Letcher, Deborah C. PhD, RN; Nelson, Margot L. PhD, RN, CNL
The speed of new knowledge generation and the complexity of modern healthcare present formidable challenges for nursing. Augustana College and Sanford USD Medical Center have responded by redesigning the teaching-learning environment. Nursing leaders in education and practice, staff nurses, and nursing students created a Culture of Caring (COC) framework for an innovative education-practice approach, embracing shared clinical teaching-learning values and strategies.
Today’s application of new knowledge for improvement of nursing and healthcare quality has led to care bundles, translating research evidence into practice. As defined by the Institute for Healthcare Improvement,1 a care bundle is “a small set of evidence-based interventions for a defined patient segment/population and care setting that, when implemented together, result in significantly better outcomes than when implemented individually.”1(p2) The COC model expands the notion of care bundles beyond their individual patient care application to encompass the teaching-learning environment. The model guides teaching-learning interactions among patients, students, nurses, faculty, and leaders in clinical practice and education toward excellence in patient care.
Background and Significance
Essential elements for the partnership were identified through a crosswalk of regulatory and professional standards and competencies from The Joint Commission,2 Magnet Recognition Program®,3 Quality and Safety Education for Nurses© (QSEN),4 The Advisory Board Company,5 the National Council of State Boards of Nursing (NCSBN),6,7 Transforming Care at the Bedside (TCAB),8 and the Essentials of Baccalaureate Nursing Education (American Association of Colleges of Nursing [AACN])9 (Table 1). Crosswalk themes inform the 5 COC dimensions. We assert that a COC requires a bundle of teaching-learning strategies incorporating dimensions of patient-centered care (PCC),4 leaderful alliance,10 community and vitality,11 safe reliable care,12,13 and professional development (PD).14
The gap between worldviews of nursing education and nursing practice has been well documented. Berry11 asserts that academia and practice hold separate beliefs, perceptions, and expectations. The Advisory Board Company reports that 90% of academic leaders perceive graduating nurses as well prepared, whereas only 10% of nurse executives view them as practice ready.5 Educators believe that education is a professional responsibility of all nurses, whereas many practicing nurses view nursing students as an annoyance and as an increase in their workload. Practice leaders expect nimbleness in response to complex demands, historically attained over years of practice. Current new graduates are expected to hit the ground running. New graduates report particular difficulty with clinical decision making while managing and caring for multiple complex patients.15
Nursing is carried out in an environment fraught with surprises, threats, incomplete information, interruptions, vagueness, and multitasking. The differing views of education and practice leaders, along with rapid changes and increasing complexity of the practice environment, contribute to the gap between student learning experiences and practice expectations, suggesting a crucial need for realignment and a call for shared responsibility.
Berkow et al5 assert that “with widespread concerns regarding safety and quality of patient care, the time has come for academe and service to collaborate during the student’s educational process to enhance the competencies essential for entry into practice.”5(p22) Citing a faculty shortage, shifting patient demographics, patient acuity levels, changing healthcare system expectations, and new technologies, other nurse authors contend that the traditional model of 1 faculty member with 8 to 10 students is no longer realistic for nursing clinical education.15,16 Debourgh13 declares that practice leaders must partner with academia to provide students with “authentic formative learning experiences, …[and] opportunities… to become part of the culture of the healthcare agency.”13(p59)
Triadic teaching-learning teams (practice nurse, faculty member, and student) may substitute for the more familiar faculty-student group configuration. The Clinical Academic Partner (CAP) model17 illustrates such role shifting for faculty and staff. The primary role of faculty in these models is to support the development of the staff nurse as clinical instructor and to foster deeper synthesis of concepts by students. Benefits of reconfiguring the role of staff nurses as teachers are described as (1) buffering demanding expectations of faculty, (2) providing a mentor with current clinical expertise, and (3) increasing faculty credibility with students and nursing staff. Several models have integrated best practices recommended by the Advisory Board Company,5 including clinical rotations for students with full patient loads and entire shifts and student-centered units where staff nurses embrace responsibility for teaching students.
Redesigning roles for both faculty and clinical nurses is essential, but not sufficient. The challenge is to create a shared teaching-learning environment that realigns the educational process with the realities of nursing practice. Academic-practice partnerships, such as the COC, provide a “context for the active presence of… the scientific essence of the nursing profession and for expansion of evidence-based practice within clinical settings.”18(p135) The individual faculty member of the past, as an academic outsider, becomes a team member and coleader within the practice environment, consulting and collaborating at the unit and organizational level (e.g., performance improvement and evidence-based practice). Faculty and students are “not viewed as visitors in the clinical setting but as integral members of the nurse team, committed to building a culture of quality and safety.”16
The unique contributions of this model include: 1) blurring boundaries between the cultures of nursing education and practice; 2) strengthening the organizational infrastructure for academic-practice collaboration; 3) developing a teaching-learning culture grounded in contemporary nursing standards; and 4) articulating a bundle of interventions to accelerate and enhance clinical learning.
The Institute of Medicine (IOM)19 and the Agency for Healthcare Research and Quality (AHRQ)20 actively promote PCC. QSEN defines PCC as “recognizing the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient preferences, values, and needs.”4 Nurses are pivotal to positioning the patient at the center of care through respectful, compassionate, and coordinated care, active interprofessional engagement, and interventions tailored to patients’ preferences, values, and needs.
Research supports the positive impact of PCC on quality indicators (eg, shorter lengths of stay, lower costs, and higher patient and staff satisfaction scores).21 Patient-centered care also leads to fewer diagnostic tests, increased adherence to therapy, greater trust in healthcare providers, and improved psychosocial, health, and functional outcomes.22-24 Qualitatively, PCC nursing interventions have been described as responsive, individualized, coordinated, and proficient.25 Findings illuminate PCC as reflective of the invisible nature of nursing’s work and affirm the importance of focusing care on patient preferences.
Leaderful alliance fosters teaching-learning encounters in community with others. Raelin10,26 suggests that leadership can (1) arise from multiple members of a group, (2) be assumed by more than one team member, (3) exist among all team members, (4) operate to preserve the dignity of others while placing high value on democratic participation, and (5) directly affect quality, innovation, change, flexibility, learning, resiliency, proactivity, patience, and commitment. “Leaderful practice exhibits humility and seeks to serve others rather than power for its own sake.”26(p18)
The COC model emphasizes the importance of increased interaction among the practice leader, the faculty, staff nurses, nursing students, and patients. The dimension of leaderful alliance presents a new opportunity for all participants to assume leaderful roles to accomplish quality patient care and create innovative teaching-learning opportunities.
Community and Vitality
Community and vitality depend on a network of partnerships to promote quality teaching, learning, and patient care. According to Baker et al,27 an effective partnership or team possesses specific knowledge, skills, and attitudes. Effective teamwork requires intentionality and commitment by all members. Successful team characteristics include (1) leadership—establishing goals, giving directions; (2) backup behavior—feedback, conflict management; (3) mutual performance monitoring—understanding roles and how they fit together; (4) communication; (5) adaptability—recognizing and adjusting strategies; (6) shared mental models—understanding roles and processes necessary to achieve goals; (7) mutual trust; and (8) team orientation. These elements have been crucial to implementation of the COC model.
Safe and Reliable Care
The quality and safety movement identifies nursing care as the final safeguard before an error reaches a patient. The IOM28 recognizes quality nursing care as a primary determinant of health, health outcomes, and mortality. The COC model embraces nursing’s obligation to provide safe and reliable care.
Organizations with a positive safety culture are characterized by mutual valuing and trust, by shared values regarding the importance of safety, and by confidence that preventive measures are effective in addressing issues of patient safety.29,30 Quality and safety practices include National Patient Safety Goals (NPSGs),2 protocols, checklists, quality assessment tools, and initiatives such as hand hygiene campaigns to ensure the delivery of safe and reliable care. Structured communication among interprofessional team members is essential and can be promoted through specific communication tools—assertiveness, critical language with key words such as “speak up” and “stop the line,” and an environment of psychological safety and respect. The COC model promotes a shared safe and reliable nursing environment for patients.
Nursing PD encompasses active participation in learning to advance growth of competence, professionalism, and achievement of career goals. This lifelong process begins with formal academic preparation and is augmented by continuing education in the practice arena.31 Literature supports the impact of PD opportunities on increased nurse satisfaction, reduced turnover and absenteeism, and improved patient outcomes (eg, fewer patient falls, decreased length of stay, and increased patient satisfaction).32
Pullen et al33 note that successful PD in the clinical environment depends on the influence of practice leaders and clinical faculty to set the tone and objectives and to engage in open dialogue. Honest feedback, dialogue, and daily debriefings lead to transparency and growth in academic and clinical performance.33 Professional development can move both students and clinical RNs to a higher level of performance.34 Within the context of COC, expected behaviors and competencies in teaching-learning are grounded in respect, courtesy, engagement, caring, and gratefulness.27 The COC model provides a framework for academic and practice partners to discover and apply new knowledge together and to stretch the boundaries of excellence for all health team members.
Leaders in nursing education and practice planned a sequence of retreats in fall 2008. Participants included nursing leaders from both organizations, recent nursing graduates, and the executive director of the state board of nursing. Several methods were utilized to surface issues confronting new graduates and initiate in-depth conversation about environmental characteristics that hinder and facilitate new-graduate transition into practice. The goal emerging from this dialogue was to bridge the gap between nursing education and practice through a full partnership.
The key question was: How can we cocreate an innovative, effective, sustainable, seamless, education-practice nursing model for the future to facilitate the transition from nursing student to practicing nurse and benefit the patient? Through open dialogue, guided by appreciative inquiry and the use of the Theory U,35 new possibilities for a transformed teaching-learning culture were revealed.
New graduates shared experiences of high anxiety and losing sight of why they were in nursing. They cited their enjoyment of internship and directed study experiences, whereby they could be immersed in the real world of nursing, experience mentoring from seasoned nurses, and learn what nursing was “really like.” Meaningful teaching-learning experiences that harness student creativity and imagination were identified as priority.
New graduates described elements of an optimal clinical learning environment: (1) approachable nursing staff willing to involve students in patient care, (2) energetic and passionate faculty, and (3) opportunities to develop deeper understanding of the nursing role and what it takes to deliver excellent patient care in complex systems. The ideal practice culture was envisioned as a welcoming, healthy environment that embraces students as bonafide team members. Decreasing traditional paperwork assignments and venturing “outside the box” were identified as important considerations.
To create the vision for a shared culture, multiple perspectives and pockets of innovation were explored, including TCAB,8 the Partners in Nursing (PIN) program,36 The Healing Web,37 and the CAP model17 (Table 2.). Tanner’s38 clinical judgment model and the QSEN competencies4 further informed the discussion. Principal concepts emerged: intentionality, inclusiveness, the centrality of relationships, mutual valuing, authentic presence, lifelong learning, confidence, and competence.
Selected nurse orientation content was integrated into student teaching-learning experiences. The objective was to create a teaching-learning culture whereby all nurses would become preceptors (culture brokers) and faculty would teach side-by-side with staff about evidence-based practice, bundles of care, quality indicators, and NPSGs.2
The COC model is composed of 5 central dimensions (illustrated in the Figure 1 and defined in Table 3) and grounded in a transformational nursing education-practice partnership and innovative teaching-learning relationships for nurses providing patient care. Participants commit themselves to shared accountability that guides interactions among patient-nurse-student-faculty-practice leader in education and clinical practice.
The model has continued to evolve through ongoing discussion, feedback from practicing nurses and students, and evaluative research findings. In a spark of insight as the group struggled to define more clearly the COC intervention, it was reframed as a bundle of best practices to support a teaching-learning culture of caring. Table 3 includes the current dimensions, underlying principles, beliefs and values, specific bundle components, process outcomes, and outcome indicators. The bundle components identify the expected behaviors of nursing staff, students, faculty, and practice leaders, and the process outcomes describe the characteristics of such a culture and how it should be evident in a practice arena. The specific outcome indicators serve as measurable outcomes.
Implementation and Evaluation
Dimensions of the model were refined in keeping with a thorough literature review. As the model was evolving, a pilot implementation was conducted on 2 patient units, chosen because the nursing directors and faculty had been actively involved in the COC model design and because nursing staff were receptive to being more actively involved with students. A 3rd unit where the COC model was not introduced served as a comparison unit.
An evaluation was designed to assess the emerging culture change. The Organizational COC Questionnaire was adapted from the Hughes Organizational Climate for Caring Questionnaire,40 modified with permission of the author. The 10 items were crafted to represent the 5 dimensions of the COC model. The instrument was used as the primary measure of change in perspectives of students and RN staff. Following institutional review board approval, data collection began during the 2nd semester of student clinical experiences. Staff and students were oriented to the model and the expectations of nursing staff, nursing faculty, and students. The survey instrument was administered to students and staff nurses on the 1st and last day of a student group’s clinical experience on their unit. Focus group narrative data were also collected from participating RN staff and students to elucidate the characteristics of the COC model as experienced by participants. Full research findings will be reported elsewhere. Below are key results:
* Significant differences were found in student perceptions between the COC units and a comparison unit. RN staff on the COC units were rated significantly higher on items representing leaderful alliance (meaningful engagement and clear communication), community and vitality (mutual encouragement and enjoyment of partnership), safe reliable care (safety concerns), and PD (knowledge exchange and interest in learning).
* Students were rated more highly by nurses assigned to work with specific students and during students’ final versus first clinical experience on the unit.
* Overall, students rated RN staff more highly than the RN staff rated students on all dimensions except PD.
* Student feedback reflected the power of communication patterns/feedback between students and RN staff.
* Assignment to a specific nurse promoted less waiting and increased learning.
* Students experienced good days when nurses were calm, offered feedback, encouraged engagement, and actively sought learning opportunities for them.
* Students had not-so-good days when staff RNs ignored them and provided no check-ins or feedback. “The RN’s attitude really makes it or breaks it.”
Implications for Nurse Leaders
The COC model represents a new paradigm of clinical teaching-learning through partnership between nursing education and practice. It goes beyond role expansion for clinical nurses and faculty to a recreation of the nursing practice culture, with shared ownership of the nursing educational enterprise and excellence in nursing practice. Grounding in contemporary literature, standards, and regulation sets the stage for continued dialogue, refinement, implementation, and evaluation. The bundle of teaching-learning strategies provides a testable protocol for further implementation. Early evaluation suggests to nurse leaders that unit culture change can occur and that student learning and clinical nurse perceptions are positively influenced. Next steps are full implementation of the expanded role for clinical faculty in the practice organization as well as evaluation of the effect of a COC upon quality and safety of patient care and graduating nurses’ transition to practice.
Members of the COC task force are acknowledged for their participation in the design and implementation of the COC model (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A291).
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