In the late 1990s, undergraduate clinical education was transformed by the development of the dedicated education unit (DEU; Edgecombe, Wotton, Gonda, & Mason, 1999 ; Gonda, Wotton, Edgecombe, & Mason, 1999). Grounded in adult learning theory, core DEU components include collaboration, relationship building, peer teaching, and coaching and support for preceptors and students through professional development and access to academic faculty (Glazer, Ives Erickson, Mylott, Mulready-Shick, & Banister, 2011 ; Mulready-Shick & Flanagan, 2014 ; Smyer, Tejada, & Tan, 2015). Most DEUs are situated in secondary care settings, such as hospitals (Dapremont & Lee, 2013 ; Dean et al., 2013 ; Glazer et al., 2011 ; Smyer, Gatlin, Tan, Tejada, & Feng, 2015), or tertiary care settings, such as hospice or long-term care (Chmura, 2016 ; Devereaux Melillo et al., 2014). Although there are several iterations of undergraduate DEUs (Harmon, 2013 ; McVey, Vessey, Kenner, & Pressler, 2014 ; Sharpnack, Koppelman, & Fellows, 2014), no information can be found related to DEUs in primary care settings or in advanced practice nursing (APN) education.
Supported by federal funding, the authors adapted the DEU for use in a BSN-to-DNP family nurse practitioner program. Institutional review board approval was obtained from the academic institution. This article describes the innovative clinical education model, Student and Preceptor Advancement in a Dedicated Education Site (SPADES), a quality improvement project focused on adaptation of the acute care undergraduate DEU to a primary care APN dedicated education site (DES).
The core components of the DEU provide underpinning for the DES. Key adaptations for the DES include the use of clinical education assistants (CEAs), cost-effective baccalaureate-prepared nurses and a clinical education liaison (CEL), a DNP-prepared nurse practitioner faculty member with partial workload release as academic-practice liaisons in the clinical setting, collaborative clinical scheduling, clinical assessment rapid debriefing system (CARDS) recordings, and the use of rapid cycle quality improvement (RCQI; Robert Wood Johnson Foundation, 2013) strategies to improve academic and practice processes and outcomes.
CEA and CEL Support and Collaboration
Traditional DEUs use an onsite faculty liaison to support preceptors and students during clinical experiences. The authors realized that, for the APN program, this was cost-prohibitive. The dyadic student-preceptor model remains the primary method of teaching and learning; however, SPADES uses a CEA in the clinical environment for each precepted experience. CEAs serve as the primary point of contact during precepted experiences to facilitate communication among students, preceptors, and clinical faculty and to assist with non-APN issues, for example, paperwork and academic processes that arise during teaching-learning experiences. CEAs self-schedule to ensure they are on site for each SPADES precepted experience. Flexibility for onsite presence is essential to the role of the CEA and is suggested to be a nonnegotiable obligation in the SPADES model.
The faculty liaison or CEL has teaching responsibilities in the DNP program, attends DNP curricular meetings, and is a practicing family nurse practitioner with knowledge of evidence-based practice guidelines. The CEL does not remain in the clinical environment with the students and preceptors as in the traditional DEU. When APN-specific issues arise, the CEL collaborates with the CEA and facilitates resolution with clinical faculty, preceptors, and students and assists with clinical teaching as needed.
Consistent with the DEU, the SPADES model is grounded in relationship building, trust, and mutual respect. In traditional DEUs, collaboration is facilitated by an academic-practice agreement where the academic institution has exclusive use of the clinical unit and all employees on the unit are expected to participate. In SPADES, practice site administrators and preceptors were progressive and eager to participate; however, as expected, exclusive use of a primary care site by a single academic institution for APN students was not feasible, and each site continues to accommodate students from multiple institutions. Instead, SPADES is managed by members of the coordinating team, all of whom are employed by the authors’ academic institution; participation in the practice arena is voluntary.
Collaboration is also supported through an adapted scheduling process. Because APN preceptor schedules vary and accommodate multiple students, the SPADES team works with the preceptor to streamline scheduling. Clinical schedules for SPADES students are collaboratively developed between student and preceptor and then shared with the CEA. If schedules overlap or change, CEAs work with preceptors and students to revise the schedule so that appropriate student-preceptor ratios (National Organization of Nurse Practitioner Faculties, 2016) are maintained.
CARDS and RCQI
The use of RCQI is required in SPADES and is distinct from traditional DEUs. The SPADES team collects teaching-learning data from each precepted experience using an author-developed tool, CARDS. CEAs assist with CARDS data and also track concerns reported by SPADES participants. CARDS data are audio-recorded by preceptors and students privately into a secure, online learning platform at the end of each clinical day. Recordings are transcribed within 24 hours by the CEAs, and data are analyzed by the SPADES coordinating team to inform curriculum and course revisions and for the need for RCQI initiatives when opportunities to improve academic or practice processes and outcomes are identified. This is an ongoing project, and a total of 29 RCQI initiatives have been identified to date. Of these, one initiative resulted in 57 curriculum and/or course changes resultant from CARDS data. Issues of safety or those deemed of primary concern by participants are relayed to the team immediately for resolution. The CEA is not an APN; thus, clinical issues are immediately referred to the CEL. Using RCQI techniques (e.g., brainstorming, flowcharts, cause and effect diagrams, and control charts), concerns are addressed quickly, and most are resolved within 30 days. Some, such as those involving academic processes (e.g., curricular changes), are more time-consuming and require additional RCQI cycles.
Students, faculty, and preceptors in SPADES receive informal updates related to each RCQI initiative on an ongoing basis. A formal stakeholders’ report with the status of RCQI initiatives and grant work is provided to and discussed with preceptors, students, and faculty in person at the end of each academic semester. The grant-coordinating team also provides the stakeholders’ report to academic and practice administrative personnel. These processes support relationship building, enhance trust, and strengthen collaboration between and among practice and academic partners.
IMPLICATIONS FOR NURSING EDUCATION
As of spring 2018, the SPADES model is successfully implemented in one federally qualified health center and one community health center. The project is ongoing. Overall project outcomes data are currently incomplete, but there is beginning evidence that the adapted model is beneficial to APN preceptors and students. SPADES maintains core requirements of a DEU while offering viable adaptations for implementation for APN preceptorships. SPADES streamlines processes; supports students, preceptors, and faculty; facilitates student clinical placement; improves academic-practice communication; and may lessen the academic-practice gap for APN students, preceptors, and faculty.
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