THE NEED FOR radical changes in nursing education ACADEMIC/CLINICAL PARTNERSHIP AND COLLABORATION IN QUALITY AND SAFETY EDUCATION FOR NURSES EDUCATION

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1 ACADEMIC/CLINICAL PARTNERSHIP AND COLLABORATION IN QUALITY AND SAFETY EDUCATION FOR NURSES EDUCATION JUDY DIDION, PHD, RN, MARY A. KOZY, PHD, RN, CHRIS KOFFEL, PHD, RN, AND KRISTIN ONEAIL, MSN, RN The Institute of Medicine and the Carnegie Foundation for Health Education have called for significant changes in nursing education to reduce medical errors and improve health outcomes. In response to this call, a small private Catholic university undertook an innovative bachelor of science in nursing curriculum revision based in large part on the competencies described by the Quality and Safety Education for Nurses (QSEN) initiative. Part of the curriculum revision involved an innovative model of clinical education. The model emphasized integration and application of concepts across multiple didactic courses and envisioned the student as an active member of the health care team. Instead of exposing students to numerous clinical placements, the goal was to increase student exposure to one site to appreciate system issues and effectively work with a stable health care team. Implementation of this model required a strong academic/ clinical partnership between Lourdes University and a large integrated regional health care system, ProMedica. Supported by a program grant from the Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services Nurse Education Practice, Quality and Retention, the practice-based role of the clinical integration partner (CIP) was developed to implement the new clinical education model. This article describes the academic/clinical partnership and the role of the CIP in implementing a QSEN-based clinical education model. (Index words: Academic/clinical partnerships; QSEN; Clinical education) J Prof Nurs 29:88 94, Elsevier Inc. All rights reserved. THE NEED FOR radical changes in nursing education began with the two landmark publications from the Institute of Medicine (IOM, 2000, 2001) and has been reinforced by the Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett et al., 2007) and the Carnegie Foundation report (Benner, Sutphen, Leonard, & Day, 2010). The IOM and QSEN initiatives called for a focus on competencies in nursing graduates to improve Dean, Lourdes University College of Nursing, Sylvania, OH. Chair Undergraduate Nursing Studies, Lourdes University, Sylvania, OH. Clinical Integration Partner, ProMedica Center of Nursing Excellence, Toledo, OH. Assistant Professor, Lourdes University College of Nursing, Sylvania, OH. Address correspondence to Dr. Didion: PhD, RN, Dean, Lourdes University College of Nursing, 6832 Convent Blvd., Sylvania, OH jdidion@lourdes.edu /12/$ - see front matter patient safety and reduce the number of health care errors that occur daily in today's health care system resulting in unnecessary death, suffering, and expense. The Carnegie Foundation work highlighted the fact that too great a gap exists between what nurses learn in school and what is needed in practice. While nursing knowledge is becoming increasingly complex, it needs to be focused in ways that are relevant so that the transition from graduate to competent practitioners occurs quickly. Two major challenges have been laid before nursing educators: educate practitioners who will not only perform safe care but will also create safe systems, and do it in a way that minimizes the gap between education and practice. The strategy employed to embrace both challenges was a strong academic/clinical partnership for clinical education. This article will describe the development and implementation of the academic/clinical partnership essential to the implementation of a baccalaureate QSEN-based integrated clinical education model Journal of Professional Nursing, Vol 29, No. 2 (March/April), 2013: pp Elsevier Inc. All rights reserved.

2 ACADEMIC/CLINICAL PARTNERSHIP AND COLLABORATION 89 Curriculum Re-envisioned Similar to many nursing schools striving to respond to the modern health care climate, a major bachelor of science in nursing (BSN) curriculum revision at Lourdes University began in The new curriculum represented a radical change for the program resulting in a new approach to student learning. Instead of a nursing theorist, the conceptual framework was based on the QSEN competencies as well as the core values of leadership, community, diversity, and value-based care that underpin the university's Catholic Franciscan heritage. After years of adding content to courses, a concept-based approach was adopted. One of the biggest changes that occurred, however, was in the conceptualization of clinical education. Clinical Education Re-envisioned Although major shifts were made in the conceptual framework and didactic approach, just as many were made conceptualizing the clinical experience. Instead of attending a clinical for each didactic course, the students are now enrolled in an integrated clinical designed to allow them to apply theory concepts holistically. Each semester, a student registers for up to three didactic courses and one integrated clinical. In addition, the clinical experiences are designed to be more stable than in the old curriculum. Rather than sending students to multiple clinical sites over the course of the semester, they remain on one clinical site for an entire 15-week term. In the early semesters in the curriculum, clinical sites are population focused and community based and occur at senior centers, schools, housing projects, or homeless shelters. Once the students begin experiences in an acute care setting, the goal is to have them remain on the same care units for two consecutive semesters, which is equivalent to 30 weeks. This required a strong partnership with the clinical agencies in the community. The benefits to the students of this type of clinical structure relate directly to all six QSEN concepts. The early community setting helps provide learning experiences to reinforce concepts of safety, patient-centered care, and evidence-based practice. Having 15 weeks of continual experience with a population allows the students the opportunity to observe and evaluate settings over time while they learn aspects of environmental safety. Planning interventions with the housing project residents, school-age children, or senior center participants provides nursing students an initiation into patientcentered care based on community client priorities. Scientific evidence provides the basis for the planned interventions, which are geared to the students' novice skill level. Acute care clinical is conceptualized to maximize student exposure in one clinical setting. In Semester 3 of the five-semester curriculum, the student begins his or her tertiary care experience on a specific adult medical surgical unit. He or she visits that unit every other week for a full semester (alternate weeks are spent on the specialty units of labor and delivery and pediatrics). In Semester 4, the student returns to the same unit 2 days a week. These longitudinal relationships are envisioned for the student to foster the ability to develop effective working relationships with site personnel; enhance interdisciplinary communication; integrate experiences over time within a specific health care system; experience outcomes of care on both an individual patient and systems levels; have access to data so as to impact quality improvement and safety initiatives within a complex health care system; minimize time lost to orientation; and finally reduce confusion caused by learning different equipment such as medication administration and the electronic health record systems. All six of the QSEN concepts are addressed, but interdisciplinary collaboration, quality improvement, and informatics are emphasized in this working environment. Everything about the new conceptualization of clinical is different. Population-focused care, previously taught near the end of the nursing curriculum, was moved to the beginning of the curriculum to build a foundation for community care and systems thinking. Students are socialized early to question system factors to enhance patient safety and improve quality of care. The soft skills of communication and critical thinking are emphasized over early initiation of psychomotor skills. Not only did faculty need to adapt, but existing clinical sites could not be used in existing ways. Staff at all clinical sites needed to be prepared not only to provide the type of environment necessary to foster learning quality and safety but also to receive the kind of student that would be prepared under this new curriculum model. With clinical education being re-envisioned, a new conceptualization of clinical partnerships was also needed. Conceptualizing the Academic/ Clinical Partnership To implement this new curriculum, the faculty realized that they needed health care facilities for clinical education that matched the philosophical underpinnings of the QSEN-based curriculum. The success of the implementation revolved around consistent communication with the clinical education sites about the new curriculum model, strong relationships with practice partners that embraced a common goal for quality and safety, and a mutual recognition that student learners are part of the health care team. These presented particular challenges because the university is not affiliated with an academic health science center. Fortunately, the university understood the challenges of acquiring resources and values relationship building in the community. It has created a legacy for partnering, resulting in a number of collaborations with local health care agencies for grant-writing initiatives, nursing scholarship, and education articulations. This history has enhanced opportunities for clinical placement negotiations and opened doors for new project development. Ongoing communication between local health care agencies and the college of nursing are sustained through

3 90 DIDION ET AL numerous avenues. The agencies are represented on the university board of directors. Nurse faculty members, chairs, directors, and the dean are involved with these agencies' boards, professional nursing organizations, and research councils. These relationships have positioned the college of nursing for new innovative partnerships for ongoing program development, and, most recently, the implementation of the groundbreaking BSN curriculum. With this understanding, the faculty and administration began to strategize ways to disseminate information to regional health care systems about the innovative vision for educating nurses and, at the same time, strengthen existing relationships with practice partners. Negotiating the Partnership In early 2011, Lourdes University approached a large integrated health care system, ProMedica, to become a partner in a grant proposal that would support an academic/clinical partnership. This partnership would facilitate the education of both BSN students and practicing registered nurses about quality and safety improvement in health care delivery settings. The negotiations for this proposal began with informal discussions between the Chair and faculty of the BSN program and the clinical managers, as well as formally between the Dean and the Vice President for the integrated health care system's Center for Nursing Excellence. In the summer of 2011, the college of nursing was awarded a Nursing Education Practice, Quality, and Retention grant (NEPQR) from the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS). The Innovative Role of Clinical Integration Partner When the academic/clinical partnership model was conceptualized and written into the NEPQR grant, it was determined that there was a strong need to have a clinical liaison between the university and the clinical partner. This liaison would assess the current clinical education model and determine the educational needs of the registered nurses who currently work with nursing students and their faculty in the acute care setting. As a result, a doctor of philosophy-prepared nurse with strong communication, assessment, and research skills was hired as the clinical integration partner (CIP) to facilitate the integration of the new clinical education model into the practice setting. The CIP has worked for the partnering health system for 9 years in a leadership and an educational role. As director of education for the community hospital, ProMedica Flower Hospital, and as an educator in nursing professional development for the tertiary hospital, ProMedica Toledo Hospital, the CIP had a previous relationship with the nursing staff on the educational resource units. The CIP is a full-time employee working for the health system's Center of Nursing Excellence, and the salary is paid through the NEPQR grant. Currently, there is no joint appointment with the college of nursing. The role of the CIP is outlined in Figure 1. The college needed to secure clinical sites, known as educational resource units, which could provide student placement for two consecutive semesters. These clinical sites would also need to accommodate students 2 days a week. These were heavy demands for an integrated health system that serves multiple schools of nursing. The role of the CIP was developed to be the liaison between both parties in the partnership. Educational Resource Unit Not Dedicated Education Units It was decided not to refer to the units as dedicated education units (DEU) for the units that were targeted to become the new home for the students. This decision was made based on the role definitions of the staff nurse and clinical instructor and the purpose of a DEU. Moscato, Miller, Logsdon, Weinberg, and Chorpenning (2007) report their experience with the staff nurses on the DEU, serving as the instructors for the students. The university faculty's role is to support the clinical teaching, facilitate transfer classroom learning and assure the students' achievement of expected learning outcomes (Moscato et al., 2007, p. 31). In the Lourdes academic/clinical partnership, the educational resource units are units looking to create a relationship between nursing staff and nursing students, with the clinical instructor maintaining their role as instructor. The nursing staff is the clinical expert, and the clinical instructor has the relationship with the college of nursing. Unlike the DEU model, this design is not looking to be a solution to the faculty workload issues (Rains Warner & Burton, 2009). The purpose of the educational resource units is twofold, first to support the education of the student nurses in the QSEN competencies and secondly to cultivate nursing mentors for the hospital. Once the educational resource units were identified, the CIP needed to communicate the vision of the new curriculum to frontline staff and unit managers who would be working with the students. This involved not only explaining the curriculum but also providing staff development on the quality and safety initiative and competencies. The CIP became the coordinator between education and practice, relating to each party the needs and available resources of the other. The CIP became the tangible bridge between an academic vision and the practical application of the QSEN clinical model. Teamwork and Collaboration The academic/clinical partners were equally concerned about having members of the health care team possess the necessary skills and the critical clinical judgment essential to meet the new quality, safety, and patient satisfaction initiatives required for accreditation and federal reimbursement. This began the evolution of the clinical model for education in the hospital environment. With the development of the academic/clinical partnership and the creation of the CIP, the priority shifted to

4 ACADEMIC/CLINICAL PARTNERSHIP AND COLLABORATION 91 Education of clinical staff on QSEN competencies and their role with student nurses in the clinical setting. Creating inter-disciplinary experiences for the students Clinical support for new clinical adjuncts by rounding during clinical experience Facilitating placement of students on designated educational resource units Coordinator of continuing education for clinical staff Needs assessment of clinical staff with a focus on working with students Integration of students into the unit culture and behavior in acute care Evaluation of nurse quality indicators on educational resource units Figure 1. Clinical integration partner's responsibilities. facilitate the clinical placement and staff development activities between the college of nursing and the integrated health system, as well as to conduct continuing education for staff nurses, with a focus on the QSEN competencies. The CIP, who has extensive knowledge of the hospital setting as well as clinical education of students, worked closely with the nursing faculty to integrate the new clinical learning outcomes into the placement experience for the nursing students. Pre Implementation Clinical Education Analysis Since the CIP is a new role for both facilities, the first responsibility was to carry out an educational needs assessment and identify current behavior patterns of the staff, clinical instructors, and student nurses before the new curriculum model was introduced into the clinical setting. Interviews were conducted with nursing leadership, clinical instructors, and nursing staff on the educational resource units. The focus of the interviews was to clarify their current understanding of their roles with students and to determine if they were aware of the QSEN competencies. The CIP also shadowed different clinical groups in two hospitals to document interaction behavior between students and nursing staff under the traditional practice model. The goal was to identify the behaviors that supported QSEN clinical education and what behaviors might need to be modified. The analysis identified a gap between clinical instructors, students, and the nursing staff and the role that the nursing staff has with students in their unit. In the traditional education model, the patient is assigned to a staff nurse who continues to watch over the patient care provided by the student. The staff nurse intervenes when the patient care needs exceed the student's ability. He or she plans the off-unit care or procedures and rounds with the physicians. They perceive their role with the students to be answering questions, giving instructions when asked, and finishing what is not done by the students when they leave the unit. They do not see themselves as providers of education for students. The staff understands the student's role as the provider of activities of daily living, assessment, medication, and documentation under the guidance of the clinical instructor. The patient is in the center of the activity, but the staff and students are working in parallel worlds. Interaction between the student and the nurse is limited, and staff is not engaged with learning objectives of students or goals of the day. Teamwork and collaboration, a QSEN competency, quickly were identified as necessary components for successful implementation of this new relationship, as well as the new curriculum. Decisions were made for open and constant communication among the CIP and nursing faculty through bimonthly meetings. The CIP worked with clinical faculty to create learning experiences, plan education of the clinical instructors, and discuss potential problems that might occur. Successful implementation of the clinical model with staff, students, and clinical instructors could only be achieved through direct involvement of the CIP at every step of the process. Like most nursing programs in the region, the college of nursing relies on temporary or adjunct clinical instructors to teach in the nursing program. Although many of the adjunct clinical instructors return to teach for a number of years, their commitment can only be guaranteed for one semester at a time. Furthermore, adjunct clinical instructors have not received the in depth education about QSEN that ranked faculty received during the new curriculum development. As a result of this initiative, prior to the start of the academic year, and in preparation for teaching in the QSEN curriculum, adjunct clinical instructors attended a mandatory 6-hour orientation. A variety of topics was covered and are listed in Figure 2. To ensure attendance, the NEPQR grant supplemented a stipend for the adjunct clinical instructors to attend the orientation process. This resource was an important incentive to successfully launch this new clinical model.

5 92 DIDION ET AL History and background of QSEN Integration of QSEN into the BSN curriculum and clinical education The future of nursing education: An introduction to concept-based teaching Academic/clinical partnership model and the role of the CIP Clinical activities and strategies to enhance QSEN in the clinical setting Figure 2. Adjunct faculty orientation to the academic/clinical partnership and QSEN. One of the assumptions held by the nursing faculty was that the clinical instructors and nursing staff would prefer the new clinical model. Clinical instructors would spend less time orienting students to the clinical facility and unit and would have an opportunity to engage more fully with their students. This assumption is still being examined. However, the immediate response at the adjunct faculty orientation session to the new curriculum was positive and even resulted in some of the adjunct clinical instructors requesting particular days off from their clinical employers for the subsequent semesters to ensure they would be able to maintain their relationships with their particular clinical group. Clinical Setting Characteristics There are two hospitals participating in this project. The student nurses were assigned to the intermediate units and will return to the same units for two semesters in a row. This pattern is part of the new clinical design. Its purpose is to encourage a relationship between the staff nurses and the students and create an atmosphere that helps the students integrate into the nursing care team. The hospital's nursing model of care is a combination of total patient care and team nursing (Kalisch & Schoville, 2012). The nursing team is composed of registered nurses, nursing assistants, and a unit secretary. Each unit has a shift team supervisor that might also have a patient assignment. Staffing ratios for the intermediate units are four to five patients to one registered nurse, and there are two nursing assistants per unit. The medical surgical units at the community hospital staffing ratios are six to seven patients per registered nurse. Implementing the Clinical Education Model on the Practice Units The CIP is responsible for the development of those involved in the clinical practice area as well as the coordination between clinical faculty, students, and the clinicians on the units. The role includes mentoring staff as they grow more comfortable working with students, creating educational opportunities to enhance clinical judgment questions for students, and supporting clinical instructors with the changes in clinical experience design. This role monitors these social processes to identify strategies to promote students and staff interaction for the purpose of providing a positive learning environment and safe care systems. Communication issues in the traditional clinical experience that were observed by the CIP prior to implementation of this model were issues with handoff communication between student and nursing staff. Students were focused only on their assigned patients with limited awareness of any other patients in the unit, and students could not tell whether the unit was busy. Students were either uncomfortable with entering an unassigned patient's room or did not feel that they were permitted to do some activities such answering call lights or delivering meal trays. Students needed to be more fully integrated into the role of team member on the unit. Some of the strategies used to integrate the students into a role on the health care team are listed in Figure 3. Nursing Staff Education Planning workplace and annual conferences on QSEN topics with the college of nursing is also part of the role of the CIP. Conference room chats to inform the nursing staff of the QSEN clinical education model became the initial focus for clinicians. This design met the needs of the unit's requirement to stay within budget. This gave the CIP an opportunity to ask and answer questions on a one-to-one basis with the staff working in the educational resource unit. It also gave staff a name and face to connect to if there were problems. Weekly rounding by the CIP on the educational resource units during the time the students are present also allows for positive interaction and encouragement for integration behavior. These interactions built relationships and communication between the staff nurse, students, and faculty, allowing for the growth in team-based care, which served the learner and the patient. Conclusions Clinical partnerships are essential to effectively immerse BSN students into system change and quality improvement opportunities. They promote an understanding for quality improvement, teamwork, just culture and critical systems thinking for the BSN student. The traditional clinical education model where students exist in a parallel world with their clinical instructor has not facilitated student involvement in interprofessional team planning, system change processes, and quality

6 ACADEMIC/CLINICAL PARTNERSHIP AND COLLABORATION 93 Student cohorts created a poster board with their pictures to introduce themselves to the nursing staff RN shadowing experiences to learn their behavior and to identify possible mentors Utilizing a safety huddle to make the staff nurses aware of the clinical objectives for the day. Observe and participate in staff hand-off and unit safety huddles at the beginning of each clinical experience Interviewing different team members using interview guides for team role identification. Delaying direct patient care until students understand the unit behavior and patient population. Performing focused assessments on 2 to 4 patients per clinical experience. Participating in multiple lab experiences in baseline skills such as vital signs, morning care, and ambulation prior to advancing to patient responsibility. Participating in hourly rounding on all patients, a hospital safety initiative, supervised initially by the RN and overtime the students report rounding observations and patient needs to the RN Following patients for procedures such as the cardiac and endoscopy lab over multiple weeks to observe procedures, and learn interdisciplinary teamwork. While studying oxygenation as a concept, students round with respiratory therapy and assess the patients before and after treatments. Participating in unit based education programs alongside the staff nurses. Figure 3. Student integration strategies. improvement. Developing an innovative clinical education environment where the student learner is viewed as part of the health care team requires consistent communication between the bedside care providers and colleges of nursing about student learning objectives and expectations. The role of the CIP in a clinical/academic partnership provides an innovative means to enhance the level of trust and communication between academics and practice. This role provides a venue for students to become involved with the nurses in the clinical setting and to become part of the health care team. The CIP provides the educational resources to nursing staff, coordination for faculty, and support for students to promote a common vision for quality and safety in the clinical setting. This solidarity of purpose in the academic/clinical partnership improves nursing education and strengthens the overall nursing workforce. Acknowledgments We would like to acknowledge Kathy Perzynski, MSN, RN. Her commitment to excellence in nursing education truly inspired the formation of this education/practice model and the resources to support the implementation. This project is supported by funds from the DN, BHPr, HRSA, DHHS under award number 1 D11HP , Nurse Education Practice, Quality and Retention. The information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any official endorsement be inferred by, the DN, BHPr, HRSA, DHHS, or the U.S. Government. References Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). A call for radical transformation. Educating Nurses: Jossey- Bass.

7 94 DIDION ET AL Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., & Mitchell, P. (2007). Quality and Safety Education for Nurses. Nursing Outlook, 55, Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (2000). To err is human: Building a safer health care system. Washington, DC: National Academies Press. Kalisch, B., & Schoville, R. (2012). It takes a team. American Journal of Nursing, 11, Moscato, S. R., Miller, J., Logsdon, K., Weinberg, S., & Chorpenning, L. (2007). Dedicated education unit: An innovative clinical partner education model. Nursing Outlook, 55, Rains Warner, J., & Burton, D. (2009). The policy and politics of emerging academic service partnerships. Journal of Professional Nursing, 25,