TRADITIONALLY, CLINICAL rotations consist of two 6-hour shifts per week, informally called the 6/6. Each clinical day typically includes a preconference, patient care, and a postconference. We estimate that a conventional 6/6 schedule might devote 1.5 to 2 hours to pre- and postconferences, reducing the time available for students to immerse themselves in nursing practice or to reflect, process, research best practice, and compare patient care with evidence-based recommendations from the literature.
Faculty in our nursing department at D'Youville College, Buffalo, N.Y., believed it was time to offer nontraditional clinical hours to allow a selection of clinical schedules to better meet the needs of the faculty and students. To make it happen, a few faculty members pioneered a clinical format consisting of one 9-hour clinical day and one 3-hour seminar per week. We call this schedule the 9/3.
This article explains the benefits of this innovative schedule and describes the outcome of our research project comparing the benefits of the 9/3 with those of the 6/6.
A closer look at the new schedule
The 9/3 clinical consists of one 9-hour shift of patient care, followed by one faculty-led 3-hour seminar 2 days later attended by 8 to 10 students. At this seminar, students are required to provide a presentation about their assigned patients, including patient-care goals and outcomes, and to include evidence-based references that they've researched between their patient-care day and the conference. Faculty members are responsible for their own conference day, which includes presentations from the entire clinical group.
Faculty designed the 9/3 format using the teaching-learning principle of immersion. This allows the students to apply their knowledge in the clinical setting for 9 hours, then reflect on and discuss their experiences with their peers and a faculty member in the 3-hour post conference. This discussion covers what they learned, what assessment findings were abnormal, and what they could have done differently to improve patient outcomes. We believe that students extract meaning and synthesize content and professional role behaviors from experiences.1
Our literature review using several nursing databases didn't reveal any studies of our 9/3 model, but we found many expert opinions that support and embrace the extended clinical shift framework, defined as clinical time in excess of 6 hours. One report suggested that staff perceived that students didn't complete their assignments or follow up with patient care when their rotations consisted of partial shifts as in the traditional 6/6 clinical.2 Tobar et al. analyzed evaluations of longer clinical shifts in nursing education and found an overwhelmingly positive response from students, staff, and faculty. The students perceived better organization of care, staff reported improved continuity of care, and the faculty reported improved critical thinking and organization of care.3
Based on our literature review, we concluded that nontraditional clinical hours, such as the 9/3 model, can benefit students, patient outcomes, and clinical sites. Clinical immersion encourages students to focus on holistic care and is associated with less overall stress, an ability to balance other aspects of academic and personal life, and increased self-confidence and morale.3
The 9/3 clinical had been offered as a pilot program for four consecutive semesters, and students and faculty evaluated it before we began the official institutional review board program evaluation and quantitative questionnaire development. The first year of evaluation entailed an open-ended written questionnaire, which was distributed to participating students and faculty. Of the 90 students in the senior class, 55 were randomly assigned to participate in a 9/3 clinical during at least one medical-surgical or pediatric rotation.
The qualitative student responses from our first questionnaire prompted the development of a second, 26-question Likert-response questionnaire to quantify themes discovered. (See Glossary of research terms.) We grouped all responses into common themes and categories, and incorporated them into the revised quantitative tool.
Participants in the current study represent a convenience sample of all 90 senior baccalaureate nursing students in the college. We distributed the postprogram surveys to measure student preference using the same timing and procedure we use for end-of-semester faculty performance evaluations. We did this to reinforce that participation is voluntary and to ensure anonymity and faculty absence during the evaluations. Sixty-five surveys were returned.
Results of findings
We evaluated the Likert-scale responses for descriptive and comparative statistics using statistical software; we excluded all nonresponses. Responses offered were: 1, strongly agree; 2, agree; 3, neutral; 4, disagree; and 5, strongly disagree. Students indicated a strong preference for the 9/3 clinical because they perceived that it represented a "real" nursing shift. Students also strongly agreed that the 9/3 clinical provided more time with patients and strongly agreed that they preferred both the overall experience and the postconference. They believed the extended clinical immersion benefited their critical thinking and improved their nursing skills.
We used the paired t-test to determine an overall statistically significant preference for the 9/3 over the 6/6 clinical. We compared the mean for all responses to the 9/3 clinical with all items for the 6/6 clinical and verified a statistically significant preference for the 9/3 clinical, t(52) = –2.839, p = 0.006. An overall preference for the pilot 9/3 clinical offering has been established by this aggregate of participants.
Mean agreement was noted to be statistically significant when students had stronger agreement with the concept that the 9/3 prepares them for a "real" nursing shift compared with the 6/6. Students also felt the 9/3 supported their exposure to more procedural skills; t(60) = 5.472, p = < 0.001. Students perceived they spent more time with patients in the 9/3 format; t(61) = 4.530, p = < 0.001. Students' preference for the 9/3 seminar format over the 6/6 postconference format was significant as well; t(61) = 4.029, p = < 0.001. Respondents strongly agreed that the 9/3 clinical let them balance extracurricular commitments and achieve the most benefit from the seminar format. They also strongly agreed that they perceived the 9/3 better prepared them.
Besides a small sample size, the study has several limitations. Its restriction to one setting limits generalizability, and there was no psychometric evaluation of the tool.
The literature and the program evaluations supported using a longer clinical day in place of two separate days consisting of shorter clinical learning experiences. Students believed the longer clinical days improved their ability to learn skills, participate in decision making, multitask, and provide complete nursing care for their patients. Students also reported a preference for a seminar on a separate day because this gave them time to reflect on their immersion experience and incorporate the literature into an evidence-based learning experience.
Nontraditional hours also benefit the facility because nursing students are providing care for a full day instead of for a fragmented shift. Clinical instructors can assess students' abilities more fairly and offer them additional learning experiences. For example, the clinical immersion gives students the opportunity to admit and discharge patients, accompany patients to the OR, and provide pre-op and post-op care. The offering of one extended clinical day is less labor-intensive for faculty preparation, facilitates more students rotating through each unit, and can stretch faculty resources by combining clinical groups for the seminar format. A dearth of clinical sites, decreasing faculty and financial resources, a need to accommodate more students, and higher clinical acuity levels warrant change.4 We believe it's high time to offer more nontraditional clinical days for undergraduate programs.