Approaches to nursing education have evolved dramatically over the past 100 years. In the early days of the development of formal health care organizations in Canada, nursing education lay within the control of religious nursing orders. As non-religious hospitals developed across the country, a new secular model of education was developed to meet the need for a more skilled workforce. This apprenticeship model was based on the Florence Nightingale approach and dominated nursing education for almost a century.1 These early models focused on direct clinical practice and domestic unit-based tasks, with students composing the primary workforce for most hospitals.
At the turn of the 20th century, nursing leaders began to look to universities to incorporate education programs in response to concerns that the growth of hospital-based programs had contributed to lower admission standards, inadequate educational facilities and a lack of qualified faculty.1,2 The Weir Report (1932), a summary of an extensive survey of nursing education in Canada, provided a number of recommendations to improve the quality of programs, including separating nursing education from hospital nursing service.3 National common standards were published by the Canadian Nurses Association in 1936. The subsequent Hall Commission report (1965) included similar recommendations.4
As the nursing role became more complex, a major topic of debate was about the level of education needed for entry-to-practice. Today, in Canada, the baccalaureate degree is the required level of education for entry-to-practice in all provinces and territories except for Quebec. The move away from hospital-based programs to colleges and universities throughout the 1970s and 1980s was met with some opposition from employers who felt that the move meant nursing graduates were inadequately prepared for practice and were not able to “hit the floor running”.5(p.8) A key component of this argument then, which continues today, was that new graduates lacked critical thinking, assessment and psychomotor skills, and an appropriate level of independent practice.6,7 This argument is frequently framed in the literature as a concern about too much theory and not enough clinical practice experience in educational programs.8,9
Clinical practice models
Contemporary nursing education programs include both theoretical and practical components, and are aimed at the development of professional competencies based on the acquisition and application of theoretical knowledge.9,10 Nursing educators have the responsibility of ensuring that students are exposed to the realities of the healthcare system and preparing them for practice with competencies necessary for promoting and preserving patient safety.11-13 Students complete their practice education components in a widening range of hospital and community settings. Prior to formal clinical placements with patients and communities, students also participate in extensive laboratory and simulation-based activities. In Canada, on average, programs may include up to 2000 hours of clinical practice.1
There is accumulating evidence pointing to traditional clinical education processes and models not keeping pace with changes in demographics, the health system and scientific advances.14,15 New graduate nurses are reporting feeling unprepared for the full scope and complexity of current nursing practice.13 Employers continue to express concerns that new graduates are not “practice ready”.5 As such, nursing education leaders have called for transformation of clinical education models.16,17
A number of clinical education approaches have been described in the literature. Budgen and Gamroth identified and critically analyzed the benefits and limitations of 10 different approaches.18 Internationally, the most common model of clinical practice education is the faculty-supervised practicum; however, models vary by practice setting and country.10 A Canadian national nursing education survey identified a number of reasons why specific clinical practice models were chosen, including superiority of the education model, maximizing clinical resources, class scheduling, limited clinical placements and the availability of faculty.19
The traditional faculty-supervised model of student clinical practice was designed for educators to provide direct supervision to a smaller group of students in a particular clinical setting. The benefits of this model include: supervision from a clinically qualified nurse, instruction from experienced educators with curriculum knowledge, reduced teaching responsibilities for nurses, and instructor control over student learning.18 The challenges to this model include: high student-to-instructor ratio, limited student-faculty interactions, lack of time to help students develop critical thinking skills, and being seen as an outsider in the clinical setting.13 Luhanga, in her study of full-time faculty and clinical instructors in western Canadian universities and colleges, concluded that there are currently more challenges than strengths associated with the traditional model.13
A follow-up model that was developed to address these challenges was the preceptorship model. This education model was based on a preceptorship approach developed in the 1970s to assist in transitioning newly graduated nurses from school to work.20 Preceptorship is defined as “a formal one-to-one relationship between a nursing student and registered nurse that extends over a predetermined length of time”,21(p.1) and builds on recognition of the influence of the nurse preceptor on student practice. This model, the most researched practice education model, emerged for a number of economic and human resource reasons.18,21 The benefits to this model include: reduced cost for faculty, role socialization, and support of the student by an expert clinician. The challenges to this model include: the preceptor is not expert in teaching and evaluating students, students are dependent on one role model, and there is an added workload for the preceptor. Pringle et al. state that most Canadian programs, for Year 3 and 4 placements, are somewhat to very dependent on this model, resulting in overuse of experienced clinicians, preceptor burnout, and the use of preceptors who may have insufficient clinical experience to support student learning.22
Development of the collaborative learning unit model
The collaborative learning unit (CLU) is an innovation in practice education adapted from an earlier model of a dedicated learning unit pioneered in Australia.23 Both the CLU and the dedicated learning unit are designed to provide optimal learning for students, increase access to practice placements, ease transition to graduate roles, and build capacity for implementing best practice and a culture of evidence and research through strategic collaboration between practice and education sectors.23,24 The academic faculty leading the student placements is well positioned to identify strengths and gaps in evidence-based practice and leads nurses in evidence-based interventions to improve patient outcomes.
Evaluation of the CLU model suggests that partnerships among nurse administrators, point-of-care nurses, and faculty can transform clinical care units into supportive learning environments for nursing students while continuing the foundational work of providing safe quality care to patients.25 This evaluation research suggests that use of a CLU approach contributes to: i) improved relationships between nurses situated in both academia and practice;26 ii) enhanced quality of teaching and learning because faculty has significantly more time being present on the clinical care unit to address the individual learning needs of increasingly diverse students;27 and iii) integration of competencies into practice.28,29 For example, Mulready-Schick et al. suggest that the CLU approach promotes student learning about quality and safety competencies via unit-based projects, which in turn supported quality improvements in nursing care delivery.30 Thus, in this innovative model, educators and service providers are guided by the notion of flexibility, and promote the development of nurse graduates who are adaptable to change.11
Clinical education of students is a critical component of nursing education and yet it is difficult to identify best practice in clinical nursing education.19 Tanner suggests that traditional clinical placement models are no longer sustainable and that the development and testing of new models is a high priority.17 Although a stronger evidence base is beginning to develop that informs existing practice model refinement and proposals for new models, research continues to be limited on model comparison, cost analysis, student and faculty experience, and student and patient care outcomes.18,20
A preliminary search for existing scoping and systematic reviews was conducted on July 11, 2018 in PROSPERO, MEDLINE, CINAHL, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports. No current or underway systematic reviews on this topic were identified. Fifty-three relevant sources were identified during this preliminary review, indicating that there is evidence available to conduct this review. The findings from this scoping review will be used to develop recommendations for academic and practice partners related to refinement, improvement and expansion of the CLU model.
The overall objective of this scoping review is to identify and map literature that describes characteristics and processes that are included in the CLU practice education model for undergraduate nursing students.
The review will consider publications that include undergraduate nursing students, including baccalaureate and associate degree programs. These programs are aimed at preparing students for the role of registered nurse (RN). It will exclude publications that include licensed practical nurse or residential care aide students. These excluded publications will be counted if they have an English abstract.
Undergraduate students may also be identified with different student terms depending on the country. The following terms may also be used: pre-registration, pre-licensure.
This review will focus on the characteristics and processes that form the CLU clinical practice model.
For this review, we will use the following definition of a CLU developed by Lougheed and Ford:31(p.2)
“A collaborative learning unit is a nursing unit where all members of the staff, together with students and faculty, work together to create a positive learning environment and provide high quality nursing care. Students practice and learn on a nursing unit, each following an individual set rotation and choosing their learning assignment (and therefore the Registered Nurse with whom they partner), according to their learning plans. Unlike the traditional one- to-one preceptorship-, an emphasis is placed on student responsibility for self-guiding, and for communicating their learning plan with faculty and clinical nurses.”
Other terms in the literature representing a similar clinical practice education model include: dedicated education unit, dedicated learning unit, dedicated education learning unit, team preceptorship, clinical teaching unit, and collaborative cluster.
The term “characteristics” is defined by the Cambridge and Business Dictionaries, respectively, as “typical or noticeable qualities of somebody or something”32 and processes refers to “sequences of interdependent and linked actions taken in order to achieve known outcomes or results”.33
The review will consider sources that describe the CLU within health systems and community contexts where undergraduate nursing students learn to practice. These contexts include, but are not limited to, hospitals, public health, home care and community agencies.
Types of sources
This scoping review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion.
Qualitative studies will also be considered, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research. Mixed methods studies will also be considered.
In addition, systematic reviews, program evaluations and quality improvement reports that meet the inclusion criteria will also be considered.
Text and opinion papers will be considered for inclusion in this scoping review if they are published in peer-reviewed academic journals and meet the review objective.
Dissertations and theses will be included. Conference papers will not be included.
Sources published in English will be included. Sources with an English abstract that are non-English will be counted. Studies published since 1999 will be included as this is the date of the first publication related to this model of practice education.
The proposed systematic review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews as outlined in the Joanna Briggs Institute Reviewer's Manual.34 The title of this review has been registered with the Joanna Briggs Institute.
A three-step search strategy will be utilized in this review. An initial limited search of CINAHL was undertaken (January 3, 2018) to identify sources on the topic. The text words contained in the titles and abstracts of relevant sources, and the index terms used to describe the sources, were used to develop a full search strategy (see Appendix I). The second search step includes applying all identified keywords and index terms to each included database. The third step will involve searching the reference lists of all identified sources for additional relevant studies and gray literature.
The databases to be searched will include: CINAHL Complete (EBSCOhost), Google Scholar, MEDLINE with Full Text (EBSCOhost), Academic Search Premier (EBSCOhost), Cochrane Database of Systematic Reviews (EBSCOhost), ERIC (EBSCOhost) and the JBI Database of Systematic Reviews and Implementation Reports. Sources of unpublished studies to be searched include: ProQuest Dissertations and Theses.
The search for gray literature will be limited to documents identified in the reference sections of included sources that focus primarily on the CLU model.
Following the search, all identified citations will be collated and uploaded into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) bibliographic software and citation management system (Joanna Briggs Institute, Adelaide, Australia) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into JBI SUMARI. The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full text studies that do not meet the inclusion criteria will be recorded and reported in the final scoping review report. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.35
Data will be extracted from articles included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers (Appendix II). The data extracted will include specific details about the population, concept, context, articles types and key findings relevant to the review objective. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included article. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews objective and question/s. A draft data display table is provided in Appendix III.
Appendix I: Search strategy
Appendix II: Data extraction worksheet
Appendix III: Presentation of the findings (data display table)
1. Baker C, Guest E, Jorgenson L, Crosby K, Boyd J. Ties that bind: the evolution of education for professional nursing in Canada from the 17th
century to the 21st
century. Ottawa: Canadian Association of Schools of Nursing; 2012.
2. Bramadat I, Chalmers K. Nursing education in Canada: historical “progress” – contemporary issues. J Adv Nurs
1989; 14 9:719–726.
3. Weir G. Survey of nursing education in Canada. Toronto: University of Toronto Press; 1932.
4. Hall E. Royal commission on health services. Ottawa: Government of Canada; 1964.
5. Wolff AC, Regan S, Pesut B, Black J. Ready for what? An exploration of the meaning of new graduate nurses’ readiness for practice. Int J Nurs Educ Scholarsh
2010; 7 1:1–14.
6. Missen K, McKenna L, Beauchamp A, Larkins J. Qualified nurses’ rate new nursing graduates as lacking skills in key clinical areas. J Clin Nurs
2016; 25 (15–16):2134–2143.
7. Scully N. The theory-practice gap and skill acquisition: an issue for nursing education. Collegian
8. Haigh C. Embracing the theory/practice gap. J Clin Nurs
2008; 18 1:1–2.
9. Cassidy S. Interpretation of competence in student assessment. Nurs Stand
2009; 23 18:39–43.
10. Dobrowolska B, Palese A. The caring concept, its behaviors and obstacles: Perceptions from a qualitative study of undergraduate nursing students. Nurs Inq
2016; 23 4:305–314.
11. Hegerty J, Walsh E, Condon C, Sweeney J. The undergraduate education of nurses: Looking to the future. Int J Nurs Educ Scholarsh
2009; 6 1: Online 1548-923x.
12. Huston C, Phillips B, Jeffries P, Todero C, Rich J, Knecht P, Sommer S, Lewis M. The academic-practice gap: Strategies for an enduring problem. Nurs Forum
2017; 53 1:27–34.
13. Luhanga F, Billay D, Grundy Q, Myrick F, Yonge O. The one-to-one relationship: is it really key to an effective preceptorship experience? A review of the literature. Int J Nurs Educ Scholarsh
2010; 7 1: Article 21.
14. Institute of Medicine. The future of nursing: Leading change, advancing health. Washington DC: National Academies Press; 2011.
15. Niederhauser V, Schoessler M, Gubrud-Howe P, Magnussen L, Codier E. Creating innovative models of clinical nursing education. J Nurs Educ
2012; 51 11:603–608.
16. Benner P, Sutphen M, Leonard, Day L, Shulman L. Educating nurses: A call for radical transformation. San Francisco: Jossey-Bass; 2010.
17. Tanner C. Thinking like a nurse: A research-based model of clinical judgement in nursing. J Nurs Educ
2006; 45 6:204–211.
18. Budgen C, Gamroth L. An overview of practice education models. Nurs Educ Today
2008; 28 3:273–283.
19. Pringle D, Green L, Johnson S. Nursing education in Canada: Historical review and current capacity. Ottawa, ON: Nursing Sector Study Corporation; 2004.
20. McClure E, Black L. The role of the clinical preceptor: an integrative literature review. J Nurs Educ
2013; 52 6:335–341.
21. Sedgewick M, Harris S. A critique of the undergraduate nursing preceptorship model. Nurs Res Pract
22. Valizadeh S, Borimnejad L, Rahmani A, Gholizadeh L, Shahbazi S. Challengs of the preceptors working with new nurses: a phemomenological research study. Nurs Educ Today
23. Edgecombe K, Bowden K. Clinical learning and teaching innovations in nursing: Dedicated education units building a better future. The Netherlands: Springer Verlag; 2014.
24. Callaghan D, Watts W, McCullough D, Moreau J, Little M, Gamroth L, Durnford K. The experience of two practice education models: collaborative learning unit and preceptorship. Nurs Educ Pract
25. Moscato S, Miller J, Logsdon K, Weinberg S, Chorpenning L. Dedicated education unit: An innovative clinical partner education model. Nurs Outlook
2007; 55 1:31–37.
26. Wotton K, Gonda J. Clinician and student evaluation of a collaborative clinical teaching model. Nurs Educ Pract
27. Miller T. The dedicated education unit: A practice and education partnership. Nurs Leadersh Forum
2005; 9 4:169–173.
28. Day L, Smith E. Integrating quality and safety content into clinical teaching in the acute care setting. Nurs Outlook
2007; 3 2:138–143.
29. Pappas S. Improving patient safety and nurse engagement with a dedicated education unit. Nurs Lead
2007; 5 3:40–43.
30. Mulready-Shick J, Kafel K, Banister G, Mylott L. Enhancing quality and safety competency development at the unit level: an initial evaluation of student learning and clinical teaching on Dedicated Education Units. J Nurs Educ
2009; 48 12:716–719.
31. Lougheed M, Ford A. The collaborative learning units model of practice education for nursing: A summary. Victoria, BC: University of Victoria; 2005.
32. Cambridge Dictionary [internet]. [cited February 12, 2019]. Available from: https://dictionary.cambridge.org/
33. Business Dictionary [internet]. [cited February 12, 2019]. Available from: http://www.businessdictionary.com/
34. Peters MDJ, Godfrey CM, McInerney, Baldini Soares C, Khalil H, and Parker D. Chapter 11: Scoping reviews. In: Aromataris E, Munn Z (Editors). The Joanna Briggs Institute Reviewer's Manual. Adelaide: Joanna Briggs Institute; 2017 [internet.]. [cited December 13, 2016] Available from: https://reviewersmanual.joannabriggs.org/
35. Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med
2009; 6 7:e1000097.