University of Portland (Oregon), School of Nursing

Dedicated Education Unit: Evaluating Innovation in Clinical Education

Principal Investigator: Susan R Moscato, Ed.D., RN
Program Evaluators: Vicki Nishioka, Ph.D., Senior Research Associate, Education Northwest; Michael Coe, Ph. D., Cedar Lake Research Group

The University of Portland (Oregon), School of Nursing grantee team evaluated the “Dedicated Education Unit (DEU) Model.” The DEU is a hospital teaching unit designed to expand teaching capacity and improve clinical education for nursing students. The DEU reorganizes the roles of staff nurses and academic faculty to increase both the quantity and quality of faculty supervision and clinical education available to students. Practicing nurses receive additional professional development and support to become the primary teachers of students during clinical rotations; academic faculty members provide education and coaching for DEU nurses to increase their clinical teaching skills. The evaluation of the DEU model at four schools of nursing and their acute care hospital partners that operate both DEUs and traditional teaching sites was conducted by Education Northwest’s Senior Research Associate Dr. Vickie Nishioka, who worked on the project with Dr. Michael Coe, President, CedarLake Research Group. Data gathered from student and nurse faculty surveys were used to compare teaching capacity, faculty work satisfaction and quality of clinical learning environment at DEUs and traditional clinical education sites.

Read Here for principal research project findings.

UP School of Nursing websiteRead Here to link to the School of Nursing’s website and access Portland’s DEU Implementation Checklist and related materials for schools and agencies who have an interest in replicating the DEU model at their own sites.

EIN Grantee Spotlight: University of Portland, Evaluating the Dedicated Education Unit Model

DEU-Unit

Dr. Susan Moscato is Associate Dean and Tyson Distinguished Professor at the University of Portland in Oregon, and the Principal Investigator for the University’s EIN grant to study the UP School of Nursing’s dedicated education unit (DEU) model of nursing education. During mid-course of her EIN evaluation, she answered questions about her project work for this 2011 Grantee Spotlight.

EIN: The DEU model is fast becoming one that is being adopted in various settings around the country. How does Portland’s DEU compare with other DEUs that are up and running in the US?

Dr. Moscato: We continue to be amazed at the wide variations in the DEU models across the country. We think this is a benefit (an elegance) of the model – that within the conceptual vision of the DEU there are many ways to be an “optimal learning environment” as long as one includes core features of the DEU model. Additionally, allowing sites to “customize” the DEU model to the culture and daily operations of individual settings are identified assets for institutionalizing and sustaining new innovations. To date, our evaluation is in the process of completing interviews with four different Schools of Nursing (SON) who are implementing the DEU model. Although our data collection is still in process, we are finding important similarities and differences across implementation sites. Among these are the important benefit that having an onsite Clinical Instructor who remains a consistent mentor and teacher throughout the students’ rotation has to the student’s learning, confidence, and problem-solving skills. Another finding is the importance of a collaborative team across SON and clinical partners that is characterized by a shared mission, clear lines of communication, and an internal monitoring system to maintain quality. This foundation is important given the need to purposefully change the roles of the clinical faculty and the unit-based clinical instructor.

EIN: Your research project is one of two supported by the EIN program—there is another DEU model that is being studied by an evaluation team working with the School of Nursing at the University of Massachusetts, Boston. Do you know where the distinctions lie between the two?

Dr. Moscato: We know that our DEUs in collaboration with our clinical partners have been in operation for a longer time and that all of our students have DEU experiences as part of their nursing education.

EIN: What are the primary differences between the clinical instructor and the nurse preceptor model, another model used in undergraduate nursing clinical instruction?

Listen Now

Dr. Moscato: The traditional clinical instructor and nurse preceptor roles change in the DEU model. In the preceptor model, the preceptor usually works with a single capstone student and has a fairly limited working relationship with faculty. In addition, the focus of learning isn’t the unit. By contrast, in the DEU model, the students can be juniors or seniors, and the nurses in the unit work with only one school of nursing, so become very familiar with the school’s expectations of the students and the competencies expected of them. As a result, the unit “village,” as we sometimes call it, becomes an optimal learning environment.

EIN: How do DEU clinical instructors compare with staff nurses on traditional units?

Dr. Moscato: DEU CIs have the same two assigned students for a 6-week rotation and have a relationship with a clinical faculty coordinator from the UP faculty who supports their growth and development for teaching. They also are part of a unit team that is supporting the teaching and learning for the same six to eight students on their unit for the rotation. They are well aware of the expectations of the students for the learning, the program outcomes and the clinical decision-making model used by the program. The CI oversees the clinical education of the student and supervises the students giving total care to the patients. In the traditional model, a staff nurse may have different students each day and may even work with students from different schools of nursing on a given day. The School of Nursing faculty supervises the students when procedures, treatments or meds are given (a role that the CI has on the DEU). As a result, often the student and patient need to wait until the faculty member comes to the floor to supervise. There is not continuity between the student and the staff nurse in the traditional model and often not a clear and familiar relationship between the nurse and the faculty. Because many schools of nursing can be represented on the unit, there is sometimes a lack of clarity about expectations and learning outcomes.

EIN: Have you ever been to Flinders University in South Australia, where the DEU concept first originated?

Dr. Moscato: I visited Flinders in March 2009 as the guest of Dr. Kay Edgecombe, the originator of the DEU concept. During the visit, I met with the faculty and presented our version of the DEU clinical teaching model at a “Research Tea.” We have the same conceptual vision “to develop a client unit into an optimal teaching learning environment through the collaborative efforts of nurses, administration, faculty and students”, but operationalize the model in different ways to match our respective educational systems (British model vs. American model of higher education) and clinical partners.

EIN: What were the motivating factors that led to the decision by UP and its partners to adopt the DEU model?

Dr. Moscato: There were quite a few motivating factors behind our decision to adopt the DEU model. They included the overall service concerns of the nursing shortage, the retention and recruitment of nurses and the management of the increased need for student clinical placements. There were academic factors, such as the faculty shortage, the increased numbers of students and the competition for clinical placements. We needed to address the challenges set forth by the Oregon Nursing Leadership Council’s Strategic Plan (in 2000), which set out to double enrollment in Oregon nursing programs by 2004 and to “develop, implement and evaluate staffing models that make the best use of the available nursing workforce.” Additional factors involved our Academic-Service Partner parameters for the innovation – to use existing resources, to support professional development of nurses—among others. Yet another motivating factor related to issues for nurses in our clinical agencies and their frustrations and dissatisfaction with working with student nurses from multiple schools with differing levels of competencies and expectations and different surveillance requirements.

EIN: Was it a challenge to interest hospital partners in the model, given that it represented quite a change from the status quo?

Dr. Moscato: No. We were working together to address a number of common concerns, and the DEU idea seemed like a concept worth trying. We knew that we had a new clinical education model that was making a difference after the first 6-week pilot study.

EIN: Establishing successful collaboration between different partners can be a complex process—what types of buy-in and communications issues arose in developing the DEU unit and continue to be a part of the collaborative partnerships?

Themes of Innovation

Dr. Teri Murray and her colleagues identified four primary themes of innovation as they explored innovations in nursing education across the country – were: supportive relationships, communication, goodness of fit and flexibility. The DEUs at UP embody these themes of innovation. Organization and partnership activities as described below encourage and sustain buy-in and serve as vehicles for communication.

Supportive Relationships

  • Public statement of DEU collaboration
  • OSBN partnership regulation changes
  • Quarterly Meetings
  • “Lunch & Learn”
  • CFC “lynchpin” role

Communication

  • “Buy-in” DEU process
  • “Semester at a Glance”
  • Weekly updates on course content focus
  • CI Orientation
  • On-going T/L education
  • Structured evaluation process
  • Quarterly meetings

Goodness of Fit

  • Mission match
  • Openness to change
  • Students’ role as DEU learners
  • Magnet Pillar – Nurses as Teachers
  • Learning environment

Flexibility

  • Trust
  • On-going relationship building
  • Continuity of players
  • Each DEU has own culture, custom, needs
  • “Ownership” at the unit level

Dr. Moscato: Buy-in at all levels of both the academic and service organization is key, but we believe that constant, ongoing communication between partners is the life blood of the DEU model. The Robert Wood Johnson Foundation funded a grant with Dr. Teri Murray as a Co-PI, and her team identified “Themes of Innovation” that they found in exploring innovations in nursing education across the country. The themes included supportive relationships, communication, goodness of fit and flexibility. Agreed-upon assumptions were developed collaboratively by the DEU nurse managers and educators and UP faculty soon after the DEUs were started. The assumptions were reviewed and revised five years later. The changes reflect the growth in professionalism in the participants from viewing the DEU model as a method to “educate larger numbers of students in a better way” to “a partnership between faculty and nursing staff on the unit that provides a synergistic environment to best educate the next generation of nurses, an opportunity for professional development of nursing staff and the occasion for faculty to remain grounded in current clinical reality while supporting and developing nurses in their teaching role”.

EIN: What have you found surprising in your work thus far in implementing the DEU?

Dr. Moscato: We are surprised that all programs haven’t adopted this model or that hospitals haven’t demanded that they do. Our dean Joanne Warner and Deborah Burton, the chief nursing officer of one of our clinical partners, wrote that: “the type of traditional relationships and behaviors of academe and service no longer match the needs of an emerging and reforming health care system. Rather, the relationships required for the evolving healthcare system involve a cooperative and collaborative partnership.” We think that the DEU clinical teaching model that we have created together with our partners is an exemplar of this new partnership. [Read more: The Policy and Politics of Emerging Academic-Service Partnerships. Journal of Professional Nursing (2009).]

EIN: Has it been difficult to attract staff nurses to the clinical instructor (CI) role?

Dr. Moscato: We have not had difficulty for multiple reasons. Nurses are hired onto the DEUs because they “want to teach.” The Nurse Managers invite their clinically expert nurses to be clinical instructors, so that serves as an honor and a recognition. CIs with BSNs are designated as adjunct clinical faculty at UP and registered as such with the Oregon State Board of Nursing. All CIs receive UP faculty benefits, such as library privileges, discounts at the bookstore and for athletic events, and theater passes. CIs receive additional pay (usually $2.00 per hour)—the same addition that preceptors receive.

EIN: Has the number of RNs trained as CIs increased since the program’s inception? How has this been interpreted by stakeholders involved?

Dr. Moscato: The number of trained CIs has grown and we have continuous replacement of CIs. Talent and creativity shine in the CI role, and CIs have been recruited to other departments, positions and opportunities within the organization.

EIN: What has been its impact so far on student academic performance?

Dr. Moscato: Our NCLEX pass rate is consistently above our benchmark of 92 percent. Our pass rate in 2009 was 95.6 percent.

EIN: Turning again to your EIN evaluation study, can you share more details about your project for us?

Dr. Moscato: Our study addresses the three RWJF-EIN expectations—the impact of existing models on student enrollment and teaching capacity, improved faculty work-life and satisfaction, and enhanced faculty recruitment and retention—using surveys, interviews, focus groups, and available documents to produce a detailed description of the Dedicated Education Unit model that will guide replication in other settings. We will document the process of transforming the academic faculty, curriculum, hospital unit, and policies to fully support the key features of the DEU model. Using data from university records, administrators, nurses, faculty, and students from DEU sites and non-DEU sites in Portland as well as selected replication sites in other states, we will compare teaching capacity and productivity, faculty work-life satisfaction, and the quality of the clinical learning environment of DEUs and traditional clinical education placement systems.

EIN: What evidence do you hope to generate with your evaluation?

Dr. Moscato: We hope to identify the essential elements of the DEU model, to understand what makes this model work, and then to be able to disseminate the results.

EIN: How will the partnership between faculty and nursing staff affect faculty outcomes?

Dr. Moscato: To date, our focus group and interview results have indicated agreement across academic partners–both faculty and deans– that this is a viable solution to providing more effective clinical education to larger numbers of students. They also agree that the traditional clinical education model is stressful. Given their DEU experience, the CFCs interviewed to date say they would not return to teaching in a traditional education model.

EIN What will be the effect on quality of clinical education?

Dr. Moscato: Our experience is that students prefer the DEU model above all others. Students who have DEU experiences have more practice opportunities and instruction than those in the traditional model. Students and clinical instructors report that the increase in student skills and confidence are important assets. In addition, because the student has individualized instruction, their accountability for learning and practicing skills may be greater than in traditional models.

EIN: We understand that as part of your communications activities under your EIN grant the project team has designed and launched a Wiki site. Can you describe the goals of the Wiki you created for your EIN grant?

Dr. Moscato: To be a “Bulletin Board” for our project and serve as a central communication vehicle. The usefulness for writing papers and preparing documents has yet to be determined.

EIN: What other long-range plans do you have for disseminating your evaluation research findings?

Dr. Moscato: We are planning journal publications and presentations at national and international conferences, like the AACN, STTI and Magnet conferences. We will continue to do our consultations and post DEU related materials on our UP School of Nursing website.