. (2013). A clinical academic practice partnership: A clinical education redesign. Journal of Professional Nursing, 29(3), doi: /j. profnurs Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from iom.nationalacademies.org/reports/2010/ The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx Institute of Medicine. (2011). The future of nursing: Focus on education. Washington, DC: National Academies Press. Retrieved from iom.nationalacademies.org/reports/2010/the-future-of -Nursing-Leading-Change-Advancing-Health/Report-Brief -Education.aspx Knowles, M. S. (1975). Self-directed learning: A guide for learners and teachers. New York, NY: Association Press. Levett-Jones, T. L. (2005). Self-directed learning: Implications and limitations for undergraduate nursing education. Nurse Education Today, 25(5), Raines, D. A. (2006). CAN-Care: An innovative model of practicebased learning. International Journal of Nursing Education Scholarship, 3(1) article 20. doi: / x.1304 February March 2016 Nursing for Women s Health 27