Glazer, Greer PhD, RN, CNP, FAAN; Ives Erickson, Jeanette RN, DNP, FAAN; Mylott, Laura PhD, RN; Mulready-Shick, JoAnn EdD, RN, CNE; Banister, Gaurdia PhD, RN
Academe-service partnerships have yielded a number of novel approaches to preparing nurses for practice.3-6 One especially promising approach is the dedicated education unit (DEU). First pioneered in the late 1990s by an academe-service partnership in Australia,7 DEUs have slowly been adopted by groups in the United States.8-10 In the DEU model, a hospital unit hosts students from a single school of nursing, pairing each with a staff nurse who serves as the student's clinical instructor (CI). The CI works with the student for an extended period, guiding the student's clinical learning and helping the student become a full and active member of the patient care team. A clinical faculty coordinator from the school supports the CIs' teaching efforts and remains accountable for the educational outcomes of students. Organizations that have implemented DEUs describe them as win-win endeavors that enhance the quality of clinical nursing education while facilitating professional development and a culture of learning on patient care units.
Creating a DEU requires an exceptional collaboration and partnership. Like all successful collaborations, the partners must forge a relationship based on trust and a mutual, top-down commitment to ensuring the collaboration's success.11 In addition, the academe and service partners must find ways to bridge their different cultures, values, and reward and performance systems while developing a shared vision for integrating education and service activities.3,12 Developing and implementing a DEU also require advanced leadership competencies. Nurses leading the effort must demonstrate strategic vision and link the DEU to their organization's strategic direction while garnering organizational support. They must also be comfortable taking risks, skilled in translating the DEU vision for multiple constituencies, and adept at managing organizational change.13 Each of these skills is critical for reaching across the practice-academe divide and engaging in the complex planning and decision making required for developing a DEU.
In this article, we describe how nurse leaders at the College of Nursing and Health Sciences (CNHS) at the University of Massachusetts Boston (UMB), the Massachusetts General Hospital (MGH) in Boston, and Brigham and Women's Hospital (BWH) in Boston forged a partnership that resulted in the creation of 2 DEUs. In addition to describing the DEUs' structure and principles that guided the development, we highlight leadership competencies demonstrated by nurses at 3 levels1: by the university dean and hospital chief nurse executives (CNEs) who established the vision for the DEUs,2 by nursing program and clinical directors who oversaw DEUs' design and implementation, and3 by the CIs and clinical faculty coordinators who are instrumental to DEUs' ongoing success.
Forging a Partnership, Creating a Vision
The DEU initiative involving UMB, MGH, and BWH benefited from the 3 institutions' history of collaboration and their shared commitment to education, excellence, and diversity. The partnership also benefited from each institution's unique strengths. The UMB is a large, urban public research university dedicated to meeting the needs of traditional and nontraditional students from varied social, cultural, and ethnic backgrounds. Among UMB's undergraduates, approximately 60% are first-generation college students, and 37% of the 2,059 students in CNHS represent racial or ethnic minority groups. The nursing program is known for excellence and has been involved in major national initiatives, including Quality and Safety in Nursing Education14 and the American Nurses Association's Handle With Care Campaign.15 Curricular innovation, defined as a dynamic systematic process that results in new and hopefully better approaches to nursing education (National Council of State Boards of Nursing, 2009) and practice is a top priority, highlighted in the CNHS and nursing program strategic plan.16
Both the MGH and BWH are academic medical centers committed to patient care, teaching, research, and community service. The hospitals have a long history of supporting nursing education, and each maintains contracts with numerous schools of nursing, including UMB. They are also the founding members of Partners Healthcare, a large integrated healthcare delivery network serving New England. In 2000, the Partners-wide chief nurse council, led by the MGH CNE, developed a workforce strategy to support the network's continued growth in the face of the projected nursing shortage. As part of this effort, the council met with representatives from nursing education programs that had clinical affiliations with Partners Healthcare to assess their student capacity and profile, quality of educational programming, and plans for the future. Based on this assessment, the council determined that UMB's quality and diverse student population represented the future generation of nurses and established a goal of developing UMB as an important strategic partner.
Although the institutions' overlapping interests and strategic priorities set the stage for expanded collaboration, personal relationships also played a role. As peers in the Partners network, MGH and BWH CNEs enjoyed a close collegial relationship. A similar relationship was shared by the UMB dean, the MGH CNE, and the MGH executive director for nursing education, who had spent time together as RWJ executive nurse fellows and previously collaborated on a nursing scholarship program. Debating new ideas and discussing opportunities came naturally to the nurse leaders, so that when the dean suggested creating a DEU, both hospital CNEs immediately expressed interest.
Underlying each leader's interest was an appreciation for how the DEU concept complemented their vision for their departments and for nursing as a profession. For the dean, DEUs held the promise of enhancing student learning while also increasing the nursing program's student capacity without additional faculty. For the CNEs, DEUs promised expanded opportunities for staff nurse development as well as a potential pipeline of employable new graduates already known to their institutions. The nurse leaders agreed to create a cross-institutional task force charged with examining the DEU concept, assessing the feasibility of implementing DEUs at MGH and BWH, and outlining and overseeing required next steps. They also began laying required groundwork within their institutions, garnering support for the DEUs among their executive and academic peers, faculty, and senior leadership teams.
Developing a Plan
The DEU task force chartered by the dean and CNEs began meeting in spring 2007. The task force consisted of 11 nursing representatives from the partnering institutions, including the undergraduate nursing program director and nursing clinical faculty from UMB, nursing directors overseeing professional development and academic relations at the hospitals, and nursing directors of an MGH and a BWH clinical unit selected as possible DEUs.
As a first step, the task force examined DEUs implemented in Australia and the United States and sent several members to a DEU conference at the University of Portland in Oregon. Through this process, task force members came to know one another personally and professionally, developing mutual trust and respect for one another's knowledge, insights, and talents. They also gained an understanding of what was required to implement a DEU and agreed on key DEU tenets, including exclusive use of each DEU by 1 school of nursing, continuity of CIs for the entire junior and senior level clinical rotations, orientation of nurses to the CI role, ongoing CI coaching and oversight of student evaluation by college faculty, and commitment to open communication and continuous learning and professional development for all participants.17 The task force developed goals for the clinical partnership (Figure 1), describing desired outcomes for students, faculty, clinical nurses, and the partnering institutions. These tenets and goals served as the basis for the next steps, which included defining eligibility criteria for students, clarifying CI and clinical faculty coordinator roles, and mapping out plans for operationalizing the DEUs.
Student and Clinical Faculty Criteria and Roles
The task force determined that the DEUs would be reserved for junior year nursing students, because students at this level have completed 1 clinical rotation and are ready for a more independent and in-depth clinical experience. The junior year placements would last 1 semester, with the students returning to the DEU in their senior year to complete their senior preceptorships.
The group determined that nurses serving as CIs needed to have at least a bachelor's degree in nursing and a minimum of 5-year nursing experience and demonstrated facility with precepting and mentoring. The CIs would be recruited and selected by the unit nursing directors, who were best positioned to assess staff nurse interests and abilities. Each CI would be responsible for 2 students at a time. To ensure continuity, CIs would remain with their students throughout the semester, supporting them in mastering core competencies, becoming active members of the care team, and socializing to the unit's culture. Although the CIs would be responsible for ongoing guidance and mentoring, ultimate accountability for the students' learning outcomes resided with the clinical faculty coordinator, a member of the UMB nursing faculty. This faculty member was charged with supporting the CIs and partnering with them to monitor individual student performance, identify effective teaching strategies, and nurture the development of professional comportment and professional identity. Each clinical faculty coordinator would work with 6 to 8 CIs and be responsible for 12 to 16 students. To prepare CIs for their role, UMB proposed conducting an orientation covering the nursing curriculum and learning expectations, as well as teaching strategies that promote clinical reasoning and accommodate different learning styles.
The 2 units selected as DEUs were chosen by the CNEs for their commitment to teaching and reputation for innovation (Table 1). The MGH unit was a large, 36-bed trauma surgical unit with an experienced nursing staff. The unit's nursing director welcomed the DEU as an opportunity and potential catalyst for staff development in precepting and change management. The BWH unit was a high-acuity, medical step-down unit that was divided into 2 small 15-bed pods and staffed by 8 medical teams. In preceding years, both units' nursing directors had made a point of hiring many new graduates, creating a culture where precepting, mentoring, and learning were the norm.
In deciding how many students each unit could accommodate, the task force had to balance UMB's need for student placement with unit capabilities. The units' nursing directors had to consider practical limitations related to unit size, layout, workflow, and patient acuity and assess how many students their staff could support and incorporate into the unit and patient care teams. After some discussion, the task force agreed that the MGH DEU would support 12 students and the BWH DEU would support 6.
As planning for the DEUs progressed, the task force members shared their progress with the dean and CNEs, who continued to offer support and ensure the availability of necessary resources. The task force also discussed the DEUs with other faculty and staff nurses on the units. Most clinical nurses immediately recognized the value of the DEUs, although some expressed trepidation about taking on the CI role. Through dialogue at staff meetings and 1-on-1 discussions, the nursing directors helped staff members appreciate the opportunities for growth offered by the CI experience and recruited a pool of eligible nurses.
Student placements on the MGH and BWH DEUs began in spring 2008. For the initial cohort, UMB invited students who met a minimum grade point average requirement of 3.0 to submit an essay describing how they would benefit from the DEU experience and how they would give back to the unit. Eighteen students were selected for participation and assigned to a DEU and a CI.
Each student spent one 12-hour shift on the DEU each week, working with the CI and gradually assuming all aspects of the nursing role. In addition to caring for patients, students also participated in debriefing sessions in which their CIs helped them process and reflect on what they had learned. The broader nursing staff played a role in student learning by inviting students to observe and participate in unique patient care experiences.
The clinical faculty coordinators assigned to the DEUs were often present on the units and available by telephone and e-mail for consultation regarding student performance and strategies for meeting learning needs. The clinical faculty coordinator guided each group of students in researching a patient care concern for the unit. Students at MGH examined skin care, and those at BWH studied physical restraints. The groups presented their findings at the end of the semester. Both projects led to practice changes: at MGH, nurses began including time on the operating table in their postsurgery reports because this was found to be related to skin breakdown; at BWH, a diversion cart was developed as an alternative to physical restraints.
Whereas most aspects of the student experience were similar across the 2 units, differences in teaching emphasis and unit culture accounted for some dissimilarities. For example, at MGH, students began the semester caring for a single patient. After demonstrating basic competencies and becoming skilled in unit and hospital systems, they cared for up to 2 patients, gaining experience in prioritizing and managing competing patient needs. At BWH, students cared for a single patient throughout the semester. Emphasis was placed on knowing the patient and gaining fluency in all aspects of the nursing role. As students developed confidence, they were assigned more complex patients to help them refine their critical thinking and clinical reasoning skills. In addition, at MGH, the CIs and clinical faculty coordinator were responsible for supporting students and overseeing their performance, with the unit's nursing director monitoring overall operations and supporting scheduling and other logistics. At BWH, the unit's nursing director and nursing educators played a more active role, discussing nursing's philosophy with students during orientation, occasionally joining debriefing sessions, and helping guide students' professional comportment.
Throughout the semester, the DEU task force monitored DEU operations and consulted with the nursing directors and clinical faculty coordinators on needed adjustments. With operations proceeding smoothly, the group began developing plans to support another group of students in fall 2009.
Since opening in spring 2008, the DEUs at MGH and BWH have supported cohorts of junior nursing students each fall and spring semester. As originally planned, students who complete DEU rotations in their junior year return to the same CI for their senior preceptorships, in which they manage full patient assignments. To date, 200 students have completed clinical placements on the DEUs: 134 completed 1 (junior year) placement, and 66 completed 2 (junior and senior years) placements. The original DEU cohort of 18 students graduated in fall 2009, and subsequent cohorts have graduated each spring and fall semester. Students have consistently praised the DEU experience, citing its continuity and rigor and the opportunity it offers for truly becoming part of the patient care team.
The clinical units and hospitals have also benefited from the DEU experience. Since the DEUs opened, the hospitals have employed 21 DEU students as patient care assistants (PCAs) and have hired 10 DEU graduates as nurses. The orientation for students who spent time on the DEUs is notably shorter because of their familiarity with hospital systems and culture and their experience in managing patient assignments. Because of their greater comfort with the nursing role, DEU graduates also demonstrate less self-doubt and anxiety as they transition to independent practice. In addition, the units' nursing directors report that the DEU experience has enhanced the culture of learning on their units. Having students continually interact with staff and question them about practice and having faculty work with clinical nurses as peers stimulate inquiry, dialogue, and debate, which enriches the entire unit as well as patient care. A culture of learning is also promoted by the UMB tuition vouchers, used by more than 20 nurses to date, and by the student projects, which focus on quality and safety issues and facilitate practice improvements while helping students gain an appreciation for nursing's role in ensuring patient safety and quality.18
Over time, several changes have been introduced on the DEUs, such as having students spend a day with a PCA to understand the PCA role and their contributions to patient care. The number of students accommodated on the DEUs has also increased. In fall 2009, the MGH DEU raised its student capacity from 12 to 16, and in fall 2010, MGH opened a second DEU accepting another 14 students. Brigham and Women's Hospital also increased its DEU capacity from 6 to 8 students.
A formal evaluation of the DEUs is currently underway with funding support from RWJF. The evaluation, which calls for randomized assignment of voluntary participants on DEU and traditional clinical units, will assess student outcomes on DEUs and traditional units, faculty and instructor work life, teaching capacity, and costs associated with the DEUs overall and for each institution.
A variety of factors accounted for the success of the DEUs. Chief among these is the leadership demonstrated by nurses at every level: by the dean and CNEs who first envisioned the DEUs, obtained institutional support and resources, and modeled collegiality, leadership, and partnership for their staff; by the nursing directors at the university and hospitals who negotiated and coordinated the development of the DEUs, ultimately creating units that accommodated each institution's requirements and capabilities; and by the CIs and clinical faculty coordinators who worked together on a daily basis to ensure that the DEUs provide an optimal learning experience for students.
Choosing the right partners was key. Our chances of success were enhanced by forging a new relationship among institutions that had partnered successfully in the past and that shared core values related to nursing professionalism, education, diversity, and excellence, as well as a belief that challenge and risk equal opportunity. Equally important was choosing units with strong nursing leadership. Offering a welcoming and supportive environment for students and accommodation of change without compromising patient care, workflow, and unit cohesiveness was a priority. At both MGH and BWH, the unit nursing directors were comfortable taking risks and managing change and were skilled at interdisciplinary collaboration. In addition, many of the clinical nurses enjoyed teaching and welcomed new opportunities for professional development. Under the nurse leaders' guidance, they embraced the DEU concept and accepted UMB students as full members of the care team.
The DEU task force was another key to success. The collaboration, openness, and transparency modeled by task force members set the tone for the initiative and influenced interactions among CIs, clinical faculty coordinators, students, and staff. Having each institution equally represented on the task force ensured that every decision was considerate of multiple perspectives and that no single institution drove decision making.
In the past year, UMB implemented a pediatric DEU in a third hospital and is currently implementing another medical/surgical DEU in a fourth hospital. Both BWH and MGH have been approached by other schools interested in developing units for their students. In considering these and other ventures, the institutions have benefited from the experience described here, an experience that highlights the benefits and innovations gained through academe-service collaboration.
Among the insights we gained is a deeper appreciation for how DEUs impact other schools of nursing. Before creating a DEU and selecting a host unit, hospitals must consider their academic obligations and how they will support groups displaced by the DEU. Also important is considering and carefully balancing the needs and requirements of each DEU partner. Doing so will ensure that the DEU meets the learning needs of students without compromising the unit's capabilities and unique culture.
The authors thank the members of the dedicated education unit (DEU) task force; faculty and staff in the University of Massachusetts Boston's College of Nursing and Health Sciences; students participating in the DEU program; and nurse directors, nurse educators, clinical nurses, and other staff on the Massachusetts General Hospital and Brigham and Women's Hospital patient care units serving as DEUs for their support in developing and implementing the DEUs and Beth Kantz, RN, MS, of Corrigan Kantz Consulting for writing and editing support.
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