The evaluation of a successful collabora
Nurse Education in Practice 10 (2010) 17–21
Contents lists available at ScienceDirect
Nurse Education in Practice
journal homepage: www.elsevier.com/nepr
The evaluation of a successful collaborative education model to expand
student clinical placements
Tony Barnett a,*, Merylin Cross a, Lina Shahwan-Akl b, Elisabeth Jacob a
a
b
School of Nursing and Midwifery, Monash University, Switchback Rd., Victoria, Australia 3842, Australia
Division of Nursing and Midwifery, RMIT University, Melbourne, Victoria, Australia 3000, Australia
a r t i c l e
i n f o
Article history:
Accepted 25 January 2009
Keywords:
Clinical education
Collaboration
Preceptorship
Student nurses
s u m m a r y
Worldwide, universities have been encouraged to increase the number of students enrolled in nursing
courses as a way to bolster the domestic supply of graduates and address workforce shortages. This
places pressure on clinical agencies to accommodate greater numbers of students for clinical experience
who, in Australia, may often come from different educational institutions. The aim of this study was to
develop and evaluate a collaborative model of clinical education that would increase the capacity of a
health care agency to accommodate student placements and improve workplace readiness. The project
was undertaken in a medium sized regional hospital in rural Australia where most nurses worked part
time.
Through an iterative process, a new supported preceptorship model was developed by academics from
three institutions and staff from the hospital. Focus group discussions and interviews were conducted
with key stakeholders and clinical placement data analysed for the years 2004 (baseline) to 2007. The
model was associated with a 58% increase in the number of students and a 45% increase in the number
of student placement weeks over the four year period. Students reported positively on their experience
and key stakeholders believed that the new model would better prepare students for the realities of nursing work.
Ó 2009 Elsevier Ltd. All rights reserved.
Introduction
The shortage of nurses in Australia and globally has been well
documented (AHWAC, 2004; Buchan, 2005). Responses to this
shortage have included; aggressive recruitment of nurses from
other countries (Nelson, 2004; Ross et al., 2005), implementation
of more effective workforce recruitment and retention strategies
(VanOyen Force, 2005), introduction of new types or categories
of health care worker, plus other changes to workforce composition and skill mix (Duckett, 2004). Commentators have also suggested that the health care professions should critically examine
the boundaries that restrict practices and constrain health care
innovation and reform, and focus on developing a more flexible
health care workforce (Malhotra, 2006).
A key strategy to build the nursing workforce is to increase
domestic supply by: encouraging higher levels of participation
from the existing workforce (i.e. reduce casualisation) and the reentry of those who have left; reducing workforce separation rates;
and increasing graduate numbers. Given that the ageing of the
* Corresponding author. Tel.: +61 3 99026636; fax: +61 3 99026527.
E-mail addresses: tony.barnett@med.monash.edu.au (T. Barnett), merylin.cross@med.monash.edu.au (M. Cross), lina.shahwan-akl@rmit.edu.au (L. Shahwan-Akl), Beth.Jacob@med.monash.edu.au (E. Jacob).
1471-5953/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nepr.2009.01.018
nursing profession mitigates against many of these (Camerino
et al., 2006) the single most effective and sustainable solution is
to bolster the domestic supply of new graduates by increasing
the number of students enrolled in nursing courses (Daly et al.,
in press).
An important component of nursing courses is that students
undertake supervised and appropriately guided practice in a variety of clinical settings (Murray et al., 2005). Whilst the amount
of clinical is not uniformly mandated in Australia, all curricula
leading to registration include a clinical component that typically
increases as a student progresses through each year of the course.
Any increase in student numbers will therefore impact on health
care agencies, especially hospitals where much of this experience
is gained. The ability of a clinical agency (‘‘hospital”) to accommodate student nurses for clinical placement is a function of a number
of factors including: bed capacity; occupancy; patient throughput;
staffing profile, skill mix and workload; organisational culture and
receptivity to students (Kilcullen, 2007). Cognisant of the burden
students can place on staff, (Cowin and Jacobsson, 2003) further
pressure to increase student numbers may make hospitals more
reluctant to accept students for placement.
In order to graduate more nurses without contracting the time
they spend in clinical settings as part of their education, new ways
must be found to support clinical education without compromising
18
T. Barnett et al. / Nurse Education in Practice 10 (2010) 17–21
the standard of care provided by the hospital or the learning experience of the student (Hall, 2006). Clinical education can be provided through a number of mechanisms, though confusion exists
over the nomenclature used to describe the person who provides
this service (Cope et al., 2000; Hayes, 2005; Mills et al., 2005). In
Australia, the term ‘‘preceptor” rather than ‘‘mentor”, is commonly
used to describe a nurse who provides direct patient care and
works one-to-one with a student during their placement.
This paper reports on a project in which more students were
able to be placed for clinical experience in a hospital. The project
involved collaboration between a rural hospital, two universities
and an institute of Technical and Further Education (TAFE). The
aim of the project was to develop, implement and evaluate a collaborative model of clinical education that would increase the
capacity of a hospital to accommodate student placements and improve students’ workplace readiness.
The problem of providing suitable clinical experience for students is not unique to this setting (Hall, 2006). This model could
therefore be used by others to help increase the domestic supply
of graduates and reduce reliance on other sources such as inmigration.
Background and setting
The setting for this study was a health service located in rural
Victoria, Australia. Over the study period (2004/2007), the hospital
offered a range of clinical services and had 83 acute in-patient and
90 aged care beds. In 2007, this agency employed around 300 registered nurses. The majority (70%) of nurses were aged forty or over
and 87% worked part time, a profile similar to the broader nursing
workforce in rural Australia (AHWAC, 2004). Largely because of its
rural location, this organisation had difficulties attracting and
retaining nursing staff. It was keen to support more students for
clinical placement with a view to recruiting some of them as
new graduates (Courtney et al., 2002).
As with other public hospitals in the state, it did not have an
exclusive student clinical placement arrangement with any one
university. It received requests from a number of education providers who competed to place students for periods of clinical experience that ranged from a single day to six continuous weeks.
Requests for clinical places were often for the same weeks of the
year and as a consequence, the hospital experienced significant
peaks and troughs in student numbers.
In the past, students placed with the hospital were normally
supervised by a full-time clinical teacher on a 1:8 teacher: student
ratio and allocated either singly or in small groups of 2–4 across a
number of patient care areas (wards). Each education provider had
its own administrative requirements and appointed and funded
their own clinical teacher. Sometimes, the clinical teacher was seconded from the clinical area, though due to staff shortages it had
been difficult for the hospital to release staff for this role. As others
have found, lack of continuity, potential problems with entitlements, different expectations and working conditions, together
with lack of familiarity with various curricula, clinical objectives,
and clinical evaluation tools, made the role stressful, demanding
and relatively unattractive (McKenna and Wellard, 2004).
Methods
A project group was formed that included senior staff from the
hospital and representatives from the three major education providers that placed students at the hospital. A participatory action
approach was adopted (Street, 2004) that involved regular face to
face and video-conference meetings and workshops which allowed
the group to identify and explore solutions to barriers that limited
placement capacity (DHS, 2007). Through an iterative process and
informed by a critical review of relevant literature (vide: Clare
et al., 2003), a new model of clinical education was developed that
addressed many of the problems identified. The model became the
intervention for this study and had eight key attributes (Table 1).
Leadership and commitment to collaboration from all key stakeholders
The literature emphasises strong leadership, vision and a genuine commitment to work together as important to successful collaboration (Griffiths and Crookes, 2006). With encouragement
and support for the project from senior levels of participating
organisations, a platform of shared governance (Moore and Hutchison, 2007) enabled stakeholders to freely discuss and respond to
issues related to clinical education.
Philosophy of learning community and facilitation of Inter Professional
Education (IPE) opportunities
The project team recognised that students, as adults, learn practical knowledge in different ways and from a wide variety of people in addition to their clinical teacher or preceptor (Hall, 2006).
The clinical environment was therefore conceptualised as a learning community which comprised all staff who had some contact
with students (Billett, 2004). In this way, it was planned that clinicians would be engaged, empowered and recognised as an integral
part of the educative process. To help promote positive inter professional relationships, a factor associated with job satisfaction
and workforce retention, (VanOyen Force, 2005) the project team
also planned expanded opportunities for students to participate
in on-site education sessions taught by other disciplines (IPE).
A common supported and rewarded preceptorship program
Preceptorship has been widely used in nurse education though
burnout is a common problem (Watson, 2000). Our goal was to ensure clinical nurses who volunteered to act as preceptors were formally prepared and also supported in their teaching role
(Magnusson et al., 2006). Each preceptor attended a workshop in
which the background to the project was presented and topics
such as: clinical education, the undergraduate curricula, problem-solving, providing feedback and evaluating students were addressed. A resource manual was developed for preceptors that
included literature on clinical education, student learning activities
and conflict resolution as well as a range of documentation associated with student placements. Regular peer support meetings were
scheduled for preceptors to de-brief and for their ongoing development. An overarching clinical facilitator position to support and
develop preceptors was established at the hospital. Preceptors
Table 1
Key attributes and implementation of the model.
Attribute
Year
implemented
Leadership and commitment to collaboration from all key
stakeholders
Philosophy of learning community and facilitation of IPE
opportunities
A common, supported and rewarded preceptorship program
Dedicated clinical facilitator
Greater use of different shifts and weekends for placements
Shared clinical calendar and expanded number of placement
weeks
Common clinical objectives, skills set and student evaluation
tool
Regular face-to-face communication between key stakeholders
2005
2006
2007
2007
2007
2005
2007
2005
T. Barnett et al. / Nurse Education in Practice 10 (2010) 17–21
were awarded certificates of recognition, CNE points, opportunities
provided for honorary appointment to an education provider and
credit toward formal post graduate studies. The resource efficiencies generated by this model enabled some discretionary funds
to be allocated to the clinical areas from which preceptors were
drawn and students placed.
The project team estimated that around 40 preceptors would be
needed. It was expected that these preceptors would maintain
their patient case load though work closely with and be a role
model for a student for the duration of their clinical placement
block (from 1 to 4 weeks). The student would work the same shifts
(including week ends) as the preceptor, thus be exposed to a range
of experiences associated with nursing work.
Dedicated clinical facilitator
To provide continuity and consistency, a ‘clinical facilitator’ was
appointed to manage the placement program and, as recommended by Watson (2000), to support ‘‘mentors”. The role included: supporting both preceptors and students, conducting
preceptor training workshops and meetings, teaching and problem-solving, assisting with student evaluations, organising rosters,
facilitating student orientation and debriefs, rotating preceptors to
prevent burnout, liaising with educators from the hospital and academics from the education providers, and participating in research.
A critical component of the role was to work with unit managers
and engage other staff as part of the wider learning community.
Funding for the position was apportioned across education providers on the basis of student placement weeks.
Greater use of different shifts and weekends for placements
The project team was concerned to build clinical capacity in a
way that exposed students to the realities of working life (Magnusson et al., 2006). The model allowed students to be placed with a
preceptor across different shifts and at weekends, thereby spreading the student load over a greater period of time and in a larger
number of patient care areas (wards). This reduced the saturation
effect on patient care areas and increased opportunities for students to practice skills. The clinical facilitator was either present
or on-call whenever students were at the hospital and both students and preceptors had access to the hospital educators and university staff as needed.
Shared clinical calendar and expanded number of placement weeks
A working group was formed to re-configure the student clinical placement timetables from each education provider. The group
addressed areas of overlap, competition for placements, fragmentation and obvious peaks and troughs. Regular communication between stakeholders provided an opportunity to examine, negotiate
and make adjustments to increase the total number of weeks in the
year that the hospital was able to accept students.
Common clinical objectives, skills set and student evaluation tool
Differences in curricula, clinical objectives, skill sets and student evaluation tools from the various education providers can
cause confusion and create an additional burden on clinical staff
and preceptors (Watson, 2000). The project team was committed
to reducing the supervisory impost, simplifying the administrative
workload and where possible eliminating ambiguity and difference. Whilst some clinical objectives were unique to a course, similarities in clinical skills sets allowed the project team to
consolidate these by year level for all students. Analysis of the
range of clinical evaluation tools used by each educational provider
19
also identified many similarities as they were all based on national
competency standards (http://www.anmc.org.au/). This feature allowed the project team to develop a simplified evaluation tool
based on common skills sets and competencies.
Regular face-to-face communication between all key stakeholders
Communication, much of it face-to-face, inclusion and participation were critical to: achieving a genuinely collaborative outcome, preparing preceptors for their role, resolving difficulties as
they arose and providing support to all participants (Clare et al.,
2003; Woods and Craig, 2005). Regular face-to-face meetings (up
to 10 per year) were scheduled for the project group and augmented by video and teleconferencing to bridge the geographic
distances between stakeholders.
Procedures
Components of the model were phased in from 2005 and all elements fully implemented during 2007 (Table 1). It was evaluated
by the assessment of student placement metrics and feedback
obtained from a survey (n = 79), focus group discussions (9 groups)
and interviews (n = 5). Feedback was obtained from preceptors,
students, education and management staff of the hospital during
2007. All discussions followed a semi-structured format
(Table 2); were taped, transcribed and subjected to thematic and
content analysis then verified with participants.
Students and preceptors were surveyed at the completion of a
clinical placement block. The 26 items contained in the survey
sought information about the: (a) adequacy of preparation for clinical, (b) learning environment and learning community, (c) value of
shifts and weekends (d) ways to improve learning outcomes and
(e) perceptions of work readiness. The information generated
was presented to participants for discussion and recommendations
incorporated for subsequent placements.
Student placement data for the years 2004 (baseline) to 2007
was collected to assess the impact on student placement metrics.
The information gathered included: the total number of students
placed at the hospital, the total number of weeks used for student
placements, and the total number of student placement weeks.
Student placement weeks represented the total number of weeks
students had spent at the hospital. For example; three students,
each placed for two weeks represented six student placement
weeks (2 + 2 + 2 = 6).
Approval for the evaluative components of the project was obtained from the relevant institutional human ethics committee and
from each participating institution.
Table 2
Preceptor focus group and interview questions.
Questiona
Could you tell me how you felt the new clinical placement project has been
going?
What was different about these placements compared to other placements you
may have been associated with?
Could you tell me:
What worked?
What didn’t work so well?
How the placement could have been improved?
Whether you would recommend the preceptorship role to your friends or
colleagues?
Do you think this model of clinical education provided students with a better
idea of the reality of nursing work?
a
Modified slightly for students and management staff interviews and
discussions.
20
T. Barnett et al. / Nurse Education in Practice 10 (2010) 17–21
Results and discussion
Implementation of the model was associated with a major increase in the hospital’s capacity to accommodate student placements. Feedback received from key stakeholder groups was
predominantly positive and students generally reported favourably on the quality of their learning experience.
Following a call to clinical nurses interested in participating as
a preceptor with this new model, two preparatory one day workshops were held to orientate preceptors to their new role. Of the
39 RNs who attended the workshops, 36 went on to preceptor
students. In 2007, a total of 75 preceptors were needed, close
to double that predicted. This was almost singularly due to the
staffing profile of this agency; a very high proportion of parttime staff employed at a low fraction. The mismatch flags the
need for more sophisticated planning when dealing with the contemporary reality of a large part-time or casual workforce.
Students valued access to and working one-on-one with a
preceptor: ‘‘I had the same preceptor so I followed her shifts.
She was amazing; I did not want to leave her” though in reality,
most students had 2–3 preceptors. When this was the case, one
was designated the primary preceptor, the second a ‘‘secondary
preceptor” and the third (and subsequent preceptors), as a
‘‘buddy”. Those who had three or four preceptors also felt the
experience was rich and felt supported, ‘‘Even with different preceptors it was still a rich experience.” Not surprisingly there was
also feedback that too many preceptors compromised the placement experience ‘‘I had seven preceptors, some were helpful,
some were not”.
How students perceive the clinical learning environment and relate to preceptors is known to affect their learning (Mamchur and
Myrick, 2003). A number of students commented on variation in
style, skill and attitudes of preceptors. Some they found helpful
and made them feel welcome, whereas others made them feel as
if they were a burden or nuisance and had unrealistic expectations
of them.
Most preceptors reported that they enjoyed the role though as
noted by Watson (2000), the combination of maintaining a caseload in addition to the preceptor role is demanding. As one RN
wrote:
I don’t believe that there are any negative points with this system, only positive aspects, and so far it has been exhausting for
the preceptors but hopefully we will achieve an enhanced quality of graduates to care for us in our advancing years. We reap
what we sow.
Preceptors appreciated the support received from the clinical
facilitator with this new model, particularly in monitoring their
dual clinical/educative workload and need for respite from the
role.
Have previously acted in the preceptor role; this placement
model was different because the clinical facilitator was available for support and visited the clinical areas regularly to check
up on preceptors and students. This had not been the case with
previous preceptoring experiences where there was no or very
little backup.
Where possible, students worked the same roster as their designated preceptor. Preceptors were almost unanimous that working different shifts increased students’ work readiness. As one
commented: ‘‘was more realistic than the clinical teaching model
for practicum. Students are immersed in the real workplace.” Students also reported on the benefits; ‘‘working shifts teaches us
about workload and time management.” Another explained,
‘‘showed what goes on in each shift. . .different skills in each
shift. . .so was good to get a mix.” Student and preceptor comments
on the value of weekend shifts were mixed. Most favoured the
inclusion of late (pm) and early (am) shifts over the clinical placement period though were concerned that weekend shifts interfered
with students’ need for paid employment.
Students perceived the majority of staff to be approachable and
clinical units pleasant to work in. Their feedback suggested that the
philosophy of learning community was central to a positive learning environment, enriched their clinical experience and contributed to their sense of belonging (Levett-Jones and Lathlean,
2008). Students appreciated learning from and interacting with
other members of the health team and cited other nurses (RNs),
followed by doctors, allied health workers and other students as
important contributors to their clinical learning. They participated
in 11 out of a possible 12 scheduled in-service IPE learning opportunities. These sessions were attended by staff and students from
other health disciplines and included topics such as: basic life support, managing ‘‘difficult” patients, palliative care and wound care
products. A further outcome of this project was that it provided an
opportunity for the agency to collate the in-service learning sessions offered by different departments and advertise these more
widely.
Some rationalisation of students’ clinical objectives was
achieved across education providers. Of greater impact, were the
introduction of a common ‘skills set’ list that allowed preceptors
to quickly identify the intended skill capability of a student by their
year level and a common clinical evaluation tool. Feedback from
preceptors was overwhelmingly positive: ‘‘The standardised evaluation form was a noticeable improvement. Didn’t have to fill in
reams of paper, it was a very practical form to use.”
Collaborations and partnerships can be resource and time consuming (Clare et al., 2003). In this project, some participants had to
travel considerable distances (up to 250 km) to attend face-to-face
meetings. The ability of video and tele-conferencing to replace
these meetings and defray travel costs was, unfortunately, limited
by system incompatibilities and demand from other service users.
The development of a shared clinical calendar increased the
number of weeks in which the hospital could accept students for
placements. In 2004, 33 weeks were utilised to place a total of
130 students. In 2007, 40 weeks were used and 205 students were
able to be placed (Table 3). Student placements were better aligned
and there were fewer (wasted) periods when no students were
placed (Magnusson et al., 2006). With some minor adjustments
to on-campus teaching schedules and the addition of several smaller specialist areas to the placement roster, more students were
able to be accommodated more evenly, whilst ensuring that the
venue was not saturated with students at any one time.
In addition to positive feedback from key stakeholders, the
model was also associated with a major increase in placements.
From 2004 to 2007, the number of students placed at the health
service increased by 58% from 130 to 205 and the number of student placement weeks increased from 275 to 401 (45%). The potential capacity to accommodate students was greater than these
figures indicate as some planned placements did not eventuate.
In 2004, the potential capacity of the hospital was to accommodate
317 student placement weeks and this increased to 455.4 weeks in
Table 3
Student placement metrics.
Variable
2004
2005
2006
2007
Change
2004/7
(%)
Number of weeks used for clinical
placements
Number of students placed
Number of student placement weeks
33
36
39
40
21
130
275
136
261
170
321
205
401
58
45
T. Barnett et al. / Nurse Education in Practice 10 (2010) 17–21
2007. The major reason for this capacity not being achieved was
the cancellation (and non-replacement) of placements. The issue
of cancellations does not feature in the clinical education literature
but in this study, surfaced as a significant issue that can erode
capacity and frustrate stakeholders (DHS, 2007).
Conclusion
In this project, a collaborative model of clinical education was
developed that supported an increase in the capacity of a hospital
to accept students for placement. Feedback suggested that as a
consequence, workplace readiness was likely to be improved. Features of the model included: creation of a learning community, increased IPE opportunities, changes to the clinical timetable,
development of a clinical preceptorship program supported by a
full-time clinical facilitator and development of common; clinical
objectives, skill sets and a clinical evaluation tool.
A limitation to this study was that it was conducted at one hospital with its own particular structure, culture and staffing profile.
A workforce reality however, is that many nurses work part time. A
challenge for the profession is to test models of preceptorship that
can build the capacity of a hospital when there are fewer full time
and more part-time RNs available to act as preceptors. Further
evaluative studies are needed to assess how these changes may affect student learning and how best to reward and support preceptors to ensure the role is valued and job satisfaction is maintained.
The problem of providing sufficient, cost-effective quality clinical experiences for students and supporting their learning without
unnecessary duress or burden on clinical agencies and their staff is
not unique to this setting or to this country. Elements of this model
could therefore be used or adapted by others to help increase the
number of students entering health professional courses. The current shortage of nurses points to the importance of a continued
supply of sufficient numbers of new graduates to sustain the health
care system into the future. An increase in domestic supply of
nurses could reduce reliance on in-migration as the solution to
shortages in the longer term.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors thank the staff and students who participated in
this project and the Department of Human Services (Victoria)
who provided funding for the study.
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Contents lists available at ScienceDirect
Nurse Education in Practice
journal homepage: www.elsevier.com/nepr
The evaluation of a successful collaborative education model to expand
student clinical placements
Tony Barnett a,*, Merylin Cross a, Lina Shahwan-Akl b, Elisabeth Jacob a
a
b
School of Nursing and Midwifery, Monash University, Switchback Rd., Victoria, Australia 3842, Australia
Division of Nursing and Midwifery, RMIT University, Melbourne, Victoria, Australia 3000, Australia
a r t i c l e
i n f o
Article history:
Accepted 25 January 2009
Keywords:
Clinical education
Collaboration
Preceptorship
Student nurses
s u m m a r y
Worldwide, universities have been encouraged to increase the number of students enrolled in nursing
courses as a way to bolster the domestic supply of graduates and address workforce shortages. This
places pressure on clinical agencies to accommodate greater numbers of students for clinical experience
who, in Australia, may often come from different educational institutions. The aim of this study was to
develop and evaluate a collaborative model of clinical education that would increase the capacity of a
health care agency to accommodate student placements and improve workplace readiness. The project
was undertaken in a medium sized regional hospital in rural Australia where most nurses worked part
time.
Through an iterative process, a new supported preceptorship model was developed by academics from
three institutions and staff from the hospital. Focus group discussions and interviews were conducted
with key stakeholders and clinical placement data analysed for the years 2004 (baseline) to 2007. The
model was associated with a 58% increase in the number of students and a 45% increase in the number
of student placement weeks over the four year period. Students reported positively on their experience
and key stakeholders believed that the new model would better prepare students for the realities of nursing work.
Ó 2009 Elsevier Ltd. All rights reserved.
Introduction
The shortage of nurses in Australia and globally has been well
documented (AHWAC, 2004; Buchan, 2005). Responses to this
shortage have included; aggressive recruitment of nurses from
other countries (Nelson, 2004; Ross et al., 2005), implementation
of more effective workforce recruitment and retention strategies
(VanOyen Force, 2005), introduction of new types or categories
of health care worker, plus other changes to workforce composition and skill mix (Duckett, 2004). Commentators have also suggested that the health care professions should critically examine
the boundaries that restrict practices and constrain health care
innovation and reform, and focus on developing a more flexible
health care workforce (Malhotra, 2006).
A key strategy to build the nursing workforce is to increase
domestic supply by: encouraging higher levels of participation
from the existing workforce (i.e. reduce casualisation) and the reentry of those who have left; reducing workforce separation rates;
and increasing graduate numbers. Given that the ageing of the
* Corresponding author. Tel.: +61 3 99026636; fax: +61 3 99026527.
E-mail addresses: tony.barnett@med.monash.edu.au (T. Barnett), merylin.cross@med.monash.edu.au (M. Cross), lina.shahwan-akl@rmit.edu.au (L. Shahwan-Akl), Beth.Jacob@med.monash.edu.au (E. Jacob).
1471-5953/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nepr.2009.01.018
nursing profession mitigates against many of these (Camerino
et al., 2006) the single most effective and sustainable solution is
to bolster the domestic supply of new graduates by increasing
the number of students enrolled in nursing courses (Daly et al.,
in press).
An important component of nursing courses is that students
undertake supervised and appropriately guided practice in a variety of clinical settings (Murray et al., 2005). Whilst the amount
of clinical is not uniformly mandated in Australia, all curricula
leading to registration include a clinical component that typically
increases as a student progresses through each year of the course.
Any increase in student numbers will therefore impact on health
care agencies, especially hospitals where much of this experience
is gained. The ability of a clinical agency (‘‘hospital”) to accommodate student nurses for clinical placement is a function of a number
of factors including: bed capacity; occupancy; patient throughput;
staffing profile, skill mix and workload; organisational culture and
receptivity to students (Kilcullen, 2007). Cognisant of the burden
students can place on staff, (Cowin and Jacobsson, 2003) further
pressure to increase student numbers may make hospitals more
reluctant to accept students for placement.
In order to graduate more nurses without contracting the time
they spend in clinical settings as part of their education, new ways
must be found to support clinical education without compromising
18
T. Barnett et al. / Nurse Education in Practice 10 (2010) 17–21
the standard of care provided by the hospital or the learning experience of the student (Hall, 2006). Clinical education can be provided through a number of mechanisms, though confusion exists
over the nomenclature used to describe the person who provides
this service (Cope et al., 2000; Hayes, 2005; Mills et al., 2005). In
Australia, the term ‘‘preceptor” rather than ‘‘mentor”, is commonly
used to describe a nurse who provides direct patient care and
works one-to-one with a student during their placement.
This paper reports on a project in which more students were
able to be placed for clinical experience in a hospital. The project
involved collaboration between a rural hospital, two universities
and an institute of Technical and Further Education (TAFE). The
aim of the project was to develop, implement and evaluate a collaborative model of clinical education that would increase the
capacity of a hospital to accommodate student placements and improve students’ workplace readiness.
The problem of providing suitable clinical experience for students is not unique to this setting (Hall, 2006). This model could
therefore be used by others to help increase the domestic supply
of graduates and reduce reliance on other sources such as inmigration.
Background and setting
The setting for this study was a health service located in rural
Victoria, Australia. Over the study period (2004/2007), the hospital
offered a range of clinical services and had 83 acute in-patient and
90 aged care beds. In 2007, this agency employed around 300 registered nurses. The majority (70%) of nurses were aged forty or over
and 87% worked part time, a profile similar to the broader nursing
workforce in rural Australia (AHWAC, 2004). Largely because of its
rural location, this organisation had difficulties attracting and
retaining nursing staff. It was keen to support more students for
clinical placement with a view to recruiting some of them as
new graduates (Courtney et al., 2002).
As with other public hospitals in the state, it did not have an
exclusive student clinical placement arrangement with any one
university. It received requests from a number of education providers who competed to place students for periods of clinical experience that ranged from a single day to six continuous weeks.
Requests for clinical places were often for the same weeks of the
year and as a consequence, the hospital experienced significant
peaks and troughs in student numbers.
In the past, students placed with the hospital were normally
supervised by a full-time clinical teacher on a 1:8 teacher: student
ratio and allocated either singly or in small groups of 2–4 across a
number of patient care areas (wards). Each education provider had
its own administrative requirements and appointed and funded
their own clinical teacher. Sometimes, the clinical teacher was seconded from the clinical area, though due to staff shortages it had
been difficult for the hospital to release staff for this role. As others
have found, lack of continuity, potential problems with entitlements, different expectations and working conditions, together
with lack of familiarity with various curricula, clinical objectives,
and clinical evaluation tools, made the role stressful, demanding
and relatively unattractive (McKenna and Wellard, 2004).
Methods
A project group was formed that included senior staff from the
hospital and representatives from the three major education providers that placed students at the hospital. A participatory action
approach was adopted (Street, 2004) that involved regular face to
face and video-conference meetings and workshops which allowed
the group to identify and explore solutions to barriers that limited
placement capacity (DHS, 2007). Through an iterative process and
informed by a critical review of relevant literature (vide: Clare
et al., 2003), a new model of clinical education was developed that
addressed many of the problems identified. The model became the
intervention for this study and had eight key attributes (Table 1).
Leadership and commitment to collaboration from all key stakeholders
The literature emphasises strong leadership, vision and a genuine commitment to work together as important to successful collaboration (Griffiths and Crookes, 2006). With encouragement
and support for the project from senior levels of participating
organisations, a platform of shared governance (Moore and Hutchison, 2007) enabled stakeholders to freely discuss and respond to
issues related to clinical education.
Philosophy of learning community and facilitation of Inter Professional
Education (IPE) opportunities
The project team recognised that students, as adults, learn practical knowledge in different ways and from a wide variety of people in addition to their clinical teacher or preceptor (Hall, 2006).
The clinical environment was therefore conceptualised as a learning community which comprised all staff who had some contact
with students (Billett, 2004). In this way, it was planned that clinicians would be engaged, empowered and recognised as an integral
part of the educative process. To help promote positive inter professional relationships, a factor associated with job satisfaction
and workforce retention, (VanOyen Force, 2005) the project team
also planned expanded opportunities for students to participate
in on-site education sessions taught by other disciplines (IPE).
A common supported and rewarded preceptorship program
Preceptorship has been widely used in nurse education though
burnout is a common problem (Watson, 2000). Our goal was to ensure clinical nurses who volunteered to act as preceptors were formally prepared and also supported in their teaching role
(Magnusson et al., 2006). Each preceptor attended a workshop in
which the background to the project was presented and topics
such as: clinical education, the undergraduate curricula, problem-solving, providing feedback and evaluating students were addressed. A resource manual was developed for preceptors that
included literature on clinical education, student learning activities
and conflict resolution as well as a range of documentation associated with student placements. Regular peer support meetings were
scheduled for preceptors to de-brief and for their ongoing development. An overarching clinical facilitator position to support and
develop preceptors was established at the hospital. Preceptors
Table 1
Key attributes and implementation of the model.
Attribute
Year
implemented
Leadership and commitment to collaboration from all key
stakeholders
Philosophy of learning community and facilitation of IPE
opportunities
A common, supported and rewarded preceptorship program
Dedicated clinical facilitator
Greater use of different shifts and weekends for placements
Shared clinical calendar and expanded number of placement
weeks
Common clinical objectives, skills set and student evaluation
tool
Regular face-to-face communication between key stakeholders
2005
2006
2007
2007
2007
2005
2007
2005
T. Barnett et al. / Nurse Education in Practice 10 (2010) 17–21
were awarded certificates of recognition, CNE points, opportunities
provided for honorary appointment to an education provider and
credit toward formal post graduate studies. The resource efficiencies generated by this model enabled some discretionary funds
to be allocated to the clinical areas from which preceptors were
drawn and students placed.
The project team estimated that around 40 preceptors would be
needed. It was expected that these preceptors would maintain
their patient case load though work closely with and be a role
model for a student for the duration of their clinical placement
block (from 1 to 4 weeks). The student would work the same shifts
(including week ends) as the preceptor, thus be exposed to a range
of experiences associated with nursing work.
Dedicated clinical facilitator
To provide continuity and consistency, a ‘clinical facilitator’ was
appointed to manage the placement program and, as recommended by Watson (2000), to support ‘‘mentors”. The role included: supporting both preceptors and students, conducting
preceptor training workshops and meetings, teaching and problem-solving, assisting with student evaluations, organising rosters,
facilitating student orientation and debriefs, rotating preceptors to
prevent burnout, liaising with educators from the hospital and academics from the education providers, and participating in research.
A critical component of the role was to work with unit managers
and engage other staff as part of the wider learning community.
Funding for the position was apportioned across education providers on the basis of student placement weeks.
Greater use of different shifts and weekends for placements
The project team was concerned to build clinical capacity in a
way that exposed students to the realities of working life (Magnusson et al., 2006). The model allowed students to be placed with a
preceptor across different shifts and at weekends, thereby spreading the student load over a greater period of time and in a larger
number of patient care areas (wards). This reduced the saturation
effect on patient care areas and increased opportunities for students to practice skills. The clinical facilitator was either present
or on-call whenever students were at the hospital and both students and preceptors had access to the hospital educators and university staff as needed.
Shared clinical calendar and expanded number of placement weeks
A working group was formed to re-configure the student clinical placement timetables from each education provider. The group
addressed areas of overlap, competition for placements, fragmentation and obvious peaks and troughs. Regular communication between stakeholders provided an opportunity to examine, negotiate
and make adjustments to increase the total number of weeks in the
year that the hospital was able to accept students.
Common clinical objectives, skills set and student evaluation tool
Differences in curricula, clinical objectives, skill sets and student evaluation tools from the various education providers can
cause confusion and create an additional burden on clinical staff
and preceptors (Watson, 2000). The project team was committed
to reducing the supervisory impost, simplifying the administrative
workload and where possible eliminating ambiguity and difference. Whilst some clinical objectives were unique to a course, similarities in clinical skills sets allowed the project team to
consolidate these by year level for all students. Analysis of the
range of clinical evaluation tools used by each educational provider
19
also identified many similarities as they were all based on national
competency standards (http://www.anmc.org.au/). This feature allowed the project team to develop a simplified evaluation tool
based on common skills sets and competencies.
Regular face-to-face communication between all key stakeholders
Communication, much of it face-to-face, inclusion and participation were critical to: achieving a genuinely collaborative outcome, preparing preceptors for their role, resolving difficulties as
they arose and providing support to all participants (Clare et al.,
2003; Woods and Craig, 2005). Regular face-to-face meetings (up
to 10 per year) were scheduled for the project group and augmented by video and teleconferencing to bridge the geographic
distances between stakeholders.
Procedures
Components of the model were phased in from 2005 and all elements fully implemented during 2007 (Table 1). It was evaluated
by the assessment of student placement metrics and feedback
obtained from a survey (n = 79), focus group discussions (9 groups)
and interviews (n = 5). Feedback was obtained from preceptors,
students, education and management staff of the hospital during
2007. All discussions followed a semi-structured format
(Table 2); were taped, transcribed and subjected to thematic and
content analysis then verified with participants.
Students and preceptors were surveyed at the completion of a
clinical placement block. The 26 items contained in the survey
sought information about the: (a) adequacy of preparation for clinical, (b) learning environment and learning community, (c) value of
shifts and weekends (d) ways to improve learning outcomes and
(e) perceptions of work readiness. The information generated
was presented to participants for discussion and recommendations
incorporated for subsequent placements.
Student placement data for the years 2004 (baseline) to 2007
was collected to assess the impact on student placement metrics.
The information gathered included: the total number of students
placed at the hospital, the total number of weeks used for student
placements, and the total number of student placement weeks.
Student placement weeks represented the total number of weeks
students had spent at the hospital. For example; three students,
each placed for two weeks represented six student placement
weeks (2 + 2 + 2 = 6).
Approval for the evaluative components of the project was obtained from the relevant institutional human ethics committee and
from each participating institution.
Table 2
Preceptor focus group and interview questions.
Questiona
Could you tell me how you felt the new clinical placement project has been
going?
What was different about these placements compared to other placements you
may have been associated with?
Could you tell me:
What worked?
What didn’t work so well?
How the placement could have been improved?
Whether you would recommend the preceptorship role to your friends or
colleagues?
Do you think this model of clinical education provided students with a better
idea of the reality of nursing work?
a
Modified slightly for students and management staff interviews and
discussions.
20
T. Barnett et al. / Nurse Education in Practice 10 (2010) 17–21
Results and discussion
Implementation of the model was associated with a major increase in the hospital’s capacity to accommodate student placements. Feedback received from key stakeholder groups was
predominantly positive and students generally reported favourably on the quality of their learning experience.
Following a call to clinical nurses interested in participating as
a preceptor with this new model, two preparatory one day workshops were held to orientate preceptors to their new role. Of the
39 RNs who attended the workshops, 36 went on to preceptor
students. In 2007, a total of 75 preceptors were needed, close
to double that predicted. This was almost singularly due to the
staffing profile of this agency; a very high proportion of parttime staff employed at a low fraction. The mismatch flags the
need for more sophisticated planning when dealing with the contemporary reality of a large part-time or casual workforce.
Students valued access to and working one-on-one with a
preceptor: ‘‘I had the same preceptor so I followed her shifts.
She was amazing; I did not want to leave her” though in reality,
most students had 2–3 preceptors. When this was the case, one
was designated the primary preceptor, the second a ‘‘secondary
preceptor” and the third (and subsequent preceptors), as a
‘‘buddy”. Those who had three or four preceptors also felt the
experience was rich and felt supported, ‘‘Even with different preceptors it was still a rich experience.” Not surprisingly there was
also feedback that too many preceptors compromised the placement experience ‘‘I had seven preceptors, some were helpful,
some were not”.
How students perceive the clinical learning environment and relate to preceptors is known to affect their learning (Mamchur and
Myrick, 2003). A number of students commented on variation in
style, skill and attitudes of preceptors. Some they found helpful
and made them feel welcome, whereas others made them feel as
if they were a burden or nuisance and had unrealistic expectations
of them.
Most preceptors reported that they enjoyed the role though as
noted by Watson (2000), the combination of maintaining a caseload in addition to the preceptor role is demanding. As one RN
wrote:
I don’t believe that there are any negative points with this system, only positive aspects, and so far it has been exhausting for
the preceptors but hopefully we will achieve an enhanced quality of graduates to care for us in our advancing years. We reap
what we sow.
Preceptors appreciated the support received from the clinical
facilitator with this new model, particularly in monitoring their
dual clinical/educative workload and need for respite from the
role.
Have previously acted in the preceptor role; this placement
model was different because the clinical facilitator was available for support and visited the clinical areas regularly to check
up on preceptors and students. This had not been the case with
previous preceptoring experiences where there was no or very
little backup.
Where possible, students worked the same roster as their designated preceptor. Preceptors were almost unanimous that working different shifts increased students’ work readiness. As one
commented: ‘‘was more realistic than the clinical teaching model
for practicum. Students are immersed in the real workplace.” Students also reported on the benefits; ‘‘working shifts teaches us
about workload and time management.” Another explained,
‘‘showed what goes on in each shift. . .different skills in each
shift. . .so was good to get a mix.” Student and preceptor comments
on the value of weekend shifts were mixed. Most favoured the
inclusion of late (pm) and early (am) shifts over the clinical placement period though were concerned that weekend shifts interfered
with students’ need for paid employment.
Students perceived the majority of staff to be approachable and
clinical units pleasant to work in. Their feedback suggested that the
philosophy of learning community was central to a positive learning environment, enriched their clinical experience and contributed to their sense of belonging (Levett-Jones and Lathlean,
2008). Students appreciated learning from and interacting with
other members of the health team and cited other nurses (RNs),
followed by doctors, allied health workers and other students as
important contributors to their clinical learning. They participated
in 11 out of a possible 12 scheduled in-service IPE learning opportunities. These sessions were attended by staff and students from
other health disciplines and included topics such as: basic life support, managing ‘‘difficult” patients, palliative care and wound care
products. A further outcome of this project was that it provided an
opportunity for the agency to collate the in-service learning sessions offered by different departments and advertise these more
widely.
Some rationalisation of students’ clinical objectives was
achieved across education providers. Of greater impact, were the
introduction of a common ‘skills set’ list that allowed preceptors
to quickly identify the intended skill capability of a student by their
year level and a common clinical evaluation tool. Feedback from
preceptors was overwhelmingly positive: ‘‘The standardised evaluation form was a noticeable improvement. Didn’t have to fill in
reams of paper, it was a very practical form to use.”
Collaborations and partnerships can be resource and time consuming (Clare et al., 2003). In this project, some participants had to
travel considerable distances (up to 250 km) to attend face-to-face
meetings. The ability of video and tele-conferencing to replace
these meetings and defray travel costs was, unfortunately, limited
by system incompatibilities and demand from other service users.
The development of a shared clinical calendar increased the
number of weeks in which the hospital could accept students for
placements. In 2004, 33 weeks were utilised to place a total of
130 students. In 2007, 40 weeks were used and 205 students were
able to be placed (Table 3). Student placements were better aligned
and there were fewer (wasted) periods when no students were
placed (Magnusson et al., 2006). With some minor adjustments
to on-campus teaching schedules and the addition of several smaller specialist areas to the placement roster, more students were
able to be accommodated more evenly, whilst ensuring that the
venue was not saturated with students at any one time.
In addition to positive feedback from key stakeholders, the
model was also associated with a major increase in placements.
From 2004 to 2007, the number of students placed at the health
service increased by 58% from 130 to 205 and the number of student placement weeks increased from 275 to 401 (45%). The potential capacity to accommodate students was greater than these
figures indicate as some planned placements did not eventuate.
In 2004, the potential capacity of the hospital was to accommodate
317 student placement weeks and this increased to 455.4 weeks in
Table 3
Student placement metrics.
Variable
2004
2005
2006
2007
Change
2004/7
(%)
Number of weeks used for clinical
placements
Number of students placed
Number of student placement weeks
33
36
39
40
21
130
275
136
261
170
321
205
401
58
45
T. Barnett et al. / Nurse Education in Practice 10 (2010) 17–21
2007. The major reason for this capacity not being achieved was
the cancellation (and non-replacement) of placements. The issue
of cancellations does not feature in the clinical education literature
but in this study, surfaced as a significant issue that can erode
capacity and frustrate stakeholders (DHS, 2007).
Conclusion
In this project, a collaborative model of clinical education was
developed that supported an increase in the capacity of a hospital
to accept students for placement. Feedback suggested that as a
consequence, workplace readiness was likely to be improved. Features of the model included: creation of a learning community, increased IPE opportunities, changes to the clinical timetable,
development of a clinical preceptorship program supported by a
full-time clinical facilitator and development of common; clinical
objectives, skill sets and a clinical evaluation tool.
A limitation to this study was that it was conducted at one hospital with its own particular structure, culture and staffing profile.
A workforce reality however, is that many nurses work part time. A
challenge for the profession is to test models of preceptorship that
can build the capacity of a hospital when there are fewer full time
and more part-time RNs available to act as preceptors. Further
evaluative studies are needed to assess how these changes may affect student learning and how best to reward and support preceptors to ensure the role is valued and job satisfaction is maintained.
The problem of providing sufficient, cost-effective quality clinical experiences for students and supporting their learning without
unnecessary duress or burden on clinical agencies and their staff is
not unique to this setting or to this country. Elements of this model
could therefore be used or adapted by others to help increase the
number of students entering health professional courses. The current shortage of nurses points to the importance of a continued
supply of sufficient numbers of new graduates to sustain the health
care system into the future. An increase in domestic supply of
nurses could reduce reliance on in-migration as the solution to
shortages in the longer term.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors thank the staff and students who participated in
this project and the Department of Human Services (Victoria)
who provided funding for the study.
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