Preparing undergraduate nursing

Preparing undergraduate nursing students for community-based care is a challenge for nurse educators. The Institute of Medicine 1 recommends that schools of nursing collaborate with clinicians to ensure that nursing education does not occur in a vacuum and that clinical practice incorporates evidence-based care. However, in an era when a shortage of nurses in both education and practice is the norm, the goal of increased collaboration is difficult to achieve. At the same time, if students are to graduate with beginning competency to function in community settings, they must participate in meaningful clinical experiences that promote the development of critical thinking skills. 2 Community health faculty at our institution who teach pre-licensure nursing students struggled with the goal of providing meaningful clinical experiences, while preserving patient safety and maintaining positive relationships with clinicians. Concurrently, student satisfaction with their community health rotation was not optimal. Students expressed frustration with the clinical course, because a rotation through multiple observational experiences did not provide enough depth to master complex concepts such as population-focused care. Therefore, as our institution Authors Affiliation: Clinical Instructor (Ms Mallette); Clinical Assistant Professor (Dr Loury); Professor/Associate Dean for Research and Scholarship (Dr Engelke); Associate Professor/Department Chair (Dr Andrews), Department of Family and Community Nursing, East Carolina University School of School of Nursing, Greenville, NC. Corresponding Author: Ms Mallette, East Carolina University School of Nursing, 239 Rivers Building, Greenville, NC 27858 (mallettes@mail.ecu.edu). The Integrative Clinical Preceptor Model A New Method for Teaching Undergraduate Community Health Nursing Sharon Mallette, MPH, RN, FNPC Sharon Loury, PhD, RN Martha Keehner Engelke, PhD, RN Alta Andrews, DrPH, RN embarked on the process of revising the entire undergraduate curriculum, the community health faculty took the opportunity to reexamine the method we were using to teach community health nursing. During the course revision, the guiding principle was to place more emphasis on population-focused care than on the care of individuals and families. Since students took community health nursing during the last semester of their senior year, the goal was to provide an experience that fosters the integration of concepts from previous courses related to the care of individuals and families into a synthesis course that focuses on aggregates. Updating the didactic portion of the course was the first step. The content was revised to include more emphasis on models of care for enhancing health promotion and the adoption of a healthy lifestyle (particularly case NURSE EDUCATOR Volume 30, Number 1, pp 21 26 2005 Lippincott Williams & Wilkins, Inc. The Integrative Clinical Preceptor Model was designed to provide a framework for undergraduate clinical education in community health nursing. The model is based on reciprocal collaboration between students, preceptors, and faculty. Implementation of the model has resulted in individualized, population-focused experiences for students based on the principles of service-learning, empowered preceptors who are able to increase their scope of service, and increased productivity for the faculty in research and scholarship. The authors describe the collaborative partnership between a school of nursing and nurses in community health settings that has resulted in excellent clinical experiences for undergraduate nursing students. management models). In addition, increased attention was given to the care of vulnerable groups as an aggregate rather than as individuals. Although the revision of the didactic material was relatively easy, redesigning the clinical experience in a manner that would reinforce this content was more challenging. A New Method for Teaching Undergraduate Community Health Nursing The idea of using a preceptor model for clinical education is not new. Oermann 3 found that most nursing programs (74.7%) used preceptors from affiliating clinical agencies to teach concepts such as leadership, community health, and critical care. However, the evidence suggests that preceptor models in community health nursing are used more frequently with resigtered nurse/bachelor of science in nursing NURSE EDUCATOR Volume 30, Number 1 January/February 2005 21

(RN/BSN) students, graduate students, and new graduates. 4-6 When preceptors teach pre-licensure nursing students, the preceptors usually assume a peripheral role and provide short-term, observational experiences. The Integrative Clinical Preceptor (ICP) Model (Figure 1) was developed by the faculty to represent our vision of the ideal method for teaching community health nursing. This framework represents a shift from a facultydriven teaching model to one that fosters an integrated approach among students, faculty, and preceptors. In this model, the reciprocal nature of the relationship among the student, preceptor, and clinical faculty is central. As an integrated, collaborative model, the combined contributions of students, preceptors, and faculty all work together toward the goal of optimal health of the population. Students, preceptors, and faculty have particular roles, responsibilities, and rewards. The Integrative Clinical Preceptor Model In the ICP model, students assume a proactive, professional role. They are responsible for participating in the planning of their clinical experience based on their individual learning needs. Rather than accepting and completing the assigned tasks, students are expected to reflect, revise, and restructure their goals throughout the semester. In addition, they adopt a service-learning model of education that emphasizes their role not only as learners but also as active members of the healthcare team who contribute to the agency in a positive manner. In the ICP model, the preceptor role changes from a limited, passive role to one in which the preceptor is viewed as the clinical teacher, role model, and mentor. Preceptors participate in planning and implementing the clinical experience and they are encouraged to develop innovative learning experiences that result in a win-win situation for both the preceptor and the student. Expertise of the preceptors is valued; therefore, they are empowered to take an active role in fostering student learning and addressing student problems. A commitment to a reciprocal relationship between preceptor and faculty is particularly important to ensure that this experience goes beyond traditional approaches to clinical education in community health. The role of the faculty also changes in the ICP model. Instead of coordinating a complex schedule of rotating experiences for students, faculty members become a resource for both the student and the preceptor. The primary roles of the faculty are educator, facilitator, advisor, and role model for both the students and preceptors. Communication is maintained through various approaches including on-line as well as face-to-face. The faculty provides preceptor development and support, oversight for the student experiences, and evaluation of both student performance and outcomes related to the ICP model. In facilitating the course, faculty members provide guidance to preceptors on issues related to the preceptors own career development. Because of the efficiency of the ICP model, faculty members acquire increased flexibility, which results in more time for related research and scholarly activities. Laying the Groundwork To move the ICP model from the conceptual stage to reality, several issues Figure 1. Integrative Clinical Preceptor Model (ICP model). were addressed. The first challenge for the clinical faculty was to merge the vision incorporated in the model with the guidelines set forth by the Board of Nursing. 7 The Board of Nursing in our state mandates a studentfaculty ratio of 1:10 for clinical supervision. Therefore, each faculty is assigned a clinical group of no more than 10 students on a particular day. In addition, the ICP model is based on the premise that each preceptor should have a semester-long, individualized relationship with 1 to 2 students. Since our school of nursing admits 100 to 110 students each semester, operationalization of the ICP model required many more preceptors/sites than used traditionally for teaching community health nursing. Expanding clinical sites and the recruitment of effective preceptors required a great deal of time and planning. The school of nursing applied for, and received, a grant from Eastern Area Health Education Center (EAHEC) to fund a faculty member during the summer to work on clinical site development. The faculty member developed a data collection tool that served as a guide for compiling information from potential sites in the region. The tool includes items on agency demographics including the type of agency, a description of 22 NURSE EDUCATOR Volume 30, Number 1 January/February 2005

services, a description of staffing, and the number of potential preceptors. It also includes information on the number and type of student experiences that the agency could provide. After developing the tool, the faculty member contacted potential clinical sites and visited each site to discuss the ICP model, gather information, and tour the facility. On these visits, program directors and nursing supervisors usually provided information. The value of meeting with managers was that they had the authority to endorse the program as well as the expertise to identify preceptors who would be effective. As these managers were part of the community health nursing network in the region, they frequently identified other community-based agencies that could provide effective learning environments for students. Since many of our students do not live in the immediate area of the university and may be enrolled in campus-based and/or distance education classes, it was important to identify clinical sites throughout the state. Most agency administrators were enthusiastic about the change in focus; therefore, we were able to maintain current agency partnerships and establish new ones. Many agency administrators expressed the belief that the ICP model would increase student learning and staff satisfaction. They also thought that this approach might increase the hiring pool for vacant community health nursing positions. Agency administrators varied in the number of students that they could accommodate. At some sites, issues such as reduced resources and inexperienced staff limited the ability to accommodate more than 1 or 2 students. All administrators discussed the ICP model with their staff and made the final decision on the number of students they could accommodate, on what days, and who the preceptors would be. Overall, this intensive approach to clinical site selection resulted in a significant increase in clinical sites that was sufficient to meet the needs of our large enrollment and the learning goals envisioned for the students. Data from these site visits were assembled into a database that was much more detailed and comprehensive than previous information available on clinical sites. Maintenance of this database is an ongoing part of the ICP model. The faculty continues to identify potential sites to improve access for students not residing in the local community and to ensure adequate sites for our growing student population. In some cases, preceptors and students also contributed to the identification of potential sites. The importance of development and maintenance of this database is critical for the long-term success of the ICP model. The database serves as a resource for selecting learning experiences each semester so that faculty members do not scurry about at the beginning of the semester trying to find clinical sites for students. Rather, students are matched with a clinical site that meets their individual learning interests, needs, and goals. Preceptor Training After the development of clinical sites, the next step was training the preceptors. The original goal was to recruit preceptors with a baccalaureate degree in nursing (BSN) and 5 years of practical experience; however, this was not realistic. There were many BSNs with only 1 or 2 years of experience who were willing to become preceptors. Also, there were many associate degree nurses (ADNs) who were highly skilled clinicians interested in becoming preceptors. Because of the variation in education and experience, preceptor role training was essential to assure that preceptors had a similar knowledge base, to implement roles outlined in the ICP model. Preceptor training was made possible through another grant from the EAHEC. Training was offered in several locations throughout the eastern region to encourage participation. This 3-hour workshop includes a didactic portion taught by a faculty member, as well as a variety of interactive activities between all of the community health faculty members and preceptors. Content includes a discussion of the ICP model, characteristics of a good preceptor, role expectations and responsibilities, conflict resolution, and an overview of teaching/learning principles for effective clinical teaching. The interactive portion of the course focuses on problem solving and discussion of case studies that portray potential issues that occur while teaching students in the clinical setting. Experienced preceptors and faculty members are instrumental in helping new preceptors understand the role of a clinical teacher. However, even the more experienced preceptors and faculty members benefit from this interaction, as misconceptions and misunderstandings are clarified and addressed. These workshops are invaluable in that they enhance the preceptor s skill in problem solving and affirm the faculty member s commitment to work in a partnership to foster student learning. Student Orientation In addition to orienting preceptors, we provide an orientation to the ICP model for our students. Students enter the community health nursing course with limited experience in negotiating a clinical experience that requires a high level of autonomy. Most of their clinical rotations have occurred under the direct supervision of a faculty member. Therefore, students needed an orientation to their roles and responsibilities in the ICP model. Students participate in a 9-hour orientation prior to reporting to their first clinical day. The orientation is presented in 2 sessions. During session 1, content includes an introduction to course objectives, discussion of the role of the community health nurse, and a description of available clinical sites/populations. Each student selects an assignment in collaboration with faculty. Students are encouraged to select a population for their practicum based on their learning needs. Occasionally, there is a conflict because too many students choose the same clinical site or population. In this instance, the students negotiate with each other to determine who will be placed at each site. At the end of the first orientation session, students are assigned to review the literature related to their population and develop tentative objectives for their clinical rotation.this assignment is completed before they return for the second day of orientation. The amount of time between the first and second day of orientation is dependent on the academic calendar but is usually 1 to 3 days. NURSE EDUCATOR Volume 30, Number 1 January/February 2005 23

During session 2, students report the results of their literature review to members of their clinical group (usually 1 faculty member and 8 10 students). They discuss population needs and aspects of the nurse s role that were valuable in writing objectives for their clinical experience. Following this seminar, students participate in a 1-to-1 conference with a faculty member to review and revise objectives. Prior to starting clinical, students participate in a windshield survey. The windshield survey provides students with an entry-level experience to community health nursing and allows them to confront anxiety about practicing in the community. The windshield survey is a bridge to the student s entry into the clinical agency and provides the opportunity to identify a variety of environmental factors that might impact the health of their aggregate. The final aspect of orientation is provided by the preceptor. They review agency policies and procedures with the students, provide a tour, and introduce key personnel. Students share their objectives with the preceptor who, if needed, helps them revise the objectives on the basis of the realities of the clinical site. Once a student reports to the agency, he or she works with the designated preceptor for the duration of the semester. Although most students attend clinical on a specific day, flexibility in hours is encouraged so that students can benefit from alternative experiences such as staff meetings, multidisciplinary conferences, countywide health planning meetings, and workshops. Student Assignments There are 3 clinical assignments that are integral to the ICP model. These are the community project, the interactive clinical seminar, and the reflective clinical journal. The community project is based on the concept of service-learning, which suggests that students can have meaningful learning experiences at the same time when they are providing a valued service to the agency. Through servicelearning endeavors, reciprocal learning occurs for students, the preceptor, and the community. 8 Students collaborate with the preceptor to identify a need that has an impact on the health of their population. The student, faculty member, and preceptor work together to complete the project. For example, if a preceptor recognizes the need to have more educationally and culturally appropriate materials available for Spanish-speaking clients, the student, in consultation with a faculty member, might develop such materials or contact organizations to obtain materials and then adapt them for the agency. The faculty member helps the students appreciate the broader context of the project. For example, in this situation, the students would complete a literature review and a local assessment of how many Spanish-speaking clients are in this aggregate. They might work with interpreters or other members of the team to ensure that the reading level is appropriate and the material incorporates principles of cultural sensitivity. When the community project is complete, students present their projects to other students and faculty. Preceptors often attend these presentations. The student leaves a copy of the materials and the presentation with the preceptor for future use and reference. In agencies where students have worked for several semesters, students may build on projects initiated in previous semesters or they might evaluate and revise a project that was initiated by an earlier student. The projects have been diverse and include the development of educational materials for foreign language clients or those with low literacy, assessment of target populations to plan for new program initiatives, health education sessions for ongoing initiatives such as the control of communicable disease, and the evaluation of agency programs such as a new case management model. The community project component of the clinical rotation is highly valued by both preceptors and students. Preceptors see it as a tool for extending the scope and effectiveness of their role and students perceive that they are making a positive contribution to the agency rather than just completing an assignment. The second critical component of the ICP model is the interactive seminar. Most of these seminars occur on-line. Faculty members post a discussion prompt and students are expected to post a response and participate in discussion with their clinical group each week. The faculty guides the discussion by asking questions to stimulate and foster critical thinking. Preceptors have the opportunity to enter discussions, but this is limited because of problems with computer access in some rural agencies. We are currently addressing preceptor discussion involvement with the long-term goal of facilitating more interactive discussions with the preceptor. The final component of the ICP model is the reflective clinical journal. Journaling is designed to facilitate critical thinking and close the theory-practice gap. 9,10 The template for the journal has several prompts that ask students to analyze their population, environment, personal growth, and relationship with the preceptor. Students comments range from enthusiasm about their autonomy during clinical experiences to expressions of confidence with problem solving related to situations they encounter. Examples from the journals include the following. I thought it was an excellent learning experience today about how things in the world are not always perfect. I think growing up in a world where I was never exposed to situations like this makes you somewhat unaware that things like this happen. I feel that I began to understand how cultural differences really do affect healthcare. We spent time with different clients and it is evident how the different cultures affect the way they react to healthcare. The preceptor, faculty member, and student review the student s clinical performance at midterm and final. Clinical performance is graded as pass/fail and the faculty member and preceptor provide input into the grade. A passing grade in clinical performance must be achieved before any other grades are determined. The community project and seminars receive a numeric grade from the clinical faculty member and these clinical grades are averaged with grades from 24 NURSE EDUCATOR Volume 30, Number 1 January/February 2005

the didactic portion of the course to arrive at a final grade. Faculty Role The key to success of the ICP model is effective implementation of the faculty role. This role must foster timely communication between the faculty, students, and preceptors. Faculty must be keenly aware of the quality of care provided by students. Because students are located in various rural settings, communication occurs on-line, via telephone, or face-to-face. The majority of on-line communication is asynchronous and occurs through e-mail, the drop box, and the group discussion options available through Blackboard. During the semester, faculty members are available by cell phone and pager. Students and preceptors are encouraged to call with questions and concerns. Faculty members are committed to respond immediately, unless unexpected events prevent this. If a particular faculty member is unavailable for a certain period of time, another faculty member will assist with coverage. At the beginning of each semester, faculty members contact preceptors in person or by phone to update information and to note any changes prior to orienting the students. This is also an opportunity to identify issues that have emerged since the previous semester. On a typical day, early in the semester, faculty members are usually in the office, reviewing reflective journals, facilitating seminar discussions, or meeting with individual students. The students are able to work 1-on-1 with the faculty member in focusing and developing their projects, or they can strategize about interventions related to their client population. Through the reflective journal, the faculty member makes comments, asks questions, and stimulates dialogue with each student. This facilitates evaluation of individual student learning early in the semester and students are less likely to get to fall behind. Later in the semester, the faculty begins to make site visits to each agency to meet with students and preceptors. Since many of the sites are at distant locations, requiring a significant amount of driving, only 3 to 4 visits can be completed each day. In preparation for a site visit, students complete a self-evaluation and the preceptor evaluates the student on the basis of course and individual objectives. During the visit, objectives are reviewed and student progress is discussed. A particular focus of this visit is to ensure that the student is meeting both the service-learning component of the class and the objectives related to population-focused care. Time is allotted to observe the students as they practice in the setting and to discuss student performance with both the student and the preceptor. Faculty members usually make 1 to 2 site visits to each student during the semester. Another important role of the faculty is to provide opportunities to recognize and celebrate the joint efforts of the preceptors and the faculty. Preceptors are encouraged to apply for adjunct faculty status and are recognized at our annual agency appreciation luncheon. Additionally, community health faculty members arrange agency-specific end-of-the-semester meetings to discuss strategies, celebrate successes, and affirm the commitment for the upcoming year. The productivity of the faculty is enhanced because of this increased collaboration. Community health faculty, in collaboration with the EAHEC, have developed continuing education programs for preceptors in the region. This is an important component of the service mission of our school of nursing. In addition, faculty members have made scholarly presentations at professional meeting and developed manuscripts related to community health nursing clinical education. Doctorally prepared faculty members have engaged in clinical research projects that have emerged from community service projects and are currently involved in several interdisciplinary research projects. Evaluation and Future Directions Student feedback on the ICP model has been obtained with a school of nursing preceptor evaluation form that has been adapted for community health nursing. The vast majority of students believed they enhanced their communication skills (91%) and professional behaviors (81%). The main area where students felt they needed more experience was in developing confidence in their nursing judgment (57%). The students were unanimous (100%) when asked whether the preceptor and the preceptor experience met their expectations. Ninety-six % of the students identified their preceptors as professional with sound clinical proficiency. Although there has been informal evaluation of the ICP model by the preceptors, there is not a specific tool that addresses this. The faculty is in the process of developing an instrument that will elicit preceptor feedback on the effectiveness of the model as well as suggestions for faculty on how the collaboration might be improved. One of the serendipitous outcomes of the ICP model is that the faculty member often becomes a resource and mentor for the preceptor. Since faculty members establish long-term relationships with preceptors, the preceptors value the expertise of the faculty in the area of theory-based practice, research, and career development. For example, a faculty member was asked for assistance in locating a tool to evaluate case management outcomes related to care givers and clients. The faculty member shared a conceptual model addressing issues related to the client population and guided the preceptor in a search of the literature. As a result, the preceptor developed an evaluation survey incorporating research-based items. In addition, the faculty member discussed advanced practice nursing with the preceptor and provided information about graduate school and potential collaborative research projects. Another faculty member was asked for guidance in updating a curriculum vitae for a preceptor who was contemplating career advancement. Yet another preceptor expressed frustration with caring for clients of different cultures and was assisted in finding resources to improve the preceptor s cultural competency. These opportunities for meeting the individual needs of the preceptor are important avenues for ensuring that this is a win-win situation for everyone. A valuable outcome from implementation of the ICP model includes recognition of a need for more collaboration among academic and practice NURSE EDUCATOR Volume 30, Number 1 January/February 2005 25

sectors within our region. This was evident by the networking that occurred during faculty site visits and during the preceptor workshop series. In addition, as preceptors become more experienced, it is clear there is a need for an advanced preceptor workshop that addresses specific needs of preceptors. Education related to cultural competent care is one topic preceptors have repeatedly identified as a need. Our long-term goal is to develop stronger bridges between the clinical and academic settings. One avenue we are pursuing is the development of a virtual community in which the faculty, students, and preceptors can participate in on-line mentoring, collaborative research, and continuing education. Several community projects have the potential to be valuable to other agencies in the region and the on-line virtual community would facilitate sharing of these projects. In summary, while the ICP model was initially implemented to address the clinical education of community health nursing students, there have been many other benefits. As a result of the collaborative process central to the ICP model, new avenues have evolved for recruitment of students for our graduate program in community health nursing as well as the recruitment of new faculty. Preceptors have gained an ally in documenting the outcomes of their practice and planning for career mobility. Overall, students, faculty, and preceptors have acquired a shared vision of how to enhance the care to community-based clients in the region. Acknowledgment Partial funding for this project was provided by the Eastern Area Health Education Center of North Carolina. References 1. Gebbie K, Rosentstock L, Hernandez L. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: National Academy Press; 2003. 2. Ben-Zur H, Yadil D, Spitzer A. Evaluation of an innovative curriculum: nursing education in the next century. J Adv Nurs. 1999;30(6):1432-1440. 3. Oermann MH. A study of preceptor roles in clinical teaching. Nurs Connect. 1996;9(4):57-64. 4. Gavin MJ, Haas LJ, Pendleton PB, Street JW, Wormald A. Orienting a new graduate nurse to home healthcare. Home Healthcare Nurse. 1996;14(5):381-387. 5. Lawless RP, Demers KA, Baker L. Preceptor program boosts recruitment retention. Caring. 2002;21(9):10-12. 6. Yu XGA. Developing community health nursing skills collaboration in a culturally diverse population. J Cult Divers. 2002; 7(3):76-79. 7. Board of Nursing Criteria for Utilization of Preceptors in Approved Nursing Education Programs. Available at: http://www.ncbon. com/education-preceptor.asp. Accessed April 19, 2004. 8. Mayne L, Glascoff M. Service learning: preparing a healthcare workforce for the next century. Nurse Educ. 2002;27(4):191-194. 9. Atkins S, Murphy K. Reflection: a review of the literature. J Adv Nurs. 1993;18: 1188-1192. 10. Nativio NG. Advanced practice. Servicelearning, the scholarship of service. Nurse Outlook. 2002;49(4):164-165. Nurse Educator Instructions for Authors Instructions for Authors can be found online at the address below. To ensure that your manuscript is in compliance with new submission procedures, you should read this document carefully prior to manuscript preparation. All manuscripts must be submitted electronically through this system. Please visit http://ne.edmgr.com 26 NURSE EDUCATOR Volume 30, Number 1 January/February 2005