Doctor of nursing practice (DNP) programs are expected to provide practice immersion experiences that prepare graduates for the highest levels of nursing practice.1 DNP students should acquire the ability to incorporate, synthesize, and translate evidence into practice to address health care challenges across varied practice settings. DNP programs provide not only clinical experiences but also practice immersion experiences that advance their abilities to develop solutions that improve health care outcomes in an effort to transform health care. However, faculty still experience challenges in implementing quality DNP curricula including how to provide meaningful clinical experiences congruent with the role of the DNP.2
As part of accreditation standards, programs require a minimum of 500 to 1000 hours of postbaccalaureate clinical practice experience to fulfill requirements for the DNP degree.3,4 Clinical experiences are “planned learning activities in nursing practice that allow students to understand, perform, and refine professional competencies at the appropriate program level.”5(p21) Given the uncertainty as to the specific roles an individual with a DNP degree could fill in the workforce, faculty struggle with determining appropriate experiences and sites to meet these clinical hour requirements.2
The unique role of the DNP is to translate evidence into practice, generate new knowledge through innovation of practice change, and implement quality improvement (QI) processes in practice settings, systems, or with specific populations to improve health outcomes.6 To achieve this end, emphasis is placed on the importance of strong foundational collaborative partnerships between academia and practice. Educational institutions are responsible to provide DNP students the opportunity to apply, integrate, and synthesize their learning in an area of advanced nursing practice to improve health care systemically.4 With this guidance, faculty members need to develop innovative DNP clinical experiences to provide students with the knowledge and skills necessary to fully use the DNP degree.
The purpose of this article is to describe the development of a unique practice immersion course in a DNP program joining DNP students with community health care partners to ensure meaningful clinical practice experiences and the transformation of health care. An overarching goal of these practice immersion experiences is to maximize community partnerships, provide opportunity to advance systemic improvements in health care, and cultivate long-standing partnerships between academia and practice. These experiences provide students the opportunity to translate evidence into practice solutions while working with faculty and established teams in the community.
The University of Miami DNP program incorporates a hybrid model of online and face-to-face modalities. The program incorporates 2 entry levels: the BSN-DNP for nurse anesthesia students and MSN-DNP for post–master’s degree students. The practice immersion courses offered within the DNP curriculum were started in 2009 by the lead course faculty member. The faculty member was provided an additional 1 credit (1 hour per week) of workload effort to develop the course including coordination of community partnerships. Initially, course credits ranged from 2 to 12 clinical credits with approximately 14 didactic hours per course. This range of credits allowed individual students flexibility based on their previous education to ensure they reached the postbaccalaureate clinical hours required by accrediting bodies for the DNP degree. These practice immersion clinical credits were not part of the advanced practice clinical practicum hours required for licensure. These courses were designed to immerse students in a practice setting to apply higher-level thinking skills of application, integration, and synthesis, while engaging with practice leaders in live QI projects across their individual communities. Of note, these course practice immersion projects were distinctly different from the student’s final scholarly project. In addition to the faculty course coordinator, faculty advisors provided guidance for the immersion clinical components (1:6 ratio).
During the first years of implementation, students were responsible for identifying their own community partners and practice immersion projects. This approach was hindered by limited access to community organizations and practice sites; large variability in type, depth, and breadth of projects; and a lack of visibility and understanding of the DNP program as well as DNP role across the community. As tackling system-wide problems often takes time, these projects rarely were able to reach their full potential outcomes. There was limited continuity from 1 cohort to the next in terms of faculty advisors, students, and partners. Thus, a new approach to DNP practice immersion was developed with the goals of improving the quality and impact of the projects while expanding community outreach, partnerships, and outcomes.
In 2012, the school decided to modify its protocol for the DNP practice immersion. The new model included established partnerships between the academic institution and various community health partners. These community health partners informed the school about their challenges and desired projects. The school would match and coordinate the assistance of the DNP students. The first step initiating the process involved collaborative meetings with the lead faculty and university health partners to review potential QI/practice improvement projects. To foster interdisciplinary collaborations, a formal agreement was established between the business, medical, and nursing schools. After reaching out to various community partners, numerous joint projects were identified. The projects were listed with brief descriptions involving a project name, site, problem statement, and key elements; DNP students were then asked to select a project of interest from the list.
By 2013, the partnerships had developed, and after 1 cohort of students progressed in the program, the following cohort would assume responsibility for the next phase of the project. At the same time, the practice projects evolved and progressed along with the students’ roles. In addition to listing the project topic, problem statement, and key elements, students were asked to develop goals, objectives, and deliverables that aligned with the DNP Essentials4 and practice partner project needs. Students developed practice initiatives as a fusion of the student, course, and partnership objectives incorporating Magnet® considerations when applicable. These goals, objectives, and deliverables are then reviewed and agreed upon by the student, faculty, and community partner prior to proceeding with project implementation.
During this same time, the didactic component was enhanced to allow for scheduled coaching sessions with advisors, student presentations, and sharing of deliverables. Over time, stability and continuity were established within the agency contacts and faculty advisors related to the projects. While key leadership had been traditionally involved at project sites, this expanded to leadership teams designating key on-site contacts at the partner institutions for each individual project. This stability generated momentum in the strength of the community partnerships and improved quality and impact of the projects.
In 2017, the program further evolved with the development of system-wide practice immersion initiatives building on the successes of the localized practice immersion projects. It became increasingly evident that different entities within community health systems were requesting similar projects based on identified practice problems such as reducing central line–associated bloodstream infection (CLABSI) rates. Rather than addressing these locally and individually, lead practice partners identified key system-wide projects. DNP students were assigned to work with designated leaders across the system to address the issues, develop evidence-based system-wide practice improvement recommendations, and potentially participate in system-wide implementation of the agreed-on practice projects. These projects have continued to evolve, allowing students to engage in live practice improvement opportunities across the health systems, meeting educational objectives as well as community partner goals and objectives.
As a learning opportunity, specific components were built into course calendars and topical outlines to provide didactic support to all students, as well as to guide, monitor, and support individual student learning needs and opportunities within specific projects. Each student was assigned an individual faculty advisor and a lead on-site contact for the specific project. This included joint development and approval of individual student learning objectives incorporating project-specific information; recommended initial, midsemester, and final coaching sessions with on-site contacts and faculty advisors; mutual agreement on project deliverables including recommendations for next steps; and end-of-semester formal dissemination of individual project results and deliverables within the course as well as to community partners.
From 2013 to 2016, the number of practice immersion partnerships more than doubled (Figure, Supplemental Digital Content 1, http://links.lww.com/NE/A514). As a result, the number and types of projects available to students expanded, offering an increasingly diverse array of educational experiences with a broad range of health care partners. DNP students had more opportunity to expand their leadership skills through ongoing coaching and mentorship.
At the same time, the direction of these projects shifted from unit-based to systems-wide solutions leading to changes across health systems. Because of the growing success of the practice immersion projects, the scope of several projects expanded to an interdisciplinary level. At present, the agencies have requests for more problems/projects than the program can fill with student placements, although the academic-practice partnership continues to build to meet this need.
The practice immersion projects provide DNP students the opportunity to become directly involved in transforming health care with community partners. Projects range in scope from general practice improvement, to system-wide, interprofessional, and global improvement. Examples of the range of projects are described.
Nursing-focused projects have included development of nurse residency programs for new graduates (RN-to-BSN, advanced practice nursing), incorporating nursing peer review, and formulating and implementing nursing care delivery models for 23-hour observation units. The majority of practice immersion projects related to patient-focused practice issues were identified by the community partners. The topical areas ranged from patient safety projects relating to prevention and reduction of CLABSI, falls, and hospital-acquired pressure ulcers, to addressing patient flow issues in ambulatory care and inpatient settings. Several projects involved literature reviews examining evidence-based practices and working with community providers to update policies and protocols directly related to patient care. A current project at a local children’s hospital involved students developing and implementing a nursing care delivery model for a 23-hour observational care unit. Another project at this site involved students reviewing outcomes of parental participation for induction of anesthesia. The goal was to review current practices at the facility and develop evidence-based protocols for parental participation during induction of anesthesia to enhance family-centered care and the overall patient experience.
For students, these patient-centered projects promoted improved patient care and opportunities to critically appraise evidence-based literature. Students honed skills as they conducted literature reviews, learned first-hand to focus on outcomes, and developed the ability to work through projects with phased-in deliverables promoting the patient experience. The majority of these projects were smaller in scope and unit based so that students were actively engaged with transforming care at the bedside. These opportunities supported the learning experience while allowing students to engage in practice development and transformative changes in a variety of health care settings.
DNP students were assigned to projects that promoted change at the system level. One project entailed transitioning a health care facility to a shared governance model. Another project related to development of nursing leadership programs (for new graduates, advanced practice nurses, managers, and middle managers, and for executive development). As the practice immersion program has transitioned, it became apparent that many health partners were experiencing the same clinical challenges, as similar projects were being requested across health systems. This prompted faculty and academic partners to revisit the overall project goals and experience for students as well as partners. Although there were individual nuances specific to some sites, partners agreed to consolidate efforts and projects that were considered to have potential impact across the health system. Often, the original site-specific projects provided pilot data to assist with these scale-up efforts.
System-level projects included development of a nursing retention project, nursing clinical ladder project, and a professional work environment patient experience project. This initiative is in the beginning stages building on previous work completed at the local levels. Within large health systems, this has required a shift as nursing and other health professionals collaborate to address issues across the system. From the student and faculty perspective, these projects provide unique opportunities as students experience the nuances of working on QI projects to create and sustain change at higher organizational and system levels.
Interprofessional focus and scope are inherent in the practice immersion experience. Practice immersion experiences cannot be successful without incorporating colleagues from other disciplines in the project experience. Many projects involve on-site contacts from business/finance, medicine, human resources, information technology, community health, family resources, and other health professions. Students are encouraged to reach beyond the nursing profession and nursing-specific literature as they engage in the various experiences. For example, projects related to pain management in a postsurgical unit involved working with the school of music as they developed and implemented a therapeutic music listening program on the unit. Nursing anesthesia students developed clinic site-specific orientation modules to facilitate clinical assignment transitions that were then shared with and adapted for the medical anesthesia students and residents. This project was led by a DNP student and involved working with instructional design teams, information technology, medical colleagues including students and residents, and the local perioperative teams. Providing students practice immersion experiences that involve other professions allows them to learn and develop communication and other skills critical to transformation.
An especially memorable ongoing nursing leadership project requested by the World Health Organization (WHO)/Pan American Health Organization (PAHO) involved 8 students over the course of 2 semesters.7 These students joined faculty and PAHO representatives in developing and fully implementing an online leadership course currently offered on the WHO Virtual Campus Web site. Initial implementation was offered in English to nurse leaders in Latin America and the Caribbean to 58 participants representing 24 countries. Of these, 83% completed the course, with 95% of participants reporting that they strongly agreed or agreed that course material was relevant to their professional development; the evaluations demonstrated satisfaction overall. Currently, DNP students have continued to participate in the PAHO project throughout the full implementation process, including rollout of the Spanish translation course and follow-up evaluation and dissemination phases. This project exemplifies the potential for DNP students to participate in a diversity of opportunities, including engaging in various stages of the projects, observing the evolution of projects through their phases, and actively participating in a unique global health experience.
As this initiative has evolved, we have used a triangulated approach for purposes of evaluation and program improvements. Feedback has included student course evaluations, end-of-program focus groups, clinical site evaluations provided by students, and evaluation of the student’s performance by the community partner. Students are graded on a pass/fail basis by their course faculty member with input from the community partner.
In a time when the role of the DNP continues to evolve, this article illustrates how educators can foster and enable DNP students to serve as leaders of transformative health care. At first, the concept of a practice immersion lacked clarity, but after forging strong, enduring partnerships within the community, the DNP students were able to bridge evidence to practice and improve health care system outcomes. This unique model of attending to the needs of the community partner, incorporating the DNP Essentials,4 and soliciting student interest is consistent with adult learning principles, and sustaining projects, faculty, and agency leaders has resulted in robust changes and a positive impact for patients. This design is recommended to enhance student learning at the DNP level and prepare our future advanced practice nurses to be change agents.
After carrying out the latest iteration of the practice immersion course for several years, valuable lessons were obtained. Ensuring quality practice immersion opportunities requires strong bonds with community provider networks. Further, relationships and networks need to be built across communities and with nontraditional partners to provide diverse opportunities for projects. In developing these relationships, it is critical to have a faculty leader who possesses strong negotiation skills. In particular, faculty met with students and partners to resolve differences related to project activities and deliverables to ensure that all parties shared a mutual understanding of expectations. As the clinical partner may not be on the same timeline as the student, flexibility and persistence are needed.
As with any clinical experience, challenges may arise. Preparing the students to communicate frequently is key. In addition, projects may not always be a fit with the student’s skill sets or expectations or with the community partner expectations. Navigating through these individual situations has been facilitated by the lead course faculty member along with community partners and individual students on a case-by-case basis. Faculty monitor student progress through a Web-based clinical tracking system, and when students demonstrate lack of progress or inadequate deliverables, they meet to discuss concerns. These are live projects; therefore, as with any live projects, there lies opportunity for changes and assignments based on negotiations across the teams. We also have found that some projects require more than 1 semester and have worked with our community partners to transition these projects including student-to-student handoff to the following cohort. Regular meetings are held between course faculty and community partners to review project progress on assignments prior to and at the end of each semester.
The value chain is an important aspect of success as the projects must hold value to all members. The faculty member may have to remind and reinforce the value of projects to students, as they often take months to complete, and tangible results may not be achieved immediately. Also, students should be provided a clear sense of the project’s key elements and expected deliverables throughout the process. To this end, students require ongoing communication with faculty and partner guidance and support and most importantly need to be held accountable for project deliverables. Last, a lesson learned from the practice immersion experience was the importance of intermittent didactic components. The coaching between faculty member and student and the requirement for students to present their progress and deliverables helped solidify skills of leadership and learning.
As the program expanded in community partners, it became evident that some practice sites were much stronger than others with respect to availability to students, constructive feedback to faculty and students, on-site leadership support, and overall quality of practice immersion opportunities. This resulted in prioritizing sites and downsizing the number of practice partners included while increasing the number of robust projects.
Moving forward, DNP programs need to build immersion programs that address needs within their community, as well as the needs of the advanced practice nurse. Graduating DNPs need to develop knowledge and skills through practice immersion experiences that allow them to become adept transformers of health care translating evidence from research into practice. This does not occur through shadowing or miniobservation experiences. Rather, integrating a transformational practice immersion into the curriculum enables students to further develop collaborative and leadership skills and creates a whole greater than its parts.8 Providing students with robust practice experiences and engaged, experienced faculty and practice advisors allows students the opportunity for knowledge and skill acquisition in a safe learning environment. These skills are imperative for transforming health care across our communities.
As this project has evolved, the program has continued to build on current partnerships and develop new connections within the local area and beyond, including international partners. Strategies have included further integrating key partners into didactic components of the courses and overall program. Community partners are included in school advisory, strategic planning, and individual course planning meetings. These ongoing initiatives reflect the policies recommended at a 2013 summit endorsing best practices for academic-practice partnerships, including establishing mutual benefits and investing time in the relationships.9
Alumni networks present opportunity for development of practice immersion activities beyond typical initiatives. Building these relationships with advancement and alumni network teams presents new opportunity for unique practice partnerships beyond traditional partners. Sharing news of DNP student projects while noting the need for innovative practice experiences has the potential to open new doors for initiatives and tap into the breadth of alumni knowledge and experience.
The roles of the faculty advisor and the community on-site contacts have evolved during the course of the project. Identifying DNP faculty with the project experiences necessary has been a logistical challenge. As a result, the on-site contact as advisor has become increasingly significant to the students. Coaching sessions scheduled throughout the practice immersion individual courses typically have included the student and faculty advisor with key community partner contacts invited to participate. There is potential opportunity to expand the community partner role to that of a formal faculty advisor for the individual courses in an adjunct role.
Ongoing evaluation and program development are critical with regular community advisory meetings and student feedback. Gathering candid student perspectives about placements sites, partner contacts, and overall experiences is a critical aspect of the continuing refinement and improvement of the practice immersion experience for future cohorts.10 In addition, further expansion of interprofessional teams with a systems focus is expected. Ideally, faculty from different disciplines could bring graduate students together as teams, addressing health care issues while learning to problem solve together in the true spirit of interprofessional practice.
Schools of nursing may struggle with finding clinical opportunities for DNP students that fully engage their role as leader and partner to advance health and health systems. The practice immersion described in this article presents a design that forges long-lasting partnerships with academia and practice settings, enabling DNP students to maximize their learning and preparing them as change agents. Increasingly visible student immersion projects that have impact on health care will serve to improve understanding of the role of the DNP.