Nurse leaders and educators must create and implement integrated and innovative care delivery and education models to support advanced education of entry-to-practice nursing students and expand and sustain the future of the nursing workforce in acute care hospitals.
COVID-19 exacerbated an already challenged hospital nursing workforce shortage, with more RNs reporting they plan to leave the workforce at higher rates compared with the past decade.1 The average age of RNs has increased to 52 in 2021, and 19% of the RN workforce is 65 years or older.2 Greater than 20% of RNs in the United States report planning to retire from nursing over the next 5 years.2 More RN jobs will be available through 2022 than any other profession in the United States.3 RN employment opportunities in the United States are expected to grow 9% from 2020 to 2030, with approximately 194 500 openings projected each year, on average, over the decade. This could create a need for more than 1.9 million nurses by 2030 if these positions remain unfilled.
Postpandemic nursing education continues to struggle with the availability of experienced preceptors, educators, and limited clinical sites. The new American Association of Colleges of Nursing's The Essentials: Core Competencies for Professional Nursing Education4 requires schools of nursing to re-envision their curricula with opportunities for students to demonstrate core competencies across multiple settings and with multiple populations. In addition, the country is seeing a diversion of experienced nurses to travel and agency roles and new nurses leaving the profession before becoming experienced. Improvements to mentoring and support for new nurses are needed at a time when experienced nurses are overextended, and retention is critical. An innovative model to create an immersive experience for novice students to learn in a safe and supportive environment is vital. The model could also provide instruction in pedagogy to novice preceptors, building their capacity in leadership, education, and management.
University of Maryland Medical System
The University of Maryland Medical System (UMMS) is a private university-based regional healthcare system focused on serving the healthcare needs of Maryland. It is the largest health system in Maryland, which comprises 13 hospitals in urban, suburban, and rural communities.
University of Maryland School of Nursing
The University of Maryland School of Nursing (UMSON) offers 2 entries into practice programs, an upper-division BSN and clinical nurse leader (CNL) MSN, as well as an RN-BSN option, 3 MSN specialties, 8 DNP advanced practice specialties, a post–master's degree DNP option, and a PhD program. With more than 2000 students, UMSON is the largest contributor to the nursing workforce in Maryland.
Founded in 2007, UMNursing is the academic-practice partnership between the University of Maryland Medical Center and UMSON. In 2019, the partnership expanded to include all hospitals in UMMS. UMNursing aims to maintain and grow a collaborative environment that promotes lifelong learning and development for professional nurses through innovative opportunities for research, practice, and education focused on optimizing healthcare outcomes.
Academy of Clinical Essentials
Evolving to a Future State
The collaborative UMNursing goal was to integrate the principles and goals of the academic and practice environments to optimize a new and comprehensive education and care delivery model. UMMS implemented a pilot of the Academy of Clinical Essentials (ACE) program in partnership with UMSON that transforms the education of nursing students and provides affordable staffing support for the medical system hospitals. Over a school semester, a cohort of nursing students is paired with a UMMS nurse, who is counted in the staffing numbers and functions as their school of nursing on-site clinical instructor for the entire semester, and together, they assume complete care of 4 to 5 patients for a 12-hour shift. The students receive academic credit from the school for their work that partially meets their requirements for their course and ultimately graduation. ACE facilitates nursing students' participation in an immersive experience that is grounded in the reality of being a hospital nurse. They receive comprehensive clinical instruction from a nurse who works on the unit where they fulfill their clinical rotation and knows the patient population, practice expectations, policies, procedures, and use of equipment.
UMMS finds and funds the ACE clinical instructors for the school and will ultimately enable the school to accept more qualified nursing student applications in the future. ACE goals are to 1) improve the student nurses' education with immersive and experiential learning where they are embedded in hospital culture; 2) bolster hospital workforces; 3) recruit students to join the UMMS workforce as new graduates; 4) facilitate decreased orientation costs over time; and 5) diversify UMMS nurses' roles to increase engagement.
The ACE program was piloted for a full semester as an experiential education model for students from 3 courses: Fundamentals of Nursing, Medical-Surgical Nursing for BSN, and Medical-Surgical Nursing for entry-to-practice CNL.
For the 1st 7 weeks of the semester, 4 medical-surgical students were paired with a hospital-employed clinical instructor. During this time, the medical-surgical students cultivated their practice in the care setting, whereas the Fundamentals students gained experience for the acute clinical setting by practicing in the school's simulation laboratory.
Eight weeks into the semester, 2 Fundamentals students joined the medical-surgical cohort, creating a mixed student cohort for the remainder of the semester. The advanced nursing students cultivated the art of delegation as they delegated tasks to the Fundamentals students.
Once the patients in their assignment are cared for, the students assisted the rest of the nurses and patient care technicians, which was appreciated by the unit's care team and further embedded the students in the unit's culture of teamwork. This support also fortified the workforce on the unit, particularly when staffing was challenged.
The ACE program was piloted on 7 nursing units: 4 within an academic medical center and 3 within a community hospital. The units were diverse in both patient population and acuity, including a thoracic intermediate care unit (IMCU), a surgical IMCU, a vascular IMCU, a general medical-surgical unit, an orthopedic medical-surgical unit, a cardiac and stroke medical-surgical unit, and an emergency department. In all but 1 of the cohorts, the nurse acted as a clinical instructor within his or her own employed unit. Clinical instructors, having confidence and practical comfort within their employed unit and among familiar colleagues, were able to integrate the students into the fabric of the unit, providing a robust care delivery team experience.
Each ACE clinical instructor was asked and paid to attend a 2-day clinical instructor workshop at UMSON, prior to the start of the semester. In the pilot, clinical instructors provided on-site instruction for cohorts as an extra 12-hour shift in addition to their full-time equivalent (FTE). They also graded student assignments and submitted student evaluations to UMSON. Clinical instructors were paid a stipend for the semester that was based on an average rate of pay and applicable differentials.
Connections Through Meetings
To guide the development and implementation of the novel program, the ACE leadership team formed and met regularly. Key participants included the chief nurse executive of the health system who led the pilot, academic leaders from the school of nursing, nurse leaders from current and future participating member organizations, nurse scientists from the health system and school of nursing, and the program manager.
In the development phase, the ACE leadership team met weekly to select units for ACE clinical placements, define expectations of clinical instructors and students, and determine measurable outcomes for the pilot. After the pilot was implemented midway into the semester, the ACE team shifted to biweekly meetings to monitor the progress of the participants, modify the program based on feedback from clinical instructors and students, and plan for program expansion and sustainability.
Lessons learned from the ACE team meetings were as follows: 1) consistent meetings allowed the ACE team to troubleshoot issues immediately; 2) with extensive knowledge of the program requirements, ACE leadership team members were well-positioned to recruit participants for the pilot; and 3) sharing information about staffing needs at the health system and education needs at the school of nursing allowed the ACE team to utilize nontraditional units for clinical placements.
To facilitate the teaching and learning process and the administration of the program, the evaluation team held a series of focus groups involving various clinical instructors and medical-surgical and Fundamentals student cohorts. Three focus group interviews were conducted to explore the clinical instructors' experiences and challenges; students were also interviewed about their clinical experiences and challenges. All 7 clinical instructors participated at least once in the 3 instructor's focus groups and 5 medical-surgical students, and 5 Fundamentals students participated in the 2 separate student focus groups.
Key findings from the clinical instructor focus groups included the following: 1) clinical instructors are experienced nurses, but 1st-time clinical instructors and would benefit from mentorship by an experienced clinical instructor or faculty liaison; 2) adequate communication between the school of nursing and the instructors regarding relevant course design and materials, particularly regarding care plans, is essential for setting both instructor and student expectations; and 3) teaching on one's employed unit promoted seamless clinical group integration and facilitated more efficient patient care, but instructors' shifts should be included in their normal work schedule, not in addition to it. All clinical instructors shared they would participate in the ACE program again.
Key findings from the student focus groups included the following: 1) students loved the immersive experience and shared learning exceeded their expectations; 2) medical-surgical students enjoyed working with the Fundamentals students as it provided opportunity to delegate and teach; 3) Fundamentals students valued learning from the medical-surgical students; 4) students requested clearer upfront communication about the ACE program and expectations; and 5) all students would participate in the ACE program again and asked to be placed in future ACE cohorts together.
Development of Support Tools
The ACE program identified the need for a structured toolkit to help facilitate the clinical instructor and the ACE students with orientation to the units (Table 1).
Table 1 -
Academy of Clinical Essentials Toolkit References
|Understanding the Difference: Traditional vs ACE Clinical Groups
||See document, Supplemental Digital Content 1, http://links.lww.com/JONA/A964, which differentiates traditional and ACE clinical groups
|Unit-Based Safety Orientation
||See document, Supplemental Digital Content 2, http://links.lww.com/JONA/A965, which provides an overview to all safety and unit operations measures on the assigned unit
|Student Skills Assessment Checklist
||See document, Supplemental Digital Content 3, http://links.lww.com/JONA/A966, an assessment checklist that helps to individualize and guide the development of a nursing student
|Unit Operations Tip Sheet Template
||See document, Supplemental Digital Content 4, http://links.lww.com/JONA/A967, a template used to familiarize staff and students with the unit
|Accelerated New Grad Blueprint
||See document, Supplemental Digital Content 5, http://links.lww.com/JONA/A968, a blueprint designed in levels to ensure that the orientee's skill set progresses in a linear fashion
|Nursing Role Descriptions
||See document, Supplemental Digital Content 6, http://links.lww.com/JONA/A969, which differentiates the scope of practice for the different roles
|Hospital documentation standards by level of care
||See document, Supplemental Digital Content 7, http://links.lww.com/JONA/A970, a description of documentation for acute care units and IMCUs of participating hospitals
||See document, Supplemental Digital Content 8, http://links.lww.com/JONA/A971, which describes each unit participating in the pilot
|Sample Assignments and Clinical Guideline
||See document, Supplemental Digital Content 8, http://links.lww.com/JONA/A971, which provides a sample guideline for assigning patients to the clinical group
||See document, Supplemental Digital Content 8, http://links.lww.com/JONA/A971, which lists the questions that each ACE clinical instructor must complete via Smartsheet at the end of each shift
|ACE Staffing Grid
||A Smartsheet to be completed by the unit manager that calculates per-diem nurse savings based on budgeted and actual unit staffing numbers for each ACE shift
|ACE Unit Guidelines
||See document, Supplemental Digital Content 9, http://links.lww.com/JONA/A972, which outlines the role and expectations of the charge nurse, unit staff, and ACE cohort
Short- and Long-term Outcomes
To measure the success of this education model, the evaluation team identified a set of short- and long-term outcomes for both practice (UMMS) and academic (UMSON) settings (Table 2).
Table 2 -
Academy of Clinical Essentials Program Outcomes and Goals
|| Short-term outcome
| Cost savings: agency nurse or premium pay
|| Student readiness for practice as reported by Casey-Fink Readiness for Practice Survey
| Unit nurse/patient ratio with and without ACE cohort
|| Clinical site evaluation—by student
| Enrollment in UMMS Student Nurse Extern Program
|| Clinical instructor evaluation—by student
| Student nurse tech employment
|| Clinical site evaluation—by instructor
| Unit nurse feedback
|| Long-term outcome
| Orientation time
|| No. of nurse graduates
| Student employment on unit/within hospital at graduation
|| NCLEX pass rate
| Enrollment in Practice-to-Practicum and Clinical Scholars Program
|| Pool of clinical instructors
| 1-y Retention of ACE student who becomes UMMS employee
|| Clinical site opportunities across UMMS
| Retention of UMMS employee who serves as UMSON clinical instructor
|| Use of nontraditional shifts for clinical rotations (nights and weekends)
| Repeat clinical instructor
The evaluation team built a tracking database to record ACE students' academic information and career path, including Casey-Fink Readiness for Practice information,5 NCLEX results, and employment data. The evaluation team also created a Smartsheet to record daily staffing information from nurse managers. These data were used to evaluate the savings accrued by the ACE cohort relative to nurse and staff utilization. The University of Maryland institutional review board determined this project met the criteria for nonhuman subject research.
39 students (19 medical-surgical BSN, 8 Fundamentals BSN, 8 medical-surgical CNL, 4 Fundamentals CNL) participated in the ACE program in 7 clinical groups. All the UMMS nurses who served as clinical instructors were new to UMSON; only 1 had previously been a clinical instructor. We added 1 new clinical site (an emergency department) and 1 new clinical shift each for 2 inpatient units. We increased the use of nontraditional shifts for clinical rotations and added Saturdays for 2 of the units/groups and a night-shift clinical rotation.
Staffing data for 1 of the units with an ACE cohort confirmed a savings of 2 per-diem nurses over a 10-week period. Another unit with an ACE cohort was able to float 1 travel nurse to another unit 1 week and 1 unit nurse to another unit the next week by having the ACE cohort on the unit. ACE cohorts were also able to support certified nursing assistant (CNA) duties when units had stretched CNA ratios; 1 unit was able to lower CNA ratios for 4 of the weeks during the semester. Although not an initial goal, feedback from the students and nurse managers demonstrates that having the ACE cohorts fully integrated into the unit culture has a positive impact on staffing and unit and team member morale.
The ACE program offers opportunities to expand the role of both the clinical instructor and the nursing student in the clinical environment. Working on their home unit, ACE instructors enter the experience of clinical instruction in a familiar setting, which eases some of the stressors of role transition between staff nurse and clinical instructor. In their study exploring role transition from clinical expert to clinical instructor, Wenner and Hakim6 found similar themes to those we found in these clinical instructors' focus groups. Their participants also expressed challenges related to grading and academic expectations, as well as experiencing professional development opportunities. Likewise, Owens7 describes role transition themes related to communication, support, and professional development. Clinical instructors in ACE also described similar challenges and needs.
The small clinical groups and full 12-hour shifts allowed students to fully experience the flow of a shift and have expanded opportunities to engage with patients, families, and members of the interprofessional team. The 12-hour shift was largely perceived as positive, although some students initially struggled with stamina. Similar challenges were seen for students who were assigned to the night-shift clinical groups. Smaller clinical groups with 4 to 6 ACE students compared with 6 to 8 students in a traditional clinical group permitted students to have more hands-on learning opportunity and time with the clinical instructors. Noerholk and colleagues8 found that although learning group size does not significantly impact skills transfer, students in larger group sizes had as little as 25% of hands-on time as those in smaller groups. Likewise, as learning group size increased, the time spent in passive learning increased. The authors suggest that the additional collaboration that was required in larger learning groups compensates for hands-on learning. In the ACE model, medical-surgical students oriented and delegated care to the Fundamentals students who joined the clinical groups in the 2nd half of the semester. This unique opportunity has the potential to accelerate learning and could encourage leadership skill development.
The innovative ACE model also deepened the connection nursing students had with their patients. One student was recognized by name in the unit's patient experience survey, and 2 students each received recognition in the comments made on postdischarge phone calls. Previous research supports the connection between nursing student competency and student-patient relationships.9 Similar positive student-patient relationships have been revealed when students perceive their instructor is supportive of their professional development.10 Units also benefited from the ACE model; unit managers noted that there was a positive impact on morale and unit culture. Fundamentals students also benefited from an immersive experience that differed significantly from other Fundamentals students traditionally placed in long-term care and nursing home settings and where skill acquisition occurs in the simulation laboratory.
The ACE model directly addresses UMSON needs for finding and funding instructors and using nontraditional clinical sites and shifts. Simultaneously, staffing data revealed that ACE groups positively impacted staffing by reducing the number of per-diem staff required on certain shifts and allowed for travel nurse and unit nurses to float to other units. In addition, units that did not have enough CNA staffing were able to benefit from the additional help from students to complete necessary work.
Whereas short-term outcomes have shown to be positive, long-term outcomes cannot yet be measured. Data collection and analysis will continue related to reduction of new-nurse orientation costs, diversification of staff nurse roles, improved NCLEX pass rates, and increased recruitment of student nurses who have completed ACE clinical rotations.
The quick timeline from conception to implementation, which was a 3-week period to ensure it was piloted for the spring 2022 semester instead of waiting 9 months for the fall semester, created challenges for the onboarding and orientation process with new instructors. It also did not support optimal communication with the students. Future programs that may be modeled after the ACE program should develop clear plans for communication and support for instructors.
The strength of the relationship between the academic health system and the school of nursing made this pilot possible. The long-standing UMNursing relationship allowed for direct communication between UMMS and UMSON, as well as trust between program leaders. Although replication of this model may be possible between schools and hospitals that are not part of a large healthcare system, the close working relationships across the academic and practice organizations eased the challenges of the pilot.
The ACE model can be replicated across the country through academic-practice partnerships. Hospitals must be a critical partner of schools of nursing to offer experiential and competency-based education. Benefitting from an ACE collaboration, hospitals can have a fortified daily workforce, robust recruitment pipeline, and pathway from nursing student to new-graduate nurse. Additional job-ready nurses can be hired, and onboarding time for new-graduate nurses will be reduced. Hospital nurses engaged in ACE clinical instruction will have a more diversified role, which will support job engagement and advancement on career clinical ladders. Some UMMS nurses have considered teaching but have resisted education full time because of a reduced income and loss of clinical skills. The ACE model facilitates hospital nurses sampling a formal teaching role while earning their hospital salary plus an hourly premium when they are ACE instructors.
Schools of nursing may benefit from an increase in experienced clinical instructors and clinical sites. In addition, the cost of the experienced nurse who serves as a clinical instructor is paid for by the hospital, reducing financial burden for the school. Student nurses benefit from a more intimate and immersive educational experience where they are embedded in the culture of the unit by virtue of being taught by a member of that unit's team. Ultimately, patients benefit from receiving excellent, individualized care from nurses and students who are trained in the ACE model.
For the fall 2022 semester, UMMS supplied UMSON with 19 ACE instructors and also launched 13 additional cohorts with 2 other schools of nursing, expanding to 32 cohorts with 128 students in aggregate. As this project continues, schools of nursing will be able to admit additional qualified applicants. With our UMSON partner, this will include medical-surgical nursing clinical education for 80 nursing students. By midterm, the team will begin rotating 2 Fundamentals students to the ACE cohort, allowing the medical-surgical students to practice leadership and delegation skills to the Fundamentals students. This will create a 6-student cohort with the plan to move the Fundamentals students into the same unit for their medical-surgical semester.
In addition, after considering the feedback from the ACE instructors, the team changed the expectation that the ACE shift is additive to their normal schedule. Moving forward, UMMS nurses will be an ACE instructor as part of their normal FTE and schedule and paid an incremental hourly rate. Also, grading papers and care plans will be the responsibility of the school of nursing faculty, and this expectation will be removed from future ACE instructor roles. In addition, and moving forward, UMMS will require school of nursing partners in ACE to provide a faculty liaison for the ACE instructors to contact for timely responses to questions and provision of advice. Last, if a student needs any remediation, it will be the responsibility of the school of nursing. Because of the early stage of the program, the return on investment and other long-term indicators will be reported in a future publication.
We believe that the UMMS ACE model can serve as a prototype for academic-practice partnership internationally to support the education of nursing students and growth of the future supply of nurses to the workforce. This model could impact the curve of the nursing shortage and ultimately offer a sustainable solution to supply the necessary number of nurses for acute hospital settings, while increasing the resilience and support those new nurses need to remain in the profession.
The authors acknowledge the following individuals for their important contributions: Nancy Richardson, MSN, RNCOB, C-EFM; Tara Stoudt, MS, RNC-NIC; Leah Wolferman, BSN, RN; Hannah Murphy Buc, PhD(c), RN; Courtney Cioka, MS, RN; and Jane Kirschling, PhD, RN, FAAN.
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