UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Volume and utilization patterns of nursing clinical placements Burrows, Andrea Maxine 2012

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
24-ubc_2013_spring_burrows_andrea.pdf [ 1.24MB ]
Metadata
JSON: 24-1.0071865.json
JSON-LD: 24-1.0071865-ld.json
RDF/XML (Pretty): 24-1.0071865-rdf.xml
RDF/JSON: 24-1.0071865-rdf.json
Turtle: 24-1.0071865-turtle.txt
N-Triples: 24-1.0071865-rdf-ntriples.txt
Original Record: 24-1.0071865-source.json
Full Text
24-1.0071865-fulltext.txt
Citation
24-1.0071865.ris

Full Text

VOLUME AND UTILIZATION PATTERNS OF NURSING CLINICAL PLACEMENTS  by ANDREA MAXINE BURROWS  B.Sc.N., The University of Alberta, 2008  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  December 2012  © Andrea Maxine Burrows, 2012   ii Abstract Healthcare restructuring and projected workforce shortages have resulted in the expansion of nursing programs and subsequent increase in student enrolment. The competition for student practice education experiences is adding pressures on academic institutions to find and coordinate practice education and resulting in pressures on healthcare agencies to provide these experiences. Placing student in the appropriate clinical setting at the appropriate time in their education is a complex and challenging process. In British Columbia, nursing schools and healthcare agencies have used a Web-based tool, Health Services Placement network (HSPnet), to communicate about and track nursing student placements since 2003. The purpose of this retrospective longitudinal study was to examine nursing student clinical placement hours over six academic years, 2005-2006 (2005/06) and 2010-2011 (2010/11) within a large health authority in British Columbia. Data were examined for differences across years, between nursing programs (BSN, LPN, RPN, international RN), between types of placements (group or preceptorship), and between types of clinical settings. Overall, student practice hours increased by 77% between academic years 2005/06 and 2010/11, from 605,855 hours in 2005/06 to 1,074,544 in 2010/11. Although practice hours increased over time for all nursing programs, between 2005/06 and 2010/11, practice hours increased by 243% for LPN programs and by 43% for BSN programs. Group and preceptorships are the predominant model of practice education used, however, clinical learning units (CLU) and field experiences also exist. In 2010/11, group experiences accounted for 15% and preceptorships accounted for 6% of the total number of practice hours. The majority of placement hours occurred in medicine (N=1,875,331) and in surgery   iii (N=998,198). Health service sites with statistically significant changes in practice hours over time occurred in medicine (p=.002), end of life (p=.008), maternal child (p=.008), mental health (p=.024), residential (p<.001) and community (p.012).Over time, settings which had the greatest growth in clinical practice hours were critical care (125%) and end-of-life (110%). In conclusion, future research should explore methods to support student clinical placements in diverse practice settings, methods to enhance academic and practice partnerships, and methods to enhance learning environments that will be beneficial to both staff and students.    iv Preface No part of this research was published in articles. The study was approved by the UBC Research Ethics Boards, ID: H11-03458 and the Fraser Health Research Ethics Boards, ID: 2012-011.    v Table of Contents Abstract ........................................................................................................................................... i Preface ........................................................................................................................................... iii Table of Contents ......................................................................................................................... iv List of Tables ................................................................................................................................. v Acknowledgements ...................................................................................................................... ix Chapter  1: Introduction .............................................................................................................. 1 1.1 Problem Statement ............................................................................................................. 2 1.2 Significance ....................................................................................................................... 3 1.3 Statement of Purpose ......................................................................................................... 4 1.4 Research Question and Hypotheses ................................................................................... 4 1.5 Situated Learning ............................................................................................................... 5 1.6 The Cognitive Apprenticeship Model ................................................................................ 6 1.6.1 Ideal Learning Environments for Cognitive Apprenticeship ...................................... 7 1.6.2 Cognitive Apprenticeship Learning Environments – Content .................................... 8 1.6.3 Cognitive Apprenticeship Learning Environments - Teaching Methods ................... 9 1.6.4 Cognitive Apprenticeship Learning Environments - Sequencing ............................ 10 1.6.5 Cognitive Apprenticeship Learning Environments - Sociology ............................... 11 1.7 Summary .......................................................................................................................... 11 Chapter  2: Literature Review ................................................................................................... 13 2.1 Introduction ...................................................................................................................... 13 2.2 Practice Education in Nursing ......................................................................................... 13 2.3 Models of Practice Education .......................................................................................... 14   vi 2.3.1 Group Clinical Placements ....................................................................................... 16 2.3.2 Preceptorship Clinical Placements ............................................................................ 16 2.3.3 Cooperative Clinical Placements .............................................................................. 18 2.3.4 Clinical Learning Units ............................................................................................. 18 2.3.5 Summary of Models of Practice education ............................................................... 19 2.4 The Nursing Workforce ................................................................................................... 20 2.4.1 Types of Workers ...................................................................................................... 20 2.4.2 Demographic Trends ................................................................................................. 22 2.5 Clinical Placement Capacity ............................................................................................ 23 2.6 Clinical Placement Coordination ..................................................................................... 25 2.7 Clinical Placement Settings ............................................................................................. 26 2.8 Clinical Placement Databases .......................................................................................... 27 2.9 Summary .......................................................................................................................... 29 Chapter  3: Methods ................................................................................................................... 31 3.1 Introduction ...................................................................................................................... 31 3.2 Setting .............................................................................................................................. 31 3.3 Local Context ................................................................................................................... 31 3.4 Research Design .............................................................................................................. 33 3.4.1 Research Question and Hypotheses .......................................................................... 33 3.5 Definitions ....................................................................................................................... 34 3.6 Methods ........................................................................................................................... 36 3.6.1 Ethics......................................................................................................................... 37 3.6.2 Inclusion Criteria ...................................................................................................... 37   vii 3.6.3 Exclusion Criteria ..................................................................................................... 37 3.6.4 Sample and Sample Size ........................................................................................... 37 3.6.5 Sample Characteristics .............................................................................................. 38 3.6.6 Statistical Analysis of Data ....................................................................................... 40 3.6.7 Assumptions .............................................................................................................. 41 3.7 Issues of Rigor ................................................................................................................. 41 3.8 Summary .......................................................................................................................... 41 Chapter  4: Results...................................................................................................................... 42 4.1 Introduction ...................................................................................................................... 42 4.2 Number of Student Clinical Placement Hours ................................................................. 42 4.3 Number of Student Clinical Placement Hours by Program ............................................. 43 4.4 Number of Student Clinical Placement Hours by Type of Placement ............................ 44 4.5 Number of Placement Hours by Nursing Programs and Clinical Placement Type ......... 47 4.6 Number of Placement Hours by Health Service Site and Placement Type ..................... 50 4.7 Number of Placement Hours by Health Service and Placement Site .............................. 54 Chapter  5: Discussion ................................................................................................................ 59 5.1 Discussion of Findings ..................................................................................................... 59 5.1.1 Findings in Relationship to the Research Problem ................................................... 59 5.1.2 Findings in Relationship to Hypotheses ................................................................... 62 5.1.3 Findings Compared to Previous General Research .................................................. 65 5.1.4 Findings Compared to Previous Nursing Research .................................................. 67 5.1.5 Findings Linked to Theoretical Framework ............................................................. 69 5.2 Limitations to the Study ................................................................................................... 71   viii 5.3 Implications for Nursing Practice .................................................................................... 71 5.4 Recommendations for Nursing Research ........................................................................ 74 5.5 Implications for Nursing Education ................................................................................. 74 5.6 Summary and Conclusion ................................................................................................ 76 References .................................................................................................................................... 78   ix List of Tables Table 1.1 Aspects of Ideal Learning Environments ........................................................................ 7 Table 1.1 Aspects of Ideal Learning Environments (con’t) ............................................................ 8 Table.3.1 Characteristics of Nursing Programs in BCLM ............................................................ 35 Table 3.2 Characteristics of Health Service Sites ......................................................................... 36 Table 3.3 Data Categories, Variables and Data Types ................................................................. 38 Table 3.4 Clinical Placement Types ............................................................................................. 39 Table 4.1 Number of Clinical Placement Hours by Nursing Programs for Academic Years, 2005/06 to 2010/11. ...................................................................................................................... 46 Table 4.2 Number of Clinical Placement Hours by Clinical placement Types for Academic Years, 2005/06 to 2010/11. ........................................................................................................... 46 Table 4.3 Number of Clinical Placement Hours by Nursing Program and Placement Type for Academic Years, 2005/06 to 2010/11. .......................................................................................... 49 Table 4.4 Clinical Placement Hours by Health Service Site and Placement Type for Academic Years, 2005/06 to 2010/11. ........................................................................................................... 52 Table 4.4 Clinical Placement Hours by Health Service Site and Placement Type for Academic Years, 2005/06 to 2010/11(con’t) ................................................................................................. 53 Table 4.5 Clinical Placement Hours by Service and Site for Academic Years, 2005/06 to 2010/11 ....................................................................................................................................................... 57 Table 4.5 Clinical Placement Hours by Service and Site for Academic Years, 2005/06 to 2010/11 (con’t) ............................................................................................................................................ 58     x Acknowledgements Working on my Master’s thesis has been wonderful and challenging journey. The topic has been a real learning experience yet I have learned a lot about life, research, how to tackle new problems and how to solve them. I am indebted to many people for making the time working on my thesis an unforgettable experience. First of all, I am deeply grateful to my advisor Dr. Leanne Currie for enlarging my vision of nursing and whose penetrating questions taught me to question more deeply. To work with you has been a real pleasure. You have been patient and encouraging with new ideas and challenges along the way. Your ability to select and to approach compelling research problems, your high scientific standards and your hard work set an example. Furthermore, I am grateful to my committee for insightful comments, support and motivation during this process. I offer my enduring gratitude to the faculty, staff and my fellow students at the UBC School of Nursing, who have inspired me to continue my work in this field. I would like to thank my fellow colleagues for their friendship and support. I have fond memories of our study sessions in the library and at Oakridge center. The long discussions with Carla H. while hiking have inspired new research directions and personal growth. Finally, special thanks are owed to my parents for their infinite love and support throughout my years of education.   1 Chapter  1: Introduction Successfully placing nursing students in clinical learning environments is a complex process involving a dynamic partnership between academic institutions and health care provider organizations (Barnett et al., 2008; Barnett, Cross, Shahwan-Akl, & Jacob, 2010; Hoe Harwood, Reimer-Kirkham, Sawatzky, Terblanche, & Van Hofwegen, 2009; Murray & Williamson, 2009; P. M. Smith, Corso, & Cobb, 2010). The complexity within the process has been heightened due to an increase in healthcare trainee seats and programs designed to accommodate projected nurse vacancies and the growth of the aging Canadian population (Canadian Federation of Nurses Union, 2012; Carrière & Galarneau, 2011; Government of Canada, 2012; Service Canada, 2012; P. M. Smith et al., 2010; P. M. Smith, Spadoni, et al., 2007). Real-life clinical experiences are an important part of nursing education because they provide students with the opportunity to apply their skills in real-world situations (Wolff, Pesut, & Regan, 2010). According to the British Columbia Academic Health Council (BCAHC), the goal of nursing education is to provide sufficient breadth and depth of education to prepare nurses with the foundation required for specialized knowledge and skills to work in a variety of settings inside and outside acute care (British Columbia Academic Health Council, 2011; College of Registered Nurses British Columbia, 2012a). The BCAHC (2012b) defines practice education as exposure to a variety of practice-based settings where learners can apply and develop the necessary skills, knowledge and attitudes to successfully practice in their field. Practice settings typically include community health, acute care, mental health, and residential care. The desired outcome of nursing student practice education is to develop a high performance workforce in British Columbia leading to improved health outcomes of the population.   2 Many schools of nursing use models of practice education to guide clinical practice experiences. Group and preceptorship experiences are the most commonly used model of practice education. Group experiences are often used during the early stages of the program of study, and typically occur in settings where patients are less complex. During this stage, students start building a foundation of knowledge, skills are less complex and patients are often less complex and more predictable. As students progress through their programs, and as skills and knowledge become more complex, preceptorships provide one-on-one supervision to develop problem-solving skills and ultimately student autonomy. Other less common models of practice education are the collaborative/clinical learning unit, where all the staff on the unit supervise the student, and the cooperative experience, a three-way partnership between cooperating employers, students and the academic institution, in which students are employed by the healthcare agency and matched with a staff member. These models will be described in detail in Chapter 2. Methods of coordinating clinical experiences involve communication between the school of nursing and the healthcare setting. In 2003, the BCAHC created the Health Sciences Placement Network (HSPnet), a Web-based tool to help track and coordinate student clinical placements (British Columbia Academic Health Council, 2011). The system was developed to support specific goals of increasing availability of placements, improving communication between placing and destination coordinators, tracking placement activity, enhancing access to various placements and improving profile and priorities of practice education. The system is in use in several provinces across Canada. 1.1 Problem Statement Healthcare restructuring and projected workforce shortages have resulted in the expansion of nursing programs and subsequent increase in student enrolment (P. M. Smith,   3 Spadoni, et al., 2007). Increased enrolment has led to competition for clinical placements adding pressures on academic institutions to find and coordinate placements and resulting in pressures on healthcare agencies to provide nursing student placements (P. M. Smith, Spadoni, et al., 2007; Thompson, 2005). Typically, placements have been secured by a school’s longstanding relationship with a practice setting that has hosted students in the past. However, with more students needing placements, there has been an increase in the number of requests being declined (P. M. Smith, Spadoni, et al., 2007). Despite the use of the HSPnet placement and tracking tool, barriers to nursing student placements persist (Chouinard, 2009). Few studies descriptively evaluate data from the clinical placement data (Thompson, 2005). There is a lack of research regarding volume in different clinical settings (e.g., acute, residential, community, and mental health), differences between types of programs, or whether utilization of sites changes over time (Barnett et al., 2008; Henderson, Heel, & Twentyman, 2007). 1.2 Significance Practice education is a component of education for Registered Nurse (RN), Registered Psychiatric Nurse (RPN), and Licensed Practical Nurse (LPN) programs because it provides the medium for experiential learning to help students acquire the necessary skills, attitudes and knowledge to practice effectively in their field (Mannix, Faga, Beale, & Jackson, 2006; Pollard, Ellis, Stringer, & Cockayne, 2007). However, the availability and applicability of practice education opportunities places a natural limit on the number of student placement hours that can be provided. This is particularly important in times of actual or projected workforce shortages because an increase in the number of educational programs and concurrent increase in student enrolment may have a significant impact on the health service sector.    4 1.3 Statement of Purpose Managing practice-relevant experiences for successful placement of nursing students in clinical learning environments is a complex process (Murray & Williamson, 2009). The purpose of this retrospective longitudinal study was to examine the volume and utilization patterns in nursing student placement hours by nursing education program, placement type, and health service site over six academic years, 2005-2006 (2005/06) and 2010-2011 (2010/11) (from August 15, 2005 to August 14, 2011) within a large urban health authority in British Columbia, Canada. 1.4 Research Question and Hypotheses The primary objective of this study was to explore the differences in volume and utilization patterns of clinical placement hours between academic years of 2005/06 to 2010/11. The following research questions were addressed: 1. How do number of clinical placement hours change over time?  H0: There is no change in number of clinical placement hours over time. H1: There is an increase in number of clinical placement hours hosted between academic years of 2005/06 and 2010/11. 2. Is there a difference in number of clinical placement hours between nursing programs (BSN, RPN or LPN)?  H0: There is no difference in clinical placement hours among nursing programs.  H1: BSN programs will have more clinical placement hours than other nursing programs. 3. Is there a difference in number of clinical placement hours between clinical placement types (group, preceptor, or clinical learning unit)?  H0: There is no difference in clinical placement hours between clinical placement types.   5  H1: Group experiences will have more clinical placement hours than other types of clinical placement types. 4. Is there a difference in number of clinical placement hours between practice settings?  H0: There is no change in number of clinical placement hours among practice settings.  H1: Settings with less complex patients will have higher student hours than settings with more complex patients. 1.5 Situated Learning The theory of situated learning suggests that the types of social activities in which a student engages provide context for learning (Lave & Wenger, 1991). The characteristic of legitimate peripheral participation, which denotes the process of engagement of a learner who participates in the activities of an expert, is central to situated learning (Lave & Wenger, 1991). This theory also suggests that knowing is inseparable from doing and learning is more than storage and retrieval of conceptual knowledge. Instead, learning is situated in context and the culture of expertise is fostered through social interaction and collaboration. According to situated learning theory, communities of practice are formed by people who engage in a process of collective learning of a shared domain, interact together to learn how to do it better and who have common goals (Lave & Wenger, 1999). In the context of nursing student practice education, acute care and community practical experiences provide students with the opportunities to integrate into the nursing community. Through interactions and collaborations, the student progresses from peripheral participation to full participation within the community when entrusted with more complex tasks, thus gaining independence in their own practice (Hall, 2006). In nursing, the practice setting provides the context to the situation, the purpose for the activity and the social milieu whereby students can reason through actions using conceptual and   6 practical knowledge. This context provides students with the ability to operationalize concepts and explore creative nursing practice (Hall, 2006). New learners in a community of practice learn from dialogue and role modeling of other members about routines, identities, artifacts, and communities of knowledge in which learners then develop their own learning trajectories, identity, and membership (M. K. Smith, 2009). How well this occurs, however, depends on social dynamics of the community and organizational power structures. 1.6 The Cognitive Apprenticeship Model The Cognitive Apprenticeship model (CAM) by Brown, Collins and Duguid, (1989) provides a framework to guide this study. CAM is a sub-set of the theory of situated learning (Brown et al., 1989; Ghefaili, 2003). Advocates of the cognitive apprenticeship model challenge the traditional idea that knowledge is context-free and that knowledge is transferred from teacher to student in a classroom or in a laboratory setting (Engestrom, 2001; Greeno, Collins, & Resnick, 1996; Hutchins, 1995; Lave & Wenger, 1991; Nersessian, Kurz-Milcke, Newstetter, & Davies, 2003; Rogoff, 1990). Instead, CAM suggests that learning and teaching are contextually- based, where the environment plays a significant role in the learners’ development of cognitive, psychosocial and affective skills. The notion of the apprentice working under the expert practitioner to develop and acquire the necessary skills to succeed in the practice environment is also grounded in CAM (Brown et al., 1989). The term apprenticeship emphasizes the centrality of ‘practice’ in learning and highlights the context-dependent and acculturating nature of learning (Brown et al., 1989). Collaboration and multiple practice opportunities ensure that learners meet expectations of professional practice, and emphasis is placed on the thinking process that precedes and accompanies the skills at hand (Brown et al., 1989; O'Connor, 2007; Taylor & Care, 1999).   7 1.6.1 Ideal Learning Environments for Cognitive Apprenticeship According to Collins, Brown and Holum (1991), an ideal learning environment to foster apprenticeship should include four main aspects: content, methods, sequencing and sociology. Table 1.1 shows the four aspects of an ideal learning environment as described in CAM (Collins, Brown, & Holum, 1991).  Table 1.1 Aspects of Ideal Learning Environments Category Definition Content Domain The conceptual and factual knowledge and processes recognized within particular subject matter content. Heuristic strategies The generally effective, simple and efficient rules with broad application used to accomplish tasks. Control strategies Strategies with assessment, diagnostic, and remedial components, that operate on many different levels in order to guide the decision making processes and determine how to proceed. Learning strategies The strategies for learning drawing on other required types of knowledge. Teaching Methods Modeling The expert demonstrates a particular task to the learner to help build a conceptual model of the task. Coaching  The expert observes the learner performing specific tasks and provides constructive feedback. Scaffolding  The expert enacts strategies and methods to support the students learning. Articulation  The learner is able to articulate their knowledge, reasoning or problem solving processes, often through critical inquiry. Reflection  The learner begins to compare their own thought and action processes with the experts. Exploration  The learner is given independence to explore their own practice; in this case, often the expert will withdraw supports and scaffolding. Sequencing Increasing complexity & Increasing diversity Students acquire a growing repertoire of strategies and skills as they are exposed to increasingly complex and diverse problem situations in order to acquire more contextual associations. Global before local skills Allowing students to build a conceptual map before attending to the details of a specific task. Table adapted from Collins, Brown and Holum (1991) (Collins et al., 1991).   8 Table 1.1 Aspects of Ideal Learning Environments (con’t) Category Definition Sociology Situated learning  Opportunities to help develop skills to identify problems and to pursue emergent goals. Culture of expert practice Explicitly articulated cognitive processes that the expert engages in as they solve problems. Through purposeful and focused interactions among learners and experts, students are incorporated into a culture of expert practice in cognitive domains for the purpose of teaching them how to “think like experts”, to problem solve and perform tasks. Intrinsic motivation  An important characteristic of learning environments that allows students to set relevant professional goals to perform tasks and seek solutions and, of which the student is interested in, so that they are self-motivated to learn. Exploiting cooperation A powerful motivator and mechanism to extend learning resources and foster cooperative problem solving. Table adapted from Collins, Brown and Holum (1991). 1.6.2 Cognitive Apprenticeship Learning Environments – Content CAM differentiates between types of knowledge required for expertise within the specific context. An expert has a high level of domain knowledge in that they have explicit understanding of concepts, facts and procedures associated with a particular subject matter in order to solve problems and accomplish tasks. Within domain knowledge there is explicit and implicit knowledge. Explicit knowledge is easily transferred, generated through logical deduction and acquired through practical experience (Collins et al., 1991). The ability for the individual to apply explicit knowledge is supported by tacit knowledge, which is intuitive and unarticulated. In this case, the expert works skillfully without deliberation or focused attention. Tacit knowledge is not easily transferred and requires extensive and purposeful interaction between learner and expert (Eraut, 2000). Students can benefit from insight into these cognitive processes, which underlies the expert’s performance, making it easier for them to reproduce skills on their own (Taylor & Care, 1999). Strategic knowledge is revealed through practice in particular contexts and transmitted through social interactions. Heuristic, control and learning strategies are developed by the expert and used in solving complex and ill-defined problems.  For example,   9 heuristic strategies use techniques that usually work in certain situations to accomplish a task successfully; control strategies enact diagnostic skills; and learning strategies help develop new knowledge and draw out essential principles of competent practice. 1.6.3 Cognitive Apprenticeship Learning Environments - Teaching Methods Brown, Collins and Newman (1989) described six teaching methods rooted in CAM. These six teaching methods help bring cognitive processes to the surface where learners can then observe, enact and practice them in order to refine the skills, attitude and knowledge necessary to a profession. Additionally, these teaching methods foster the student’s autonomy by encouraging them to formulate learning goals (Stalmeijer, Dolmans, Wolfhagen, & Scherpbier, 2009). These methods include: modeling, coaching, scaffolding, articulation, reflection and exploration. Modeling, coaching and scaffolding assist the learner with cognitive and metacognitive developments to reach beyond the physical skills associated with apprenticeship; and in articulation and reflection, the learner becomes aware of problem solving strategies and performances similar to that of the expert; and finally, as independence, self-confidence and control increases, the ability of the learner to problem solve on their own is maximized through exploration (Collins et al., 1989). Early on in the stages of cognitive apprenticeship, experts model skills of increasing complexity. Modeling is used to assist the learner to develop conceptual models of the processes required to complete tasks that are demonstrated by the expert. Once the leaner observes and builds these conceptual models they then mimic the task accordingly, while receiving coaching or feedback from the expert. In scaffolding, the learner is provided with the strategies of learning and control to support them in the novice stages of development and in the future exploratory stages of independence (Collins et al., 1989). As the learner develops understanding of less   10 complex skills the process of modeling, coaching and scaffolding continues with complex skills and abstract knowledge. Experts ask the learner to articulate their actions and thought processes while performing the skill at hand. The act of articulation is thought to develop the individual’s knowledge, reasoning and problem-solving processes. Through reflection the learner compares their own problem solving processes to that of the experts’. In clinical nursing, students are required to articulate the steps when performing nursing skills and subsequently, asked to reflect upon them. Furthermore, reflection in practice continues beyond the educational program and is a yearly competency requirement that is mandated by the professional nursing regulatory bodies (CRNBC, 2012). In exploration, learners are given the autonomy to problem-solve on their own. It is important to note that in this step the expert withdraws their input and use of scaffolds in problem solving methods and settings. The learner sharpens their ability to explore, research and develop their own hypotheses while perfecting the skills. Expert nursing practice is developed over time and through multiple diverse learning opportunities (Taylor & Care, 1999). 1.6.4 Cognitive Apprenticeship Learning Environments - Sequencing Additionally, with the advancement of the learners’ thinking, generalizability and situational exemplars, the learner becomes more confident and shows increased control in actions and thinking. Sequencing of learning activities ensures that over time and in a real-world context the complexity of skills and diversity increases. Appropriate sequencing of learning experiences help learners acquire, integrate and use knowledge. In practice education, global skills are presented before local skills where students participate in complex interactions and procedures to develop an overarching conceptual model of the task before emphasizing on the   11 step-by-step instructions (Taylor & Care, 1999). As the learner gains autonomy in practice, they are able to apply strategies of problem-solving across diverse situations and demonstrate advanced level thinking. Learners require less support and coaching from the expert and they eventually become the expert. 1.6.5 Cognitive Apprenticeship Learning Environments - Sociology In addition to bringing thinking processes of skills to the surface, the cognitive apprenticeship model highlights that learning is contextual. The social characteristics of the learning environment are important in that learners participate in social interaction with real-life experiences and collaborate with experts to consolidate a set of beliefs and behaviours (Brown et al., 1989). The interaction between the learner and the collective group of professional experts gives meaning to the activity that helps develop the individual’s performance across situations. Through this interaction the learner learns of types of knowledge required for expertise. In the early stages of the learners’ interactions with the environment, conceptual meanings are defined by the instructor. This fits with the notion of constructivism in that it allows the learner to experience with the environment to acquire and test new knowledge. The instructor guides the learning experience to support and challenge the learner’s thinking (Brown et al., 1989). As the learner’s thinking evolves, independent meanings are constructed into concepts that continually evolve with each occasion of use and thus from each occasion, the learner develops a deeper conceptual understanding and an ability to generalize across settings (Brown et al., 1989). 1.7 Summary Projected workforce shortages, structural pressures and healthcare restructuring have increased the complexity of effectively coordinating clinical placements for nursing students during their programs of study (P. M. Smith, Spadoni, et al., 2007). The availability and   12 appropriateness of clinical practice opportunities places a natural limit on the number of accepted student placements. The development of HSPnet in 2003 has provided a standardized method to track student placement requests. Although the theory will not be tested in this study, the cognitive apprenticeship model provides a foundation to understand the types of practice education offered in nursing programs. This study will help describe the volume and utilization patterns of various practice settings between programs and between models of practice education in a large urban health authority in British Columbia.   13 Chapter  2: Literature Review 2.1 Introduction In this chapter topics related to student clinical placements are discussed including nursing practice education in nursing, models of practice education, workforce trends, capacity for nursing practice education, and placement coordination. 2.2 Practice Education in Nursing Nursing is a practice-based profession where mastery of skills and knowledge is achieved over time and with practice (Barnett et al., 2008; Bourbonnais & Kerr, 2007; Budgen & Gamroth, 2008; Canadian Association of Schools of Nursing, 2003; Croxon & Maginnis, 2009; Tony, Louise, Christine, & Majda, 2008). Nurse experts assist in educating novice nurses to develop the skills, attitudes, knowledge and judgments necessary to practice competently as a professional nurse (Benner, 1984; College of Registered Nurses British Columbia, 2012a; Cummins, 2009; Health Canada, 2006; Holmlund, Lindgren, & Athlin, 2010; Pollard et al., 2007). In the past, nursing education was provided in hospital-based programs (Health Canada, 2006; Zilm, 1977), but since the 1920’s community colleges and universities started offering nursing education, and currently nursing education in Canada is based primarily in colleges and universities (Health Canada, 2006). College and university education offers more classroom instruction than previous hospital-based programs, but with less clinical practice education time. Instead, college and university programs provide students with pre-determined periods of clinical experience in a variety of practice settings. The current structure is believed to have helped advance the foundations for specialized skills for nurses to practice in a variety of clinical settings (CRNBC, 2012a).    14 2.3 Models of Practice Education A number of models of practice education are described in the literature. Each type of practice education model includes a variety of clinical learning experiences including: group, preceptorship, cooperative and collaborative/clinical learning units. All of these experiences differ in the amount of time that students receive one-on-one supervision, and differ in who provides the majority of the supervision. In all clinical experiences the student provides service to and for the benefit of patients under the direction and supervision of healthcare providers and/or academic-appointed faculty. Employees or appointees providing supervision are practicing health professionals who are authorized and qualified to provide services (Newberry & Mickelson, 2007). In the supervisory role, the employee or appointee ideally should be familiar with the student’s curriculum and learning objectives, plan a sequence of learning activities, coach and debrief the student and participate in student evaluations (Newberry & Mickelson, 2007). Elements of cognitive apprenticeship model appear in models of practice education and are used in the planning, implementation, and evaluation of clinical learning experiences for nursing students. Students begin their practice experiences in peripheral roles and by sharing in knowledge, skills and beliefs of practice experts, they gradually gain membership into the community of practice (Taylor & Care, 1999). Situating learning opportunities in ideal practice environments allows students to develop global skills prior to higher order skills in a clinical placement system that provides increasing complexity and diversity of experience through their program of study (O'Connor, 2007). Situating learning in ideal learning environments also provide scaffolding of problem solving to help the learner develop his or her own understanding of the content and to support the learner to become an effective thinker. Learning is an active and   15 social process and an important part to the dynamic interplay between the learner and the skills, is the instructor’s culture, values and background. Learning through apprenticeship fosters integration of knowledge, conditions under which knowledge applies and culture which knowledge is used (Brown et al., 1989). Many schools of nursing have a clinical learning model in which students participate in group experiences, commonly occurring at the beginning of their program, and where groups of four to ten students are placed on a practice setting for a short period of time (Croxon & Maginnis, 2009; Cummins, 2009). Another common model of practice education is the preceptorship experience, which typically occurs near the end of the student’s program of study, and where students are paired one-to-one with a practicing nurse (Budgen & Gamroth, 2008). Other programs use the cooperative experience as the primary form of practice education. In the cooperative experiences model, students are matched with a staff member from a specialty practice setting to develop the necessary competencies to practice in that area upon graduation. Yet another model of practice education is the clinical learning units (CLU) model. Clinical learning units (CLUs) are adopted from a successful practice education project established in Australia in 1997 (Barnett et al., 2010; Callaghan et al., 2009). In this model, students are placed on designated education units (i.e., CLUs) and all staff assists in student learning and professional development in partnership with academic instructors. CLUs benefit practice education in a variety of ways including greater hands-on learning and teamwork, increased inter-professional collaboration, and the creation of positive learning environments for students (British Columbia Academic Health Council, 2012b).     16 2.3.1 Group Clinical Placements In a faculty-supervised clinical placement, often referred to as group, a faculty member is assigned to work with a group of students in an area where the faculty member has expertise (Budgen & Gamroth, 2008). One faculty member supervises a group of between four and ten students on one or more units. Faculty are instrumental in the success of the clinical experience for staff and students and are expected to be practice experts, knowledgeable of curriculum, student learning and evaluation. Success may be dependent on the faculty member’s abilities to: i) negotiate learning activities around patient care needs and student learning needs, ii) outline program expectations, iii) effectively supervise students, and iv) constructively manage conflict between staff, patients and students (Barnett et al., 2010; Budgen & Gamroth, 2008). Other limitations to group experiences that are not related to faculty capabilities include: i) lack of qualified faculty, ii) lack of appropriate health service sites, iii) inadequate mentorship or support for faculty, iv) diversity of students within a group, v) different levels of students, vi) amount of time the faculty can designate per student, and vii) the sense that faculty and students are not part of the team (Budgen & Gamroth, 2008). Despite limitations, students benefit from having access to an expert practitioner and teacher to provide them with immediate and continuous feedback, emotional support and guidance. During group experiences students are exposed to nurses’ work in a variety of contexts, increase their knowledge base, and have opportunities for hands-on experience through actual practice early in their program (Budgen & Gamroth, 2008). 2.3.2 Preceptorship Clinical Placements The term preceptor is commonly used to describe a healthcare provider who provides direct patient care and works one-on-one with a student (Barnett et al., 2010). The preceptorship   17 model is used in undergraduate nursing programs in many countries including Australia, Canada, the United States of America, United Kingdom and in most Scandinavian countries (Luhanga, Billay, Grundy, Myrick, & Yonge, 2010). Preceptors can be matched with either one or two students and the individual student follows the preceptor through their work schedule which may include rotating shifts. A faculty advisor is also assigned to the student and preceptor, acting as an academic liaison to clarify course expectations, define roles, perform student evaluations, and provide support and guidance. Preceptors are typically recruited on a volunteer basis by practice setting managers or clinical nurse educators, and are assigned to a student who is in his or her final year of study (Callaghan et al., 2009). The preceptor is typically an experienced nurse who functions as a role model for a nursing student and provides transitional role support via a collaborative and collegial relationship. In conjunction with a nursing faculty advisor, the preceptor is responsible for mentoring, supervising and evaluating the nursing activities of a nursing student during the final clinical preceptorship (Nursing Education Program Approval Board, 2005). During the preceptorship experience, students not only refine their skills and acquire professional values but also they begin to assume full participation of the nursing role. Over this period of time students learn routines, engage in the setting’s community of practice and consolidate their knowledge and skills under the supervision of an experienced employee (Bourbonnais & Kerr, 2007; Budgen & Gamroth, 2008; Cummins, 2009). Preceptors play a major role in influencing the nature and success of the students’ learning experience. Some preceptor characteristics can impede the success of students’ learning experience such as the preceptors’ inexperience in teaching and evaluation, inexperience in one’s practice, and inabilities to resolve conflicts. These characteristics can ultimately affects the students’ confidence, professional identity and achievement of program outcomes (Bourbonnais & Kerr,   18 2007). The preceptor is expected to be consistent, provide a safe space for learning, promptly answer questions; address the learner’s needs and provide immediate constructive feedback. There are, however, emergent challenges to this model in light of the pressures on healthcare agencies to deliver clinical placements (Luhanga et al., 2010). Finding and securing preceptors is a part of the complex process in confirming student clinical placements. Conflicts in preceptor availability due to stress leave, sick leave and vacations can lead to split preceptorships where students share preceptors. Studies have reported that nurses feel burned out or fatigued in their workplaces and as a result may hinder the amount of time to preceptor students (Budgen & Gamroth, 2008; Luhanga et al., 2010). 2.3.3 Cooperative Clinical Placements The cooperative experience involves a three-way partnership between employers, students and the academic institution. Students are employed by the healthcare agency and matched with a staff member (Ross & Marriner, 1985). Cooperative experiences are common in many practice fields such as engineering where the goal is to ensure that the student understands the actual work of the professional. The cooperative experience can provide the real life work experiences in a supportive environment to facilitate transition to the workplace (Ishida, Ako, & Sekiguchi, 1998). Currently, British Columbia Institute of Technology (BCIT) offers a hybrid model of cooperative placements for undergraduate students with a specialty area of focus in the final year of the program. 2.3.4 Clinical Learning Units Clinical learning units, also known as clinical teaching units or dedicated teaching units, have only recently developed and are a less common type of clinical placement than group and preceptorship experiences. The clinical learning unit, adapted from the dedicated teaching unit   19 model in Australia, was first introduced in British Columbia in 2003 as a partnership between the University of Victoria and the Vancouver Island Health Authority. This model has been used in undergraduate degree nurse programs during the students’ final practicum. The salient elements of clinical learning units are that the whole unit provides supervision and support for the student, the unit is dedicated to practice education, as well as to patient care, and students are responsible for their own learning goals and activities (Callaghan et al., 2009). Based on individually identified learning goals and activities, students choose their patients and may work with several different clinicians during their clinical placement. A faculty advisor is assigned to the student to ensure the students have relevant learning experiences and to evaluate the students’ progress (Budgen & Gamroth, 2008). A challenge to this type of model is that the student must be confident and mature enough to articulate their own learning needs and proactive in seeking learning experiences (Budgen & Gamroth, 2008). As with other student placement models, challenges to this model include: i) faculty having difficulty obtaining feedback from clinicians about student progress, ii) staff uncertainty about role, and iii) lack of continuity in student progress as more than one staff members provides supervision and feedback. 2.3.5 Summary of Models of Practice education Currently there is not conclusive evidence to favour one practice education model over another. It is important that students undertake supervised and appropriately guided practice in a variety of clinical settings, however, there is little evidence to support the amount of time and frequency of clinical supervision (Tony et al., 2008). The goal of practice education is to provide sufficient, cost-effective quality clinical experiences for students to provide direct patient care across the life span and to support their learning without any unnecessary burden on healthcare agencies (Newberry & Mickelson, 2007). The various models of practice education help foster   20 environments where students have the opportunity to engage in evaluation, reflection and, through hands-on experiences, develop their own clinical practice and support for one another (Cummins, 2009). Through the experiences in the workplace a philosophy of respect and trust is fostered between clinicians and faculty to support student learning (Cleary, McBride, McClure, & Reinhard, 2009; Cummins, 2009; Henderson et al., 2007; Lambert & Glacken, 2005). 2.4 The Nursing Workforce The provision of high quality healthcare services requires a workforce that is equipped to respond to current needs and to face future challenges (CIHI, 2010). Nursing students become the future workforce and providing students with practice opportunities facilitate the growth and strength of the graduating workforce. 2.4.1 Types of Workers A status report published by the Canadian Institute of Health Information, CIHI (CIHI, 2010), described the longitudinal trends of three regulated nursing professions, RN, RPN and LPN, in Canada for the years 2005 to 2009. The nursing workforce shows continued growth. In 2009, 76.4% of the workforce were RNs, 22.1% LPNs and 1.5% RPNs. This growth represented an annual percentage increase of 2% contributing to an overall growth rate of 8.5% between 2005 and 2009 (CIHI, 2010). Growth rates for nursing are expected to continue to increase annually by 1.4% between 2010 and 2014. In British Columbia in 2009, the regulated nursing workforce practicing in a acute care setting included: 61.7% RNs, 47.7% LPNs and 45.1% RPNs; whereas the community sector included 15.7% RNs, 5.1% LPNs and 25.4% RPNs (CIHI, 2010). Health Canada (2007), reported increased numbers of RNs entering the workforce with a baccalaureate in nursing across Canada, and a 60% increase in admissions to entry-to-practice   21 nursing programs between 1998 and 2004. According to Canadian Association of Schools of Nursing (CASN) (Canadian Association of Schools of Nursing, 2010), enrolment in baccalaureate nursing programs across Canada was 34,037 in 2009, a steady increase from 27,457 in 2004 and there was a 76% increase in the number of graduates from nursing programs since 1999. Characteristics of the nursing workforce vary between the three regulated nursing professions in their growth percentage, gender proportion, type of work setting and type of education. Characteristics of the RN workforce in 2009 include: a growth by 2% each year since 2005, a total of 266,341 RNs, high proportion of females (93.8%), and the average age was 45.2. The majority of RNs (63%) work in acute cares whereas 14% work in the community sector. In 2009, a total of 8.3% of the RN workforce graduated from an international RN program: 31.6% of those were educated in the Philippines and 17.6% in the United Kingdom (CIHI, 2010). Characteristics of the LPN workforce for 2009 include: a growth of 18.5% since 2005, a total of 76,944 LPNs, predominantly female (92.7%), and the average age was 43.4. The majority of LPNs work in acute care (45.6%), and 39.1% work in residential care facilities (CIHI, 2010). A total of 2.3% of the LPN workforce were internationally educated: 28.3% educated in the Philippines and 21% in the United Kingdom. Characteristics of the RPN workforce in 2009 include: a growth of 5% since 2005, a total of 5,214, highest proportion of males (22.5%), and average age of 47.6. RPNs practice mostly in the acute care sector (43.9%) (CIHI, 2010). Internationally educated RPNs represent 7.8% of RPNs, with the majority being educated in the United Kingdom. Internationally educated nurses often attend nursing school programs tailored to be provided with an opportunity to acculturate to the Canadian healthcare system and   22 Canadian nursing practice. Students in programs for internationally educated nurses are also being provided with practice education experiences through their schools. 2.4.2 Demographic Trends As Canada’s population continues to age, demands for healthcare services will increase. In 2011, CIHI reported that even though people over the age of 65 represented only 14% of the population, they used 40% of healthcare resources (Canadian Institute for Health Information, 2011). However, by 2036, people over 65 years are anticipated to represent 25% of the population. As seen with the general population, the nursing workforce is also aging and projections indicate that there may be up to 60,000 nurse vacancies by 2022 (Canadian Institute of Health Information, 2010). With the transition into retirement and increased demands on healthcare, the Canadian Nurses Association (CNA) (2012) recommended that schools of nursing increase student enrolment by 1,000 per year from 2009 to 2011. The average age of entry into the nursing workforce has increased and regulated nurses are often age 30 or older when they begin their nursing careers. Additionally, in 2009, nurses between the ages of 40 to 59 dominated the nursing professions, constituting 57.1% of the RN workforce, 54.1% of the LPN workforce and 62.1% of the RPN workforce. The average age of retirement for nurses is 59, and currently, retirement rates are among the highest of all labour forces, at 3.2% annually (Government of Canada, 2012). According to CNA (2012), for every one nurse under the age of 35 there are two nurses over 50 years of age. In the coming years with the aging nurse workforce, Canada will see more nurses retiring. CNA’s recommendation to increase student enrolment may help alleviate some of the nursing shortages as the population starts to retire and demands on healthcare services increase. However the increase in student enrolment has created challenges with finding placements for students.   23   2.5 Clinical Placement Capacity The issue of capacity for practice education has received significant attention from agencies across Canada over the past 10 years. Across the health professions, nursing requires the largest number of practice education hours and nursing clinical placements have become increasingly difficult to obtain across Canada and in all jurisdictions (P. M. Smith, Spadoni, et al., 2007; Thompson, 2005). Structural pressures to increase the healthcare workforce to manage nursing shortages encouraged academic institutions to increase enrolment, thus increasing the demand for clinical sites, units and practice environments (Hoe Harwood et al., 2009; Murphy, 2009; P. M. Smith et al., 2010). Educators and agency clinicians are encountering challenges to find and secure clinical placements: educators are competing for a finite number of clinical sites; agency clinicians are struggling to manage frequent requests despite growing pressures for increased efficiency (Hall, 2006); agencies are limiting the number of students that can be accommodated; and limits are being placed on the types of experiences and support provided to workplace training (Barnett et al., 2008). In 2005 the Saskatchewan Academic Health Sciences Network (SAHSN) conducted a study to explore student numbers, hours of clinical placements and preceptorship time for all health professions. Using data from the HSPnet database to explore volume and utilization patterns of health service settings in Saskatchewan, they found that 1.1 million hours of clinical placement time was used during 2004 and that there were more clinical placement hours in less acute settings. Additionally, preceptor time is valued at a total cost of employment of   24 $100,000/year for a preceptor, they extrapolated these data to determine that the cost of preceptorships was almost $6.6 million dollars annually (Thompson, 2005). This study identified that emergency rooms, operating rooms, and labour and delivery clinical placements in Saskatoon had reached capacity, were overused or had excess demand for clinical placements. In response to the growing competition in securing clinical placement sites, educators and clinical partners in Saskatchewan centralized the coordination of clinical placements at the regional level and found options for alternative clinical placements (Thompson, 2005). These pressures are also reflected in healthcare agencies as they face challenges of increased requests for clinical placements, requests from different programs, lack of space, fiscal restraints, staff downsizing, healthcare restructuring, and limited preceptor capacity (British Columbia Academic Health Council, 2004; Darcy Associates, 2009; P. M. Smith, Spadoni, et al., 2007). Additionally, productivity levels and workloads of front line staff are not always adjusted when staff function in a preceptor role, which provies less of an incentive for experienced staff to take on the additional responsibility of supervising students (P. M. Smith, Spadoni, et al., 2007). According to Diem (2004) if a unit has reached capacity this could lead to decreased productivity of staff involved in student education (Diem et al., 2004). Healthcare agencies must balance the increased number of learners with the health and wellbeing of staff while still providing high level patient care (Newberry & Mickelson, 2007; Thompson, 2005). According to Thompson, if students are not provided with practice education opportunities, there is a threat to the future provision of health care in Canada (Thompson, 2005). However, to date the number of hours required to achieve entry level competencies has not been identified and thus clinical hours vary between academic institution and by program (Diem et al., 2004). And there is no clear   25 measurement of capacity, therefore it is difficult to assess whether or not units can provide additional clinical experiences (Diem et al., 2004). 2.6 Clinical Placement Coordination Nurse leaders from practice and academia have a long history of collaborating, however, pressures arising from organizational change and healthcare reform, are forcing new collaborative bonds between healthcare providers and health workforce educators (Beal, 2012). Bilateral negotiations between individual educational programs and health services are used to coordinate clinical placements as exclusive arrangements. The quality of relationships between academic institutions and healthcare agencies are a key component in this exchange as long standing and considerable investments are often made by the academic institute in healthcare agencies. There is no blueprint for clinical placements therefore organization of clinical placements is ad hoc and varies from year to year (Darcy Associates, 2009). With the use of HSPnet clinical placements can be tracked and compared to over time. The work involved in coordinating clinical placements has grown with increased student enrolment, introduction of new nursing programs and subsequent increased demands for practice settings. Academic institutions and practice settings negotiate the confirmation of clinical placements, however, the coordination varies by site and by program (P. M. Smith, Spadoni, et al., 2007). The volume of student hours hosted by agencies are often based on what managers believe their practice settings are able to support and are typically based on historical figures (Hutchings, Williamson, & Humphreys, 2005). Historically, the processes used to coordinate clinical placements were adequate to manage the volume of students and maintain the balance between program outcomes and health care demands. Traditionally, nursing student clinical experiences took place during the academic workweek, i.e., between 8 am and 4 pm from   26 Monday to Friday. However, to meet the increased demands for practice education, some institutions have implemented clinical experiences on weekends, during the summer and for 12- hour shifts. Schools of nursing use designated coordinators to manage clinical placements whereas the healthcare agency’s process by which the decision to take students varies widely (Diem et al., 2004). According to Diem (2004), the agency’s decision to accept placement requests can depend on willingness of staff to precept a student, historical precedent in the number of students accepted, willingness of managers and staff to take students, and prioritizing the types of student. Most barriers to effectively coordinating clinical placements relate to the lack of human resources in the schools of nursing and healthcare settings. The challenges academic institutions face to effectively confirm student clinical placements include lack of qualified faculty instructors, finding available preceptors, competition for practice settings and considerable workload to coordinate clinical placements. Recruiting instructors on part-time bases for a sessional instructor’s position is difficult as salaries are not competitive to healthcare agencies (Diem et al., 2004). Smith et al. (2007a), have suggested development of a ‘capacity model’ in which the absolute number of students that a clinical placement site could accommodate would be predetermined. However, identifying the actual number would be a challenge. 2.7 Clinical Placement Settings Smith and colleagues (2007) conducted a survey of clinical placement sites in Canada and found that the majority of clinical experiences took place in acute care and specialized community healthcare sites, however, it was common for students to obtain their clinical experiences in other parts of their province and in rural and remote sites. The most commonly used settings were medicine and surgical areas where patients are less complex and more   27 predictable. Areas that were deemed higher acuity, such as maternal/child, pediatric, mental health, emergency, and surgical recovery, had a lower number of placement hours. This study also found that academic institutions and healthcare agencies were extending their partnerships beyond traditional settings to try to utilize alternative clinical learning environments including rural settings, penitentiaries, and public health settings. In addition, educators and their clinical partners were using clinical placements on weekends and during the summer months; inter- professional training initiatives; and simulation with increased laboratory training to make up for the lack of clinical placement opportunities (P. M. Smith, Spadoni, et al., 2007). 2.8 Clinical Placement Databases Achieving coordinated clinical placements is a challenge across Canada and internationally. The Health Sciences Placement Network, HSPnet, sponsored and launched in 2003 by the BC Academic Health council is a web-based system designed to manage practice education. Since its launch in 2003 HSPnet is currently being used by six provinces and by 20 health science disciplines such as, rehabilitation, physiotherapy, occupational therapy, nursing, pharmacy and others. The database and its tools were developed to support specific goals of increasing availability of clinical placements, improving communication between placing and destination coordinators, tracking clinical placement activity, enhancing access to various clinical placements and improving profile and priorities of practice education (Health Sciences Placement Network of Brisith Columbia, 2011). The National Alliance Steering Committee is responsible for ongoing expansion of the system and manages the cost sharing across provinces that fund this centrally managed infrastructure. There are more than 3,000 HSPnet users in Canada, representing over 700 educational programs and 11,000 clinical placement destinations and there are over 175,000 clinical placement requests in the database (Health Sciences   28 Placement Network of Brisith Columbia, 2011). HSPnet data can provide a rich source to evaluate clinical placement capacity, understand request status rates and reasons, and can be used to study clinical placement utilization patterns and trends. According to Smith et al. (2007) less than one quarter of the HSPnet inventory has been evaluated and Saskatchewan is the only other province to public provide descriptive statistic of clinical placement activity and practice hours from a number of nursing programs (P. M. Smith, Spadoni, et al., 2007). Other agencies have created electronic clinical placement coordination tools. StudentMAX®, was developed in 2003 to centralize clinical placement coordination for student nurses within Oregon and Southwest Washington (StudentMAX, 2012). In 2005, the tool was adopted by Denver, Colorado in response to a high level of unmet clinical placement needs (StudentMAX, 2012). Additionally, in 2006 the Massachusetts Centralized Nursing Clinical Placement System (MCNCPS) was implemented as a regionally based stand-alone Internet- based software tool designed to manage clinical nursing clinical placements between health care organizations and nursing education programs (Massachusetts Department of Higher Education, 2012). The goal of this system is to help schools of nursing and clinical agencies to increase their capacity to facilitate and host clinical placements (Massachusetts Department of Higher Education, 2012). Coordinating clinical placements based on informal communication and bilateral negotiations between individual educational program and healthcare agencies has become more challenging due to the increasing volume of students needing clinical placement. Literature from Australia and the USA reveal that the HSPnet database is currently the most progressive system available and used by most provinces to coordinate clinical placements, track activity, build capacity by facilitating access and increase availability of practice settings, and improve   29 communication (Health Sciences Placement Network of Brisith Columbia, 2011). Benefits of this system being used by other provinces enable placing coordinators to match defined requests with available clinical placement options. With its integrated functionality it provides resources to support preceptor recognition, online orientation, and educational policies. 2.9 Summary Real-life clinical experiences are essential to prepare nurses to professionally manage the complexities of practice and adapt to a continuously changing healthcare environment (Murray & Williamson, 2009). With the shift from hospital-based nursing education to college accredited community colleges and university programs, nursing education focuses on developing the necessary skills, knowledge and attitudes to provide high quality nursing care upon graduation (British Columbia Academic Health Council, 2012b; Wolff et al., 2010). Components of nursing programs include classroom and laboratory instruction as well as clinical learning activities. Classroom instruction can be delivered using a variety of teaching methods and students receive hands-on laboratory experiences that can involve the use of patient simulation technology. Clinical learning activities provide students the opportunity to put theory and skills into practice in a variety of acute care and community health care settings (Nursing Education Program Approval Board, 2005). The model of practice education provides clinical experiences for students, typically through group and preceptorships experiences. Other experiences include: cooperative and collaborative learning units. Clinical placements are negotiated in a collaborative manner by the various education institutions and healthcare settings. The implications of workforce shortages, increase in the number of students and healthcare restructuring have implications for health care agencies’ on the capacity to provide quality clinical placements (Canadian Association of Schools of Nursing, 2003). Internationally,   30 the challenges of finding, securing and hosting clinical placements are being recognized. In response to the aging general population and nursing workforce, CNA recommended an increase in student enrolment in anticipation of a projected shortage of 60,000 full time RNs (Beal, 2012). With the increase in student enrolment and subsequent increased need for clinical placements, education institutions are struggling to find, coordinate and secure a large volume of clinical placements per year, and healthcare providers are experiencing more pressure to provide clinical experiences (Canadian Association of Schools of Nursing, 2003; Newberry & Mickelson, 2007; P. M. Smith, Spadoni, et al., 2007). In addition to managing the needs of patients, providing adequate support and supervision for students to meet learning gals is challenges. Clinical learning environments foster communities of practice where students can engage in supported and supervised practice to help them develop their own practice, learning trajectories and professional identity (Lave & Wenger, 1999). In Canada, the HSPnet, an Internet based system, is used by six provinces to help communicate and coordinate student clinical placements. Presently, there are few studies that descriptively evaluate clinical placement volume and utilization patterns.    31 Chapter  3: Methods 3.1 Introduction In this chapter the methods used in this study are described including setting, research design, research questions, conceptual definitions, ethical considerations, sample selection criteria and limitations, data collection methods, data management, assumptions and issues of rigor 3.2 Setting There are 7 public and 18 private schools of nursing in the BC Lower Mainland (BCLM) (BC Ministry of Advanced Education: Technology and Innovation, 2012). Each of these schools requires that students complete sufficient clinical practice hours to meet the accredited educational program outcomes and entry-level competencies. The participating health authority is a large urban health authority in the BCLM serving 1.6 million people (Fraser Health Authority, 2011). Within the health authority clinical settings vary in terms of size, number of services and programs delivered, mandate, budget, and number of staff and students. Types of health service sites include: acute care, residential care, mental health, public health, home health, maternal child, and pediatrics. 3.3 Local Context In response to the growing pressures to manage pre-licensure practice education, the BCAHC was formed to facilitate effective and efficient collaboration between health care providers and academic sectors (British Columbia Academic Health Council, 2011). In 2003, a development grant was issued by the British Columbia provincial government to create the Health Sciences Placement Network of BC (HSPnet), a standardized database that supports processes for initiating, considering, accepting and rejecting clinical placement requests (Health   32 Sciences Placement Network of Brisith Columbia, 2011). The database also provides information on the status of requests, clinical placements activities and clinical placement outcomes (Chouinard, 2009). Placing agencies request a clinical placement for a particular setting. Each request includes: type of clinical placement, requested time period and desired health service setting. Requests are received by the destination coordinator at the particular healthcare site for review. The placing agency and destination coordinator can accept or decline requests. When a clinical placement is accepted, it is listed as ‘confirmed’ and practice hours are documented as being hosted by the practice setting. If an educational institution wants to retract a request, they can cancel it. Since 1981, the coordination of clinical nursing education in the BCLM has been the responsibility of Nursing Interschool, a committee comprised of service sector and nursing school representatives, operating under a fixed set of mutually agreed upon rules and by-laws for the allocation and assignment of clinical learning opportunities (P. M. Smith et al., 2010). A dominant influencing principle in the design of the Interschool process was to ensure equitable access to the very best clinical units for student learning. Historically, school representatives relied on informal processes to contact healthcare agencies to locate and organize required clinical placements and Interschool served as a forum for discussion and communication about nursing clinical placements in the BCLM. Committee members constructively mediated conflicts in requests for clinical placement between schools. New challenges emerged between the healthcare and academic sector with the increase demand for clinical placements, and coordinating clinical placements through informal processes alone became too difficult to manage (Chouinard, 2009). HSPnet has helped agencies track and coordinate the large volume of   33 clinical placements and nursing Interschool works with schools and agencies using HSPnet data to identify and resolve any conflicts in clinical placement requests. More recently, another group, the Lower Mainland Nursing Practice education Steering Committee (LMNCESC), was formed mid-2009. This group represents a partnership between key decision-makers in the eight schools of nursing that offer baccalaureate nursing education and health authorities in the BCLM with the goals to optimize practice-academic collaboration and identify methods to promote high quality clinical learning environments in the large, complex multi-organization health service education community of the BCLM (Newberry & Mickelson, 2007). 3.4 Research Design A retrospective longitudinal study design was used for this descriptive study. De- identified data from the HSPnet database between the academic years of 2005/06 to 2010/11 were analyzed. Independent variables included academic year, nursing program, clinical placement type, and health service site, and the dependent variable was clinical placement hours. Even though HSPnet has been available since 2003, all clinical sites were not using HSPnet until 2005; therefore the data analyzed for this study start from August 15 th , 2005, the beginning of the 2005/06 academic year. 3.4.1 Research Question and Hypotheses The objective of this study was to explore the differences in volume and utilization patterns of clinical placement hours among nursing programs, clinical placement types, and health service sites within a large urban health authority. The following research questions were addressed: 1. How do number of clinical placement hours change over time?   34  H0: There is no change in number of clinical placement hours over time. H1: There is an increase in number of clinical placement hours hosted between academic years of 2005/06 and 2010/11. 2. Is there a difference in number of clinical placement hours between nursing programs (BSN, RPN or LPN)?  H0: There is no difference in clinical placement hours among nursing programs.  H1: BSN programs will have more clinical placement hours than other nursing programs. 3. Is there a difference in number of clinical placement hours between clinical placement types (group, preceptor, or clinical learning unit)?  H0: There is no difference in clinical placement hours between clinical placement types.  H1: Group experiences will have more clinical placement hours than other types of clinical placement types. 4. Is there a difference in number of clinical placement hours between practice settings?  H0: There is no change in number of clinical placement hours among practice settings.  H1: Settings with less complex patients will have higher student hours than settings with more complex patients. 3.5 Definitions Registered nurses represent the largest regulated health care provider group in Canada (Health Canada, 2006). Registered nurses complete a nursing program at a bachelor level and must register with a provincial or territorial nursing regulatory body. The Bachelor of Science in Nursing (BSN), Post RN, RN refresher program and International RN are among four different types of programs that provide education to nurses. The RN refresher program, along with post RN programs, provides further education to already practicing RNs. These programs offer a   35 degree or advanced education in a specialized field of nursing. International RN programs provide Canadian RN licensure to nurses coming from abroad to work in Canada. Licensed practical nurses (LPN) are the second-largest regulated health profession in Canada and receive theoretical and practice education in a one to two year community college program (Health Canada, 2006). Like RNs, LPNs must register with their respective provincial or territorial regulatory body. Some accredited programs for LPNs are sometimes referred to as practical nurse (PN) programs. Registered psychiatric nurses (RPN) must complete an education program either at the diploma or baccalaureate level and they represents the largest single group of mental health professionals (Health Canada, 2006). Table 3.1 provides a description of the different types of nursing programs that were examined in this study and Table 3.2 provides a description of ten health service sites used within the health authority. Table.3.1 Characteristics of Nursing Programs in BCLM Nursing Programs         Characteristics BSN An academic degree awarded upon completion of a 4-year course of study or nurses with a diploma certificate completing a degree from an accredited college or university. Post RN Designed for nurses who: have been previously registered in Canada and are eligible for re-registration, take courses to specialize, or for those who have not been registered in Canada and require assistance in preparing for the Canadian Registered Nurses Examination. International RN Nurses educated outside Canada and that seek employment must pass the Canadian Registered Nurse Examination. This program can include coursework in a specific area, employment at a specific facility or documented worked hours by an employer. LPN A 1-2 year diploma from a public or private post-secondary institute. Post LPN Designed to build on LPN competencies while providing courses and learning opportunities to meet the RN entry-to-practice competencies. RPN  In BC, psychiatric nursing programs offer a 2-year diploma (DPN) to 4- year degree in psychiatric nursing (BPN). From: (College of Registered Nurses British Columbia, 2012b)      36 Table 3.2 Characteristics of Health Service Sites Sites Characteristics Medicine Management, treatment and prevention for a range of medical conditions for patients across the life span. Surgery Management, treatment and prevention for patients who have undergone a minor or major surgical procedure. Critical Care Providing care for critically ill or unstable patients. Residential Care Care is provided for the elderly and/or chronically ill who need some level of assistance in the activities of daily living. Mental Health A specialty of nursing that cares for people of all ages with mental illnesses, mental distress and substance use. Pediatrics/ Neonatal Providing care for infants and children, including a number of specialties. Maternal Child A nursing specialty that provides care for patients who are attempting to become pregnant, are currently pregnant or are recently delivered. End-of-life An active, compassionate approach that treats comforts and supports persons who are living with or dying from progressive or chronic life threatening conditions. Community Public Health: providing protection and improvement of community health by organized community efforts including preventive medicine. Home Health: care is provided for the elderly and/or chronically ill and post-surgical persons who have some level of difficulty caring for themselves and in their home. Other Other specialized health services settings. From:  (Canadian Institute for Health Information, 2012) 3.6 Methods The study described in this thesis is a sub-analysis of data obtained for a larger study. In the larger study data were obtained from the HSPnet database after the health authority and schools of nursing provided approval. Data from the larger study were assigned codes, therefore the researcher for this thesis did not know the names of the sites or schools. De-identified data for this study included all confirmed requests to the health authority for academic years 2005/06 to 2010/11. It was determined that an academic school year would follow a regular school calendar year and one academic year was defined as August 15 of one year to August 14 of the following year. Although HSPnet has been used since 2003, data for academic years 2003/4 and 2004/5 are incomplete as some schools in the BCLM were not using the HSPnet to coordinate student clinical placements. Therefore, only data since August 15 th , 2005 were used in this study.   37 3.6.1 Ethics This study was approved by university and health authority ethics review boards. This study used a service code to identify specific health service sites, and program code to identify the specific nursing program, and therefore the specific names of the health service sites and nursing schools were not known by the researcher. 3.6.2 Inclusion Criteria All confirmed clinical placement hours coordinated through the HSPnet; nursing programs, BSN, Post RN (including Post RN refresher program), International RN, RPN, LPN and Post LPN; all healthcare settings within a large health authority; and clinical placement hours occurring between the academic years of 2005/06 and 2010/11. 3.6.3 Exclusion Criteria Clinical placement hours for non-BSN, non-registered psychiatric nurse and non-licensed practical nurse (LPN) students were excluded from analysis. Excluded from the analysis were graduate programs such as, nurse practitioner, nurse masters, post-doctorate, advanced practice nursing. Supervised practice referred to experiences for nurse practitioners and was excluded from the dataset. 3.6.4 Sample and Sample Size Only confirmed requests between the academic years of 2005/06 to 2010/11 were examined for this study. There were 9,479 confirmed requests between the academic years 2005/06 to 2010/11 for six nursing programs and four clinical placement types, for ten health service sites and 48 health service settings.     38 3.6.5 Sample Characteristics Nursing programs were coded into six variables. These variables include: Bachelor of Science in Nursing (BSN), Post Registered Nurse (Post RN), International RN (Int’l RN), Psychiatric Nurse (Psych RN), Licensed Practical Nurse (LPN) and post LPN.  The term Psych RN was used because students from both psychiatric nursing diploma and baccalaureate programs were hosted at the health authority. Data categories, variables and data types are shown in Table 3.3. Table 3.3 Data Categories, Variables and Data Types Data Categories Variables Data Type Program Type BSN, Post RN, Post LPN, Psych RN, LPN, International RN. Categorical Academic Year August 15 to August 14 of 2005, 2006, 2007, 2008, 2009, 2010. Categorical Health Service Type Medicine, surgery, critical care, residential care, mental health, pediatrics/neonatal care, maternal child, end-of-life, community, other. Categorical Placement Type Group, Preceptorship, clinical learning unit (CLU), Field. Categorical Student Hours  Practice hours hosted within health authority. Continuous  Clinical placement types were coded as group, preceptorship clinical learning unit (CLU), and field (see Table 3.4). Group experience is led by an instructor employed by the educational institution. A preceptorship is an experience where a student is placed with an experienced practitioner in a collegial learning relationship. In clinical learning units (CLU), also known as collaborative learning units, dedicated teaching units or shared learning units, a small group or individual students are placed in a practice setting where supervision is achieved through a teaching–learning relationship with all staff on the unit. Field are observational experiences where students are placed individually or in teams to link what is learned in class with what is seen, collected and tested in the field. Project experiences are very similar to field experiences in that students are placed individually or in teams, and collaborate with the clinical nurse educator or manager to gain experience in aspects of the process of developing and implementing health initiatives. Project experiences slightly differ from field in that the clinical   39 placement is a defined project with specific deliverables. For the purpose of this study, fieldwork and project experiences are merged in analysis. In addition, it was determined that field would be separate from preceptor and group experiences because the clinical placement hours and length of time varied for each student to be between 50 to 234 hours and 2 to 12 week experiences. Also, in the case of a field experience the clinical supervisor may or may not have direct supervision over the experience, distinguishing it from a preceptor or group experience. Table 3.4 Clinical Placement Types Study Codes Codes from HSPnet  Study Codes Codes from HSPnet Group Group Alternate Group/Field Observation  CLUnit CLUnit Preceptorship Preceptorship Co-op Work-related preceptorship Staff Theory  Field Field/Project Project Field  Health service sites were coded in the following categories: medicine, surgery, critical care, residential care, mental health, pediatrics/neonatal care, maternal child, end-of-life, community (public health and home health) and other. For the purposes of this study, public health was grouped with home health. Settings in Other health service site include: health information management, language, occupation/employment health, other health, recreation therapy, rehabilitation medicine outpatient, diagnostic imaging, occupational therapy, primary care, advanced practice, education service, research and social work. Health services sites and settings were grouped as follows: medicine includes cardiac, med/surg, medicine, medicine sub-acute, oncology, renal, neurology, dialysis and rehabilitation medicine; surgical includes surgery, surgical services, and orthopedics; critical care includes critical care, emergency, high acuity; residential includes transitional care, continuing care/residential/community and geriatrics; mental health includes psychiatry, mental health-   40 community, and addictions; maternal Child includes obstetrics-general and obstetrics- labour/delivery; pediatrics/neonatal includes pediatrics and neonatal intensive care units; end-of- life include palliative and hospice; community provides health services in public health prevention, home care and home support; and other includes: diagnostic imaging, health information management (HIM), any, primary care, occupation/employment health, occupational therapy, social work, other health, recreation therapy, language, education service, administration, research and advanced practice and clinics. 3.6.6 Statistical Analysis of Data HSPnet data: data cleaning was initially performed to detect inconsistencies from missing entries. Clean data were evaluated based on a set of quality criteria to ensure quality and were tightly integrated with data maintenance to maintain integrity and validity. Statistical analysis was performed using the software IBM® SPSS® Statistics 20 (IBM Corp, Armonk, New York) and the level of significance accepted was appropriate for the nature of these data (alpha < 0.05). These data were stored in a password-protected computer. Number of clinical placement hours were calculated for each academic year and sub-analyses were performed for clinical placement hours by nursing program, clinical placement type, and health service sites and settings. Percent difference was calculated between data from academic year 2005/06 and academic year 2010/11 using the following formula: % difference = Hours for academic year 2005/06 + Hours for academic year 2010/11 Hours for academic year 2005/06 Using the continuous variable of clinical placement hours, one-way ANOVAs were used to explore the differences between grouping variable ‘academic year’ for each of the sub- analysis groups.    41 3.6.7 Assumptions The researcher assumed that placing and receiving agencies use the HSPnet database consistently to coordinate requests and that they use the same standard terminology. The researcher also assumed that all clinical placements that are hosted are logged in the HSPnet database and that requests identified as ‘confirmed’ are actually hosted as listed in the database. 3.7 Issues of Rigor The HSPnet system is designed to require input of all data elements before a request can be processed, therefore, in this dataset there are no missing fields and requests have complete information. This is a retrospective study; therefore, no temporal relationships can be established. There may be inconsistencies in the use of HSPnet and/or informal coordination of clinical placements. This study is limited to health service sites within one health authority and to the context of nursing; therefore, the findings may not be generalizable to other health authorities and health disciplines. However, the findings are likely to be of interest to practice and education sectors, which may be experiencing similar student clinical placement challenges. There may be a small percent error rate, in a very finite number of cases, where confirmed clinical placement requests may not have been hosted due to unexpected circumstances. 3.8 Summary De-identified data from the HSPnet database between the years of 2005/06 to 2010/11 were used in this retrospective longitudinal descriptive study in order to report trends over time and determine use between nursing programs, clinical placement types and health service sites. A sample of 9,479 confirmed requests were used.    42 Chapter  4: Results 4.1 Introduction In this section, the results from analysis use descriptive statistics and one-way ANOVAs, where grouping was available. Descriptive tables of 4.1 to 4.5 show trends in clinical placement hours over six academic years from 2005/06 to 2010/11. Analysis of data categories include nursing programs, clinical placement types and health service sites, and frequencies, percentages and p-values are shown. Trends over time in clinical placement hours by nursing program are shown in Table 4.1 and by clinical placement type are shown in Table 4.2. In Table 4.3, clinical placement hours are reported for clinical placement types within each nursing program; and in Table 4.4, clinical placement hours are shown by clinical placement types for each health service site. In Tables 4.5 descriptive trends over time are shown for clinical placement hours for each health service site and setting. For statistical tests that violated the Levene’s assumption of homogeneity of variance (p<.05), the more robust test of equality of means, Brown-Forsythe, was used. In some cases, homogeneity of variance could not be performed by SPSS because at least one group had a sum of case weights that was less than or equal to 1. Only statistical significant results from one-way ANOVAs are described and effect sizes are calculated for each results using Cohen’s effect size classification where .01 as a small effect, .06 as a medium effect and .14 as a large effect. 4.2 Number of Student Clinical Placement Hours There was a steady increase in the number of confirmed clinical placement hours in 2005/06 to 2010/11 for all nursing programs (see Table 4.1). Over six years, the large urban health authority hosted 4.9 million clinical practice hours and practice hours increased by 77%   43 between August 2005 and August 2011, from 605,855 hours in 2005/06 to 1,074,544 clinical practice hours in 2010/11. 4.3 Number of Student Clinical Placement Hours by Program Overall, there were significant changes in the total number of practice hours over time for all programs. BSN clinical placement hours contribute to the majority of practice hours, followed by the LPN and Post-RN programs, with a distinct spike in practice hours from 2009 to 2010/11 for BSN and LPN programs. Cumulatively, BSN programs account for over half (57%) of the clinical placement hours while LPN account for less than one quarter (20%). Confirmed clinical placements hours have increased during the past 5 years particularly for LPNs. BSN programs experienced a 43% increase in confirmed hours when compared to 2005/06. Between 2005/06 and 2010/11 there was a 243% increase in hours hosted for students in LPN programs. Post-RN clinical placement hours did not show as much of a proportional increase from 2009/10 to 2010/11. Post-LPN programs contribute to the least amount of hosted hours since 2005. The largest actual increase in hours was for LPN programs which increased by 188,562 hours between 2005/06 and 2010/11. A one-way between-groups analysis of variance was conducted to explore clinical placement hours over time of nursing programs. Academic Years were grouped into 2005/06, 2006/07, 2007/08, 2008/09, 2009/10 and 2010/11 and nursing programs were grouped into BSN, LPN, Post-RN, Psych-Nurse, Int’l-RN, Post-LPN. There was a statistically significant difference at the p<0.05 level in clinical placement hours for three nursing programs: Total for all nursing programs, F(5,9473) = 4.986, p<.001, BSN, F(5,4493) = 21.514, p<.001; LPN, F(5, 1989) = 2.954, p=.012; Int’l-RN F(5,232) = 3.175, p=.009. As described above, the number of practice hours for BSN, LPN and International RN programs increased from 2005 to 2010, and this   44 change was statistically significant.  Despite reaching statistical significance, the actual difference in mean scores was small. The effect size, calculated using eta squared, was 0.02 for BSN, 0.006 for LPN and 0.05 for Int’l-RN. 4.4 Number of Student Clinical Placement Hours by Type of Placement Overall, there were significant changes in the total number of practice hours over time for all placement types. Group experiences are the most common type of practice education model used in the health authority. Overall, they account for 69% of practice hours between 2005/06 and 2010/11 and account for 15% of the total number of practice hours hosted in 2010/11. In 2010/11, there were three times as many group clinical placement hours (N=751,294) as preceptorship hours (N=271,552) and group hours were consistently higher than preceptorship hours (2005/06, 2.5 times higher, 2010/11, 2.77 times higher). Between 2005/06 and 2010/11 group hours increased by 78% and preceptorship hours increased by 63% (see Table 4.2). Although clinical learning units have been declining since 2006, they show the largest growth over time, at 481% since 2005 (Jonson, 2006). A one-way between-groups analysis of variance was conducted to explore practice hours over time between types of placements. Academic Years were grouped into 2005/06, 2006/07, 2007/08, 2008/09, 2009/10 and 2010/11. Clinical placement types were grouped into groups, preceptorships, CLU and field. There was a statistically significant difference at the p<0.05 level in clinical placement hours for three clinical placement types: Total for all placement types, F(5,9473) = 4.986, p<.001, preceptorships, F(5,4060) = 3.385, p=.005; group, F(5, 4681) = 11.619, p<.001, Field F(5,198) = 7.432, p<.001. The increase in number of practice hours for preceptorships, group and field placements over time was statistically significant.  Despite reaching statistical significance, the actual difference in mean scores was small. The effect size,   45 calculated using eta squared, was 0.004 for preceptorships, and 0.01 for group. Field clinical placements had a medium effect size of 0.10.   46 Table 4.1 Number of Clinical Placement Hours by Nursing Programs for Academic Years, 2005/06 to 2010/11. Program Academic Year 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 % diff a  p- value b  Total Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) BSN 383,008(8) 447,379(9) 475,332(10) 465,660(9) 458,699(9) 548,413(11) 43% <.001 2,778,491(57) LPN 77,632(2) 129,462(3) 151,756(3) 152,609(3) 190,933(4) 266,194(5) 243% 0.012 968,586(20) Post RN 83,548(2) 107,285(2) 99,946(2) 111,975(2) 123,513(3) 137,870(3) 65% 0.659 564,191(11) Psych RN 42,603(1) 43,761(1) 50,836(1) 57,023(1) 57,759(1) 90,037(2) 111% 0.580 342,019(7) Int’l RN 13,808(0) 20,812(0) 22,448(0) 19,424(0) 16,132(0) 25,472(1) 84% 0.009 118,096(2) Post LPN 5,286(0) 5,078(0) 6,244(0) 5,856(0) 7,208(0) 6,558(0) 24% 0.054 36,230(1) Total 605,885(12) 753,776(15) 806,562(16) 812,5461(17) 854,243(17) 1,074,544(22) 77% <.001 4,907,556(100) BSN – Bachelor of Science in Nursing; LPN – Licensed practical nurse; Post RN – education after attaining RN; Psych RN – diploma or bachelors in psychiatric nursing; Int’l RN – education for nurses from other countries; Post LPN – education after attaining LPN a % difference between 2005/06 and 2010/11; b p-value based on one-way ANOVA    Table 4.2 Number of Clinical Placement Hours by Clinical placement Types for Academic Years, 2005/06 to 2010/11.  Academic Year 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 % diff a  p- value b  Total Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Group 421,052(9) 514,557(10) 564,922(12) 559,553(11) 579,742(12) 751,294(15) 78% <.001 3,391,120(69) Preceptorship 166,854(3) 176,868(4) 183,554(4) 199,886(4) 220,756(4) 271,552(6) 63% 0.005 1,219,470(25) CLU 6,912(0) 53,578(1) 50,882(1) 43,208(1) 48,120(1) 40,176(1) 481% 0.119 242,876(5) Field 11,067(0) 8,773(0) 7,203(0) 9,898(0) 5,624(0) 11,521(0) 4% <.001 54,086(1) Total 605,885(12) 753,776(15) 806,561(16) 812,545(17) 854,242(17) 1,074,543(22) 77% <.001 4,907,552(100) CLU – clinical learning unit; a % difference between 2005/06 and 2010/11; b p-value based on one-way ANOVA     47 4.5 Number of Placement Hours by Nursing Programs and Clinical Placement Type Table 4.3 shows confirmed practice hours by clinical placement type within each nursing program over time. Most markedly, is the 398% increase in clinical placement hours for LPN preceptorships and 207% increase in group clinical placements for LPN students. Psychiatric nursing showed 102% increase in group clinical placement hours, a 112% increase in preceptorship hours and a 247% increase in field hours. Notably, there was an overall increase in clinical placement hours of 547% for International RN program, while Post-RN and Post-LPN programs showed small yet steady increases by clinical placement types over time. Overall, group experiences are the most common type of clinical experience and account for the majority of clinical placement hours within each program. Preceptorship clinical placements for Post-LPN are utilized more frequently than group clinical placements and Post-LPN and International RN programs do not utilize field or CLUs. There are only two programs that use clinical learning units (CLU), and the majority of their use is in the BSN programs while Post-RN programs used CLUs for three years between 2006 and 2008. A one-way between-groups analysis of variance was conducted to explore clinical placement hours over time by nursing program and clinical placement type. Academic Years were grouped into 2005/06, 2006/07, 2007/08, 2008/09, 2009/10 and 2010/11. Clinical placement types were grouped into groups, preceptorships, CLU and field nursing programs were grouped into BSN, LPN, Post-RN, Psych Nurse, Int’l-RN, Post-LPN. There was a statistically significant difference at the p<0.05 level in clinical placement hours within all programs: within BSN programs, preceptorships, F(5,1697) = 4.017, p=.001; group, F(5, 2344) = 19.593, p<.001, field F(5,198) = 3.046, p=.011; within LPN programs, preceptorships, F(5,1082) = 3.955, p=.001; group, F(5, 820) = 5.344, p<.001; within Post-RN programs, preceptorships,   48 F(5,355) = 5.300, p<.001; group, F(5, 923) = 3.078, p=.009; within Psych Nurse, Field F(4, 37) = 3.982, p=.009; within Post-LPN, preceptorships , F(5,4060) = 3.385, p=.005. The change in practice hours by program and placement type over time was determined to be statistically significant. Despite reaching statistical significance, the actual difference in mean scores was small. The effect size, calculated using eta squared, ranged from small to large. Effect size of 0.01 for BSN preceptorships, 0.04 for group clinical placements, 0.05 for field clinical placements; 0.01 for LPN preceptorships, 0.03 for group clinical placements; 0.05 for Post-RN preceptorships, 0.01 group clinical placements; 0.20 for Psych Nurse field clinical placements; and 0.10 for Post-LPN preceptorships.    49 Table 4.3 Number of Clinical Placement Hours by Nursing Program and Placement Type for Academic Years, 2005/06 to 2010/11.   Academic Year    2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 % diff a  p- value b  Total Program Hours (%) Hours (%) Hours (%) Hours (%) Hours (%) Hours (%) BSN Group 253,532(9) 285,409(10) 316,038(11) 305,072(11) 280,830(10) 367,306(13) 45% <.001 1,808,187(65) Preceptorship  115,154 (4) 106,604(4) 106,426(4) 111,278(4) 126,161(5) 137,499(5) 19% 0.001 703,121(25) CLU 6,912 (0) 48,970 (2) 48,578(2) 42,056(2) 48,120(2) 40,176(1) 481% 0.119 234,812(8) Field 7,410 (0) 6,396 (0) 4,290 (0) 7,254(0) 3,588(0) 3,432(0) -54% 0.011 32,370(1)  Total 383,008(14) 447,379(16) 475,332(17) 465,660(17) 458,699(17) 548,413(20) 43% <.001 2,771,491(100) LPN Group 62,462(6) 95,540 (10) 111,064(11) 105,804(11) 143,274(15) 191,714(20) 207% <.001 709,858(73) Preceptorship  15,170(2) 33,042 (3) 40,292 (4) 46,533(5) 47,504 (5) 74,171(8) 389% 0.001 256,712(27) Field 0 880(0) 400(0) 272(0) 155(0) 309(0)  - 2,016(0)  Total 77,632(8) 129,462(13) 151,756(16) 152,609(16) 190,933(20) 266,194(27) 243% 0.012 968,586(100) Post RN Group 60,202(9) 78,136(12) 78,084(12) 87,969(13) 99,468(15) 108,302(16) 80% 0.009 512,161(77) Preceptorship  21,862(3) 23,044(3) 18,325(3) 22,482(3) 23,700(4) 29,341(4) 34% <.001 138,753(21) CLU 0 4,608 (1) 2,304(0) 1,152(0) 0 0  - 8,064(1) Field 1,484(0) 1,497 (0) 1,233(0) 372(0) 345(0) 228(0) -85% 0.784 5,159(1)  Total 83,548(13) 107,285(16) 99,946(15) 111,975(17) 123,513(19) 137,870(20) 65% 0.659 664,136(100) Psych RN Group 31,592(9) 34,409(10) 40,872(12) 44,973(13) 43,595(13) 63,765(19) 102% 0.188 259,205(76) Preceptorship  8,838(3) 9,352(3) 8,684(3) 10,050(3) 12,628(4) 18,720(5) 112% 0.189 68,272(20) Field 2,174(1) 0 1,280(0) 2,000(1) 1,536(0) 7,552(2) 247% 0.009 14,542(4)  Total 42,603(12) 43,761(13) 50,836(15) 57,023(17) 57,759(17) 90,037(26) 111% 0.580 342,019(100) Int`l RN Group 12,976(11) 20,584(17) 18,864(16) 15,736(13) 12,576(11) 19,968(17) 54% 0.271 100,704(85) Preceptorship  832(1) 228(0) 3,584(3) 3,688(3) 3,556(3) 5,504(5) 562% 0.94 17,392(15)  Total  13,808(12) 20,812(17) 22,448(19) 19,424(16) 16,132(14) 25,472(22) 84% 0.009 118,096(100) Post LPN Group  288(1) 480(1) 0 0 0 240(1) -17% - 1,008(3) Preceptorship 4,998(14) 4,598(13) 6,244(17) 5,856(16) 7,208 (20) 6,318(17) 26% 0.035 35,222(97)  Total 5,286(15) 5,078(14) 6,244(17) 5,856(16) 7,208(20) 6,558(18) 24% 0.054 36,230(100) a % difference between 2005/06 and 2010/11; b p-value based on one-way ANOVA   50 4.6 Number of Placement Hours by Health Service Site and Placement Type Across all settings, group and preceptorship clinical placements were the most common type of practice education model used; however, end of life health service sites use preceptorships more frequently than group clinical placements. In medicine, group experiences account for 20% of clinical placement hours while preceptorships account for 10%. To a smaller degree, surgical group clinical placements account for 13% while preceptorship clinical placements account for 5%. Overall, there are greater use of clinical learning units occurring in medicine (N=102,931), surgery (N=105,284), maternal child (N=32,660) and community (N=2,928). The majority of CLUs occur in medicine and surgery; however, surgical sites host greater CLU clinical placements than medicine by 2,353 hours. In the health authority, CLUs typically do not occur in critical care, end-of-life, pediatric/neonatal, mental health, residential, and other health service sites. Clinical practice hours for field experiences occur most frequently in mental health (N=16,376), community (N=11,394), critical care (N=6,762), other (N=6,211), surgery (N=4,056) and medicine (N=3,799). Field clinical placements do not typically occur in end-of-life and residential health service sites. A one-way between-groups analysis of variance was conducted to explore clinical placement hours over time by health service site and clinical placement type. Academic Years were grouped into 2005/06, 2006/07, 2007/08, 2008/09, 2009/10 and 2010/11. Health services were grouped into 10 health service sites: medicine, surgery, critical care, end-of-life, maternal child, pediatric/neonatal, mental health, and residential care. Clinical placement types were grouped into groups, preceptorships, CLU and field. There was a statistically significant difference at the p<0.05 level in clinical placement hours by site and clinical placement type. Sites and clinical placement type of statistical difference include: medical, group placements,   51 F(5,1592) = 13.094, p<.001; surgery, CLU placements, F(4, 87) = 2.504, p=.048; critical care, group placements F(5,380) = 2.635, p=.023; end-of-life, preceptorships F(5,23) = 2.637, p=.050; maternal child, preceptorships F(5, 202) = 4.548, p=.001; mental health, preceptorships F(5, 227) = 2.622, p=.025 and field F(5, 46) = 6.513, p<.001; residential, group placements F(5, 433) = 2.071, p<.001; and community, group placements F(5,338) = 4.055, p=.001. As described above, the increase in practice hours for health service site by placement type was statistically significant over time.  Despite reaching statistical significance, the actual difference in mean scores had a range from small to large. The effect size, calculated using eta squared, was 0.04 for medicine group clinical placements, 0.09 for surgery CLU clinical placements, 0.03 for critical care group clinical placements, 0.16 for end-of-life preceptorships, 0.03 for maternal child preceptorships, 0.05 for mental health preceptorships and 0.29 for mental health group clinical placements, 0.07 for residential group clinical placements, and 0.06 for community group clinical placements.    52 Table 4.4 Clinical Placement Hours by Health Service Site and Placement Type for Academic Years, 2005/06 to 2010/11.  Academic Year  2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 % diff a  p- value b  Total Site Placement Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Medicine Group  140,125(3) 196,517(4) 209,838(4) 206,217(4) 236,873(5) 282,557(6) 103% <.001 1,272,127(20)  Preceptorship 68,704(1) 70,842(1) 82,181(2) 78,980(2) 93,695(2) 104,532(2) 57% 0.612 501,933(10)  CLU 7,920(0) 26,960(1) 23,548(0) 13,184(0) 16,860(0) 12,000(0) 83% 0.419 100,472(2)  Field 312(0) 1,303(0) 234(0) 234(0) 1,014(0) 702(0) 125% - 3,799(0)  Total 217,061(4) 295,622(6) 315,801(6) 298,614(6) 348,442(7) 399,791(8) 84% 0.002 1,875,331(100) Surgery Group 107,498(2) 99,892(2) 102,886(2) 108,806(2) 108,122(2) 119,014(2) 11% 0.892 646,217(13)  Preceptorship 49,767(1) 37,495(1) 33,654(1) 34,200(1) 45,658(1) 41,867(1) -16% 0.571 242,641(5)  CLU 0 16,352(0) 22,288(0) 21,968(0) 25,380(1) 19,296(0) - 0.048 105,284(2)  Field 1,872(0) 702(0) 312(0) 858(0) 0 312(0) -83% - 4,056(0)  Total 159,137(3) 154,440(3) 159,140(3) 165,832(3) 179,160(4) 180,489(4) 13% 0.193 998,198(20) Critical Care Group 14,820(0) 30,124(1) 31,358(1) 28,920(1) 34,398(1) 32,507(1) 119% 0.023 172,127(4) Preceptorship 7,371(0) 10,846(0) 8,782(0) 14,012(0) 15,862(0) 18,847(0) 156% 0.111 75,720(2) CLU 0 0 0 380(0) 0 0 - - 380(0)  Field 1,014(0) 1,326(0) 468(0) 1,482(0) 1,708(0) 764(0) -25% 0.318 6,762(0)  Total 23,205(0) 42,296(1) 40,608(1) 44,794(1) 51,968(1) 52,118(1) 125% 0.147 254,989(5) End of Life Group 904(0) 976(0) 1,310(0) 1,746(0) 1,640(0) 2,380(0) 163% 0.214 8,956(0) Preceptorship 2,212(0) 3,438(0) 3,028(0) 2,156(0) 2,876(0) 4,833(0) 118% 0.050 18,543(0)  Field 312(0) 0 0 0 152(0) 0 100% - 464(0)  Total 3,428(0) 4,414(0) 4,338(0) 3,902(0) 4,668(0) 7,213(0) 110% 0.008 27,963(1) Maternal Child Group 46,898(1) 41,528(1) 45,448(1) 52,286(1) 49,280(1) 50,620(1) 8% 0.720 286,060(6) Preceptorship 13,742(0) 11,049(0) 16,218(0) 17,117(0) 15,790(0) 15,546(0) 13% 0.001 89,462(2) CLU 1,872(0) 4,536(0) 6,696(0) 7,136(0) 6,420(0) 6,000(0) 221% 0.171 32,660(1)  Field 430(0) 445(0) 468(0) 390(0) 234(0) 234(0) -46% 0.307 2,201(0)  Total 62,942(1) 57,558(1) 68,830(1) 76,929(2) 71,724(1) 72,400(1) 15% 0.008 410,383(8) a % difference between 2005/06 and 2010/11; b p-value based on one-way ANOVA   53 Table 4.4 Clinical Placement Hours by Health Service Site and Placement Type for Academic Years, 2005/06 to 2010/11(con’t)   Academic Year   2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 % diff a  p- value b  Total Site Placement Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Pediatric/ Neonatal Group 21,272(0) 29,840(1) 29,508(1) 32,940(1) 35,878(1) 37,770(1) 78% 0.165 187,208(4) Preceptorship 10,145(0) 11,530(0) 9,533(0) 8,454(0) 10,669(0) 11,212(0) 11% 0.240 61,542(1)  CLU 0 1,152(0) 0 0 0 0  - 1,152(0) Field 82(0) 78(0) 234(0) 468(0) 156(0) 234(0) 185% 185% 1,252(0)  Total 31,499(1) 42,600(1) 39,275(1) 41,862(1) 46,703(1) 49,216(1) 56% 0.051 251,154(5) Mental Health Group 24,362(0) 28,197(1) 32,546(1) 29,621(1) 35,843(1) 37,561(1) 54% 0.309 188,130(4) Preceptorship 10,550(0) 11,632(0) 11,238(0) 12,554(0) 13,686(0) 19,999(0) 90% 0.025 79,658(2)  Field 2,612(0) 666(0) 1,796(0) 3,738(0) 4,680(0) 2,884(0) 10% <.001 16,376(0) Total 37,523(1) 40,495(1) 45,580(1) 45,913(1) 54,209(1) 60,444(1) 61% 0.024 284,163(6) Resi- dential Group 47,488(1) 46,766(1) 49,740(1) 52,368(1) 67,523(1) 77,8149(2) 1539% <.001 341,699(7) Preceptorship 7,025(0) 11,328(0) 7,944(0) 7,952(0) 8,867(0) 10,641(0) 51% 0.032 53,757(1)  Field 312(0) 870(0) 78(0) 312(0) 0 0 -100% - 1,572(0) Total 54,825(1) 58,964(1) 57,762(1) 60,632(1) 76,390(2) 88,455(2) 61% <.001 397,028(8) Com- munity Group 39,520(1) 43,806(1) 42,516(1) 43,284(1) 43,430(1) 52,252(1) 32% 0.001 264,808(5) Preceptorship 9,150(0) 11,869(0) 13,324(0) 15,722(0) 17,246(0) 16,136(0) 76% 0.539 83,447(2)  CLU 0 1,698(0) 1,230(0) 0 0 0  - 2,928(0)  Field 2,738(0) 3,188(0) 2,127(0) 1,518(0) 818(0) 1,005(0) -63% 0.766 11,394(0) Total 51,408(1) 60,561(1) 59,197(1) 60,524(1) 61,494(1) 69,393(1) 35% 0.012 362,577(7) Other Group 4,149(0) 3,162(0) 4,250(0) 2,888(0) 5,386(0) 2,876(0) -31% 0.736 22,711(0)  Preceptorship 1,722(0) 1,665(0) 908(0) 1,406(0) 1,380(0) 802(0) -114% 0.726 7,883(0)  Field 1,464(0) 1,909(0) 1,020(0) 786(0) 318(0) 714(0) -51% 0.505 6,211(0) Total 7,335(1) 6,736(1) 6,178(0) 5,080(0) 7,084(1) 4,392(0) -40% 0.173 36,805(1) a % difference between 2005/06 and 2010/11; b p-value based on one-way ANOVA   54 4.7 Number of Placement Hours by Health Service and Placement Site The majority of health service sites had an increase in clinical practice hours from 2005/06 to 2010/11 (see Table 4.5). Overall increases in health service practice hours occurred in: critical care (122%) and end-of-life (110%). Medicine had the largest actual increase in hours from 217,061 to 400,291 between 2005/06 and 2010/11 (84% increase). Health service sites with statistically significant changes in practice hours over time were medicine (p=.002), end of life (p=.008), maternal child (p=.008), mental health (p=.024), residential (p<.001) and community (p.012). Within each health service site, the greatest increases in clinical placement hours since 2005/06 were shown by: end of life (20%), residential care (14%), critical care (12%), mental health (11%), medicine (11%), pediatric/neonatal (9%), community (7%), maternal child (4%), and surgical (4%). In 2010/11 the number of hours hosted by service includes: medicine (N=400,291), surgical (N=180,489), residential care (N=88,455), maternal child (N=72,400), community (N=69,393), mental health (N=60,444), critical care (N=51,618), pediatrics/neonatal (N=49,216), and end of life (N=7,213). Other services hosted less hours than previous years (N=4,392) and were the only service to show a 40% decrease in hours from 2005/06. Since 2005/06, settings that hosted few clinical placement hours were: renal, dialysis, oncology, addictions, continuing care, home support, any, and advanced practice.  Owing to this, not all settings were available in HSPnet. Proportional increases from 2005/06 to 2010/11 were shown for end of life (110%), critical care (122%), medicine (84%), mental health (61%), residential care (61%), pediatrics/neonatal (56%), community (35%), maternal child (15%), surgical (13%). The actual change in number of practice hours increased from 2005/06 to 2010/11 for medicine (N=183,158), residential care (N=33,630), critical care (N=28,413), mental health (N=22,921),   55 surgery (N=21,352), community (N=17,985) and pediatrics/neonatal (N=17,717). Although the number of hours for specialty areas increased over time, maternal/child and end of life showed smaller increases of use (Maternal/Child, 2005/06, N=60,770, 2010/11, N=78,304, actual change N=9,458 hours; and End-of-life, 2005/06, N=3,428, 2010/11, N=7,213, actual change N=3,785). Settings which experienced large growth from 2005/06 were: sub-acute medicine (1395%), critical care (556%), hospice (137%) and transitional care (234%).  Addictions (1055%) and administration (130%) also increased, although, actual practice hours remained low. A one-way between-groups analysis of variance was conducted to explore clinical placement hours over time by health service setting. Academic years were grouped into 2005/06, 2006/07, 2007/08, 2008/09, 2009/10 and 2010/11. Health service settings were grouped into 10 health service sites: medicine, surgery, critical care, end-of-life, maternal child, pediatric/neonatal, mental health, residential care, community and other. There was a statistically significant difference at the p<0.05 level in clinical placement hours by setting within all health service sites. Settings of statistical significance include: general medicine, F(5,3188) = 3.029, p=.010; surgical services, F(5, 190) = 4.096, p=.001; critical care F(5,168) = 4.756, p<.001; palliative, F(5,45) = 2.583, p=.039; obstetrical, F(5, 629) = 3.971, p=.001; pediatrics, F(5,262) = 3.094, p=.010; mental health community F(5, 148) = 5.617, p<.001; residential, F(5, 434) = 5.224, p<.001; prevention, F(5,402) = 3.494, p=.004; and administration, F(5,52) = 2.655, p=.033. As described above, the change in practice hours over time among practice settings was found to be statistically significant. Despite reaching statistical significance, the actual difference in mean scores had a range from small to large. The effect size, calculated using eta squared, was 0.004 for medicine, 0.06 for surgical services, 0.07 for critical care, 0.17 for palliative, 0.03 for   56 obstetrical, 0.05 for pediatrics, 0.12 for mental health community, 0.56 for residential, 0.04 for prevention, 0.20 for administration.    57 Table 4.5 Clinical Placement Hours by Service and Site for Academic Years, 2005/06 to 2010/11  Academic Year  2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 % diff a  p- value b  Total Service Site Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Medicine  Medicine  201,663(11) 271,171(15) 285,336(15) 276,105(15) 322,185(17) 363,398(19) 80% 0.010 1,719,858(92) Sub-Acute 1,120(0) 4,512(0) 10,574(1) 6,488(0) 10,292(1) 16,748(1) 1395% 0.336 49,734(3)  Cardiac 8,090(0) 8,572(0) 7,184(0) 8,272(0) 9,445(1) 11,171(1) 38% 0.563 52,734(3)  Neurology 3,750(0) 7,626(0) 9,186(1) 5,512(0) 5,952(0) 6,132(0) 64% 0.827 38,158(2)  Med/Surg 1,458(0) 907(0) 1,359 996(0) 708(0) 1,583(0) 9% 0.466 7,011(0)  Dialysis 595(0) 300(0) 996(0) 960(0) 360(0) 0 -100% - 3,211(0)  Renal 385(0) 2,534(0) 1,166(0) 1,127(0) 0 300(0) -22% - 5,512(0)  Oncology 0 0 0 0 0 960(0) - - 960(0)  Total 217,061(12) 295,622(15) 315,801(17) 299,460(15) 348,942(19) 400,291(21) 84% 0.002 1,877,177(100) Surgical  Surgical 129,683(13) 127,444(13) 137,978(14) 139,353(14) 145,738(15) 156,417(16) 20% 0.083 836,612(84) Orthopedic 21,238(2) 21,612(2) 16,498(1) 13,144(1) 15,133(1) 14,998(1) -29% 0.931 102,623(10)  Surg-Serv 8,216(1) 5,385(1) 4,664(1) 13,335(1) 18,290 9,074(1) 10% 0.001 58,964(6)  Total 159,137(16) 154,440(16) 159,140(16) 165,832(17) 179,160(18) 180,489(18) 13% 0.193 998,198(100) Critical Care Emergency 20,289(8) 23,246(9) 20,524(8) 23,922(9) 28,958(11) 34,494(14) 60% 0.142 149,433(59) Critical Care 2,916(1) 19,050(7) 20,084(8) 20,026(8) 22,510(9) 19,124(8) 556% <.001 103,710(41)  Total 23,205(9) 42,296(16) 40,608(16) 43,948(17) 51,468(20) 51,618(21) 122% 0.147 253,143(100) End of Life Palliative 2,326(8) 2,476(9) 1,820(5) 2,692(12) 3,052(7) 4,600(20) 98% 0.039 16,966(60)  Hospice 1,102(3) 1,938(7) 2,518(7) 1,210(6) 1,616(6) 2,613(11) 137% 0.339 10,997(40)  Total 3,428(11) 4,414(16) 4,338(16) 3,902(14) 4,668(17) 7,213(31) 110% 0.008 27,963(100) Maternal- Child Obstetrical 60,142(15) 56,482(14) 65,562(16) 70,261(17) 67,752(16) 68,268(16) 14% 0.001 388,467(95) L&D 2,800(1) 1,076(0) 3,268(1) 6,668(2) 3,972(1) 4,132(1) 48% 0.312 21,916(5)  Total 62,942(15) 57,558(14) 68,830(17) 78,929(19) 71,724(16) 72,400(18) 15% 0.008 410,383(100) Pediatrics/ Pediatrics 29,801(11) 41,026(17) 37,172(15) 39,626(16) 43,907(16) 46,584(20) 56% 0.008 238,115(95) Neonatal Neonatal 1,698(1) 1,574(1) 2,025(1) 2,236(1) 2,965(1) 2,632(1) 55% 0.353 13,207(5)  Total 31,499(12) 42,600(18) 39,275(16) 41,862(17) 46,871(19) 49,216(21) 56% 0.051 251,322(100) a % difference between 2005/06 and 2010/11; b p-value based on one-way ANOVA   58 Table 4.5 Clinical Placement Hours by Service and Site for Academic Years, 2005/06 to 2010/11 (con’t)  Academic Year  2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 % diff a  p- value b  Total Service Site Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Hours(%) Mental Health Psychiatry  31,442(11) 33,395(12) 36,254(13) 34,738(12) 36,995(12) 46,511(17) 50% 0.170 219,605(77) Community 5,987(2) 7,022(2) 6,682(2) 7,851(3) 8,800(3) 10,843(4) 81% <.001 47,184(17)  Residential 0 0 1,040(0) 2,192(1) 6,255(1) 1,992(2) - 0.984 11,479(4)  Addictions 95(0) 78(0) 1,334(0) 1,132(0) 2,160(1) 1,098(1) 1055% 0.543 5,896(2)  Total 37,523(13) 40,495(14) 45,580(16) 45,913(16) 54,209(21) 60,444(24) 61% 0.024 284,163(100) Residential Residential 37,094(8) 39,660(11) 38,478(10) 36,832(9) 52,635(11) 60,072(18) 62% <.001 264,771(67)  Transition 8,468(2) 10,854(3) 14,320(3) 20,888(5) 23,515(6) 28,323(8) 234% 0.891 106,836(27)  Geriatrics 8,148(2) 7,616(2) 4,696(1) 2,912(1) 0 0 -100% 0.576 23,372(6)  Continuing 1,115(0) 834(0) 268(0) 0(0) 240(0) 60(0) -95% 0.425 2,517(1)  Total 54,825(12) 58,964(15) 57,762(15) 60,632(16) 76,390(21) 88,455(26) 61% <.001 397,028(100) Community Prevention 31,074(8) 38,526(10) 37,585(11) 41,554(11) 43,835(12) 43,308(13) 39% 0.004 235,882(65) Home Care 20,334(5) 22,278(6) 21,852(6) 18,970(5) 17,491(5) 25,851(7) 27% 0.678 126,776(35)  Home Support 0 0 0 0 0 234(0) - - 234(0)  Total 51,408(14) 60,804(17) 59,437(15) 60,524(17) 61,326(18) 69,393(21) 35% 0.012 362,892(100) Other Administration 780(2) 1,710(5) 3,708(11) 2,424(7) 868(3) 1,794(5) 130% 0.033 11,284(33) Clinics 5,462(16) 3,583(11) 2,350(7) 3,050(9) 2,523(7) 2,654(8) -51% 0.845 19,622(58) Adv. Practice 0 0 0 0 24(0) 730(2) - - 754(2)  Any 0 0 0 0 1,800(5) 300(1) - - 2,100(6)  Total 7,335(20) 6,493(18) 5,938(17) 4,802(13) 6,919(19) 4,392(12) -40% 0.173 35,879(100) a % difference between 2005/06 and 2010/11; b p-value based on one-way ANOVA .   59 Chapter  5: Discussion In this chapter findings are presented in relation to the research problem within the context of the literature. Also presented in this chapter are limitations of the study, implications and recommendations for nursing practice, research and education. 5.1 Discussion of Findings The purpose of the study was to explore volume and utilization patterns in confirmed clinical placement hours by health service type, clinical placement type and nursing program within the large urban health authority of BCLM between the academic years of 2005/06 and 2010/11. Data categories were extracted from HSPnet to explore four research questions. Main findings are presented in relation to these research questions, which address: 1. How do number of clinical placement hours change over time? 2. Is there a difference in number of clinical placement hours between nursing programs (BSN, RPN or LPN)? 3. Is there a difference in number of clinical placement hours between clinical placement types (group, preceptor, or clinical learning unit)? 4. Is there a difference in number of clinical placement hours between practice settings? 5.1.1 Findings in Relationship to the Research Problem In light of the projected RN workforce shortages, the Canadian Nurses Association has recommended increasing student enrolment into nursing programs (Canadian Nurses Association, 2009). The growing number of nursing programs has increased the challenges for placing agencies to find and secure clinical placements for the growing number of students, and also adding pressure on health service sites to host more clinical experiences. Academic institutions are competing for a finite number of appropriate clinical placements to order to   60 expose students to necessary clinical learning activities to meet designated program outcomes and entry-level professional competencies (P. M. Smith et al., 2010). There are three ways the HSPnet defines capacity, according to the BCAHC (2012a); (1) capacity is the maximum clinical placements for that practice setting, if all shifts are available; (2) what is actually used; and (3) target capacity, a level set by the destination coordinator that is optimal for the staff, students and patients. Gaining an understanding of capacity and utilization patterns can further contribute to improvement to maximize placements and students’ learning thus fostering more highly qualified nurses. Practical nursing experience has long been a key element in nursing education.  Practice education is a part of the students’ educational experience and takes place in various healthcare settings. Health authorities in BC have provided the practical settings for students to acquire skills, knowledge and attitudes; however the primary responsibility for health professional training has been through the various programs in academic institutions (Newberry & Mickelson, 2007). It is undisputed that practice education has benefits to health authorities, nurses and students; nurses who have experienced clinical supervision describe the advantage as restorative and students who have been supervised describe it as indispensable (Croxon & Maginnis, 2009; Tony et al., 2008). For clinicians, the experience can facilitate a deeper awareness of their own thinking, decision-making and performances as well as to better cope with difficult situations of loss, death, guilt and suffering to achieve a more balanced work life and increase their theoretical knowledge (Tony et al., 2008). For students, the learning partnership can enable them to better incorporate theory and practice, influence their behaviours in providing safe and quality patient care, and socialize into a set of ethical values.   61 Between the academic years of 2005/06 to 2010/11, there was a 77% increase in the number of confirmed clinical placement hours hosted within the health authority. In 2010/11, just over 1 million practice hours were hosted (N, 2005/06 = 605,885; N, 2010/11 = 1,074,544), representing an actual increase of 468,659 hours. BSN programs had the majority (63%) of confirmed clinical placement hours in 2005/06, but this decreased to 51% of the total in 2010/11. In 2005/06 there were almost five times as many BSN hours than LPN hours, this has decreased to twice as many BSN hours in 2010/11 compared to LPN hours. Between 2005/06 and 2010/11, LPN hours increased by 243%, psychiatric nurse hours increased by 111%, international nurse hours increased by 84%, and BSN hours increased by 43%. The largest actual increase in hours between 2005/06 and 2010/11 was for LPN programs, which increased by 188,562 hours. This increase in hours, particularly by LPN programs, may be contributing to the strain of clinical placement demands and impacting the availability of appropriate clinical placements. Over time there was an increase in confirmed hours for all health service sites and settings. Of the ten health service sites in 2010/11, medical and surgical sites make up 58% of all confirmed hours. In 2010/11 medicine (N=1,877,177) accounted for 38% of all confirmed hours, while surgery (N=998,198) account for 20% of hours. General nursing knowledge and skills provide the foundation early on in the program of study and practice settings in which patients are less complex and more predictable provide students with the learning opportunities to acquire and consolidate a wide range of skills. Medical and surgical practice settings are appropriate for students in the early stages of their program, as students begin to link basic nursing knowledge with practice. These settings are appropriate and can accommodate group experiences, which also occur during the early stages of one’s nursing education, and it is possible though that,   62 group experiences are formatted to maximize efficiency by assigning one clinical instructor with a group of students. In light of clinical placement shortages, there are pressures to identify strategies to increase and improve clinical placement alternatives to acute care settings (Cleary, McBride, McClure, & Reinhard, 2009). Some alternative clinical placements include the use of simulation, inter-professional clinical placements, and community settings (Thompson, 2005). With healthcare initiatives to decrease wait times and increase the efficiency of patients returning home, there has been some shift to provide more community-based learning opportunities for students (Kirkham, Hoe Harwood, Terblanche, Hofwegen, & Sawatzky, 2007; Overton, Clark, & Thomas, 2009). Community practice settings include home health, public health, community mental health, corrections facilities and schools (Kirkham et al., 2007; Thompson, 2005). In the current study, however, trends over time show a consistently high proportion of confirmed practice hours for acute care settings while fewer hosted hours for clinical placements in in the community. And although there were proportional increases in placement hours for community settings like addictions centers, the actual increase in number of hours was small. Community and non-acute care settings may hold capacity for more clinical placements; however, considerations of adequate practice opportunities and appropriate learning environments should be evaluated in order for students to meet entry-to-practice level competencies upon graduation. 5.1.2 Findings in Relationship to Hypotheses All alternative hypotheses are supported in this study.  Between the academic years of 2005/06 to 2010/11 there was an increase in practice hours among all nursing programs, health service sites and placement types within the large urban health authority. Between the academic years of 2005/06 and 2010/11, there was a 77% increase in practice hours for students, from just   63 over 600,000 in 2005/06 to 1 million in 2010/11. Over time, there was a 243% increase in the number of confirmed hours for LPN programs, while only a 43% increase for BSN programs. A similar increase was found for other nursing programs: 111% for psychiatric nursing, 84% for international RN, 65% for Post RN programs, and 24% for Post LPN programs. With the increased student enrolment, academic institutions must also adjust for anticipated growth in programs, by ensuring sufficient resources, faculty, clinical placements, preceptors, budget, and classroom space. In Canada, practice education predominantly follows two models: group and preceptorship, while other models show modest uptake. From this study, group experiences are the most common model used by all nursing programs, except for Post LPN programs. Group hours were consistently almost three times higher than preceptorship (2005/06, 2.5 times higher, 2010/11, 2.77 times higher). In 2010/11, the greatest number of confirmed hours was for group (N=751,294), a 75% increase from 2005/06 (N=421,052). Since 2005/06, there was also a 63% increase in confirmed hours for preceptorships (2005/06, N=166,854; 2010/11, N=271,552). The greatest change in utilization patterns of group clinical placement types was an increase of 207% for group experiences by LPN programs, followed by psychiatric nursing (102% increase). Increases in group experiences were found for other nursing programs and lowest changes were found with BSN programs (45%) and International RN (54%). Post LPN programs showed a decrease of 17%. Preceptorship experiences had overall increases. There was an increase of 389% for preceptorship experiences among LPN programs, a 562% increase in preceptorships for International RN programs, and 112% increase in preceptorships for Psych RN programs.   64 Group experiences typically occur at the beginning of the program of study, for a shorter period of time and do not require the same human resources compared to preceptorships. In preparing graduates for their responsibilities as registered nurses, practice experiences increase in duration, responsibility and complexity (British Columbia Academic Health Council, 2012b). In the early stages of the program, the structure of group experiences is appropriate for students to demonstrate outcomes of less complexity and greater predictability. As supported by Benner’s theory, From Novice to Expert, patients cared for in group placements are relatively “stable” and coaching can be easily provided. Through coaching and by matching textbook examples with actual clinical cases the novice begins to recognize patterns, develop confidence and create change in behaviours (Benner, 1984). As the student progresses through their program, clinical judgment develops from experiential learning with repeated exposure to a variety of cases ranging in complexity and diagnoses (Benner, 1984). With the one-to-one support provided through preceptorships, they begin to develop principles that guide their actions and are entrusted with higher level responsibilities (Croxon & Maginnis, 2009). During preceptorship experiences nurses are more aware of long-term goals, understand situations as whole parts, able to expect events and in turn modify plans of action, have intuitive grasp in decision-making and perform with fluidity and flexibility (Benner, 1984). In this study, clinical learning units and field experiences were utilized less frequently than other experiences. The largest growth in CLUs was for BSN programs (48%). Other programs showed only slight increases or decreases in use of CLUs. Since their introduction as a model of practice education, CLUs have shown a slower uptake despite the many benefits. With a strong focus of teamwork, CLUs provide hands-on learning and increased inter-professional collaboration (British Columbia Academic Health Council, 2012b). Although there is evidence   65 to support the benefits of clinical learning units, the low number of confirmed hours from this study may indicate challenges to changing the way that practice education is delivered. Within the health authority, there were notable changes over time among health service sites and settings. Proportional increases from 2005/06 to 2010/11 were shown for critical care (125%), end-of-life (110%), medicine (84%), mental health (61%), residential care (61%), pediatrics/neonatal (56%), maternal/child (15%), surgical (13%). Between 2005/06 and 2010/11, there was an actual increase in hours of 468,659. Of these, increases were seen in medicine (N=190,189), residential care (N=33,630), critical care (N=28,913), mental health (N=22,921), surgery (N=21,352), and pediatrics (N=17,717). Although there were increases in the number of hours over time, specialty areas including maternal/child and end-of-life care showed smaller increases in use (maternal/child, 2005/06, N=60,770, 2010/11, N=78,304, actual change N=9,458 hours; and end-of-life, 2005/06, N=3,428, 2010/11, N=7,213, actual change N=3,785). Specialty areas require that students have a particular skill set and knowledge base before they come for their clinical experience. It is not until students become gain experience and develop a more specialized skill base that they have the opportunity to be hosted in specialty areas such as labour and delivery, critical care and palliative care. The potential for added capacity in clinical placement hours in specialty health service settings may be attributed to skill mix, patient acuity, staff burnout and availability of staff to precept students (Thompson, 2005). 5.1.3 Findings Compared to Previous General Research The purpose of practice education is to assist students to learn from experience, progress in their expertise and serve in the best interests of patients, and clinical sites (British Columbia Academic Health Council, 2012b). The healthcare system provides a substantial contribution to practice education for health care professionals by providing access to space, patients, and staff.   66 Increased demands for health services has not only affected the nursing workforce but other health disciplines, such as physiotherapy, occupational therapy, pharmacy and medicine, are increasing their student enrolment in anticipation of workforce shortages (Thompson, 2005). Efforts to address workforce shortages by increasing enrolment thus producing more graduates has placed stress on the education system and on patient care delivery systems (Scheckelhoff et al., 2008). Challenges in allocating clinical placements are a shared issue among healthcare disciplines as they continue to examine potential for added capacity and innovative models of practice education (Currens, 2003). Healthcare professionals involved in educational programs/teaching recognize the critical need to assess the current status and future capacity of the healthcare system to engage in academic-practice partnerships for practice education (Lennon, 2005; Scheckelhoff et al., 2008). Reasons to assess the current status are clinical placement shortages, healthcare reform and practice changes. While the literature is replete with the challenges of practice education and potential strategies to increase capacity, improve quality, efficiency and success of partnerships, objective evidence of current volume and utilization patterns is limited at best. Some of the challenges identified in the literature are lack of standardization and coordination among academic and practice sectors, preparation for preceptors to be effective teachers, and recruitment and retention of faculty practice experts. Rodger et al. (2008) propose a framework of partnership for the ongoing development of a coherent and collaborative approach to clinical education, which will facilitate student learning, education, and support clinical educators (Rodger et al., 2008). Three key elements include: i) a commitment at the health care and academic sector to collaborate and share a goal of facilitating the provision of skilled   67 professionals, ii) recognition and support for clinical educators, and iii) utilization of innovative models of clinical education that provide valuable learning experiences for students. Although the nursing workforce is expected to have the greatest workforce deficit in the near future, most healthcare services in Canada anticipate a workforce shortage (Beal, 2012). In response, healthcare professional programs have increased student enrolment into their programs. Most healthcare professional programs utilize experiential learning as a component of their curriculum, and students, under appropriate supervision and as permitted by specific practice guidelines, assume direct patient care responsibilities (Overton et al., 2009; Scheckelhoff et al., 2008). Apart from nursing, other healthcare professional programs use a variation of models of practice education. Medicine programs use both group and preceptorship experiences, while occupational therapy, pharmacy and physiotherapy use predominantly preceptorship experiences as their model of practice education (Newberry & Mickelson, 2007; Overton et al., 2009). In addition, healthcare professional programs are identifying alternative models for clinical placements that could be used to increase capacity and improve quality of practice education such as community, rural and simulation to address some of the clinical placement challenges (Overton et al., 2009). 5.1.4 Findings Compared to Previous Nursing Research A report published by BCAHC in September 2012 (2012a) summarizes data from the HSPnet database for 2003/04 to 2010/11 for most health care students in programs that are using HSPnet across British Columbia. The BCAHC reported that in 2010/11 there were over 4.2 million student practice hours, of these 1.6 million were preceptor hours (39.5%), 1 million of which were nursing student preceptor hours. They also reported that the total number of clinical placement requests increased from 2,145 in 2003/04 to 23,586 in 2010/11. The majority of   68 clinical placement hours were confirmed, but there were increases in declined and cancelled requests. BSN programs account for the majority of confirmed requests (N=5,096) followed by LPN (N=2,723), health care aid (N=870), occupational therapy/physiotherapy (N=83), and pharmacy (N=3). In 2010/11, CLUs also showed an increase in use since 2005/06. In the BCAHC report, CLUs accounted for 143,672 student hours in 2010/11 and an increase of 104,504 hours since 2005/06. Rural clinical placements were also described in the report; in 2010/11 there were 91,922 student hours in rural settings and 650 requests as compared to 6,790 student hours and 37 requests in 2005/06. The majority of rural clinical placements (80%) were from Vancouver Island for BSN and LPN programs. Campbell River accepted most number of clinical placements and according to the BCAHC (2012a) there were 11 placing agencies that request in rural communities. The current study described in this thesis is a subsample of the HSPnet data reported in the above-mentioned report, however the current study reported on one health authority in BC and examined trends in nursing student placement hours. In contrast to the overall BC data, preceptorships accounted for only 25% of the total hours during 2010/11 for nursing programs in the health authority. In addition, the current study did not report on number of requests and whether or not they were accepted. Instead, this study focused on only hours that were confirmed to have been hosted in the health authority. The findings in this recent BCAHC report are similar to those described in the 1-year analysis of clinical placements for medicine, pharmacy and nursing in Saskatchewan, Canada (Thompson, 2005). In the analysis of the HSPnet data, nursing accounted for the majority of confirmed clinical placements. According to Thompson (2005), between 2004 and 2005, training programs accounted for 1,099,000 student clinical placement hours, while approximately 500,000 of these hours were attributed to nursing. Nursing programs were the single program   69 area with the largest user of clinical placement hours and preceptorship hours. There was variability in use of clinical placement hours by program; medicine programs were major users of clinical placement hours and allied health were major users of preceptorship time. Acute care settings accounted for 54%, while community care accounted for 25%, and residential care accounted for 14%. In BC, medical student clinical experiences have not been tracked in HSPnet, therefore it is not possible to draw comparisons. The survey by Smith et al., (2007) found that group and preceptorship experiences were the predominant models of practice education used, although CLUs also existed, which is in alignment with the findings reported in this thesis. In the Smith et al. (2007) study, nursing programs were identified as major users of clinical placements followed by other healthcare professional programs. Respondents reported using acute care settings most of the time, followed by community and residential care settings. Medical and surgical practice areas were used most commonly. Although key informants in the survey by Smith et al. reported always finding sufficient clinical placements to cover their needs, the clinical placements were not always the most appropriate (P. M. Smith, Spadoni, et al., 2007). Because of the retrospective nature of this study, it is unclear if the data reported in this thesis concur with Smith et al. in regards to appropriateness of placements. 5.1.5 Findings Linked to Theoretical Framework Practice education in nursing can be contextually understood by the cognitive apprenticeship model established by Brown, Collins, and Duguid (Brown et al., 1989), a sub-set of the theory of situated learning. This model emerged from a constructivist perspective of the apprentice working under the guidance of the ‘master’ or expert to help develop formal knowledge, accumulate exemplars situated in authentic activity and become exposed to a variety   70 of physical and social contexts (Brown et al., 1989). According to Brown, Collins and Duguid (1989), an ideal learning environment to foster apprenticeship should include four main aspects: content, methods, sequencing and sociology. Elements of the Cognitive Apprenticeship model link to the models of practice education in that the clinical experiences expose students to real-life situations where they are supervised and supported by practice experts to develop necessary skills and apply knowledge to meet entry-to-practice competencies. The duration, responsibility, complexity of clinical experiences increases as the student progresses through their program of study (British Columbia Academic Health Council, 2012b). Student progress from specific activity to general principles which enables them to link situations with experience and knowledge, ultimately developing their self-confidence, control and expertise (Brown et al., 1989). Cognitive apprenticeship model and situated learning theorists argue that contrary to traditional perspectives of classroom education, knowledge is not developed and deployed; instead, learning and cognition are inseparable and highly context-dependent. This model embeds learning in activity and makes deliberate use of social and physical context to understand the process of learning. The learning climate of practice education within practice settings, is fostered through the interaction of physical, human, interpersonal and organizational elements that emphasize active engagement, respect and trust among students and teachers (D. Chan, 2003). In nursing the clinical learning environment complements a student’s academic program by providing appropriate clinical experiences where students observe the environment, socialize into the profession, acquire professional values and consolidate their skills (Baglin & Rugg, 2010; K. Chan & Chan, 2004; Henderson et al., 2007; Kerridge, 2008). The degree of patients’ complexity and predictability are indicators of the model of practice education used; following   71 group experiences, preceptorships and CLUs build upon prior practice experiences and theoretical knowledge for students to acquire explicit skills and develop their cognitive and metacognitive strategies that guide the decision making process (Taylor & Care, 1999). 5.2 Limitations to the Study This was a retrospective study therefore no temporal relationships can be established. There may inconsistencies in the way placing and receiving coordinators enter student clinical placement data into the HSPnet database. The terminology used to describe the type of practice settings may have changed over time and practice settings that show few confirmed hours may not indicate idle settings. Additionally, there may be other informal communication processes that some health service settings use in order to set up clinical placements, such as phone calls. Last, the context of the placements between 2005/06 and 2010/11 may not be captured. While findings are reflective of the academic and healthcare service context in the health authority, they may not necessarily reflect the outcomes of other countries or regions in BC. There are few rural practice settings within the health authority, therefore, it is difficult to generalize findings and identify those with greater capacity to host students. Additional studies within other jurisdictions are required to determine the relevance of these findings in other contexts. Although this study uses the cognitive apprenticeship model and the theory of situated learning as the contextual framework to underpin the model of practice education in nursing, neither elements of the model or theory were measured. 5.3 Implications for Nursing Practice Reflecting conditions in many other jurisdictions in Canada, there are impending shortages of health care professionals in both rural and urban areas. Increasing the supply of graduates is critical to resolve this crisis and to meet public needs and expectation for safe,   72 timely, and accessible health services. To identify the structures, processes and resources that healthcare organizations need to have in place will help support quality in practice education (e.g., student orientation and preceptorship workshops). It is clear that student practice education is a valuable activity for health authorities as students are their greatest resource for future health care provider (Newberry & Mickelson, 2007). The increases in confirmed student hours reflects major expansion of many nursing programs within BCLM. The increased tension throughout the system to boost graduate numbers has increased competition between both academic institutions and health disciplines to access sufficient quality clinical placements for students. The ability for practice settings to accommodate students is constrained by a multitude of organizational, regulatory and education requirements, including the availability and preparedness of health care professionals to teach and mentor students (Hutchings et al., 2005). As a large volume of experienced nurses retire, there are fewer appropriate staff available to support and supervise the increasing number of students. There is a risk that pressure on practice settings to accept more students could exacerbate the supervisory role imposed on health care professionals, contributing to burnout (Newberry & Mickelson, 2007; Rudman & Gustavsson, 2011). With these cumulative pressures, decreased willingness to supervise students and resistance to new and innovative ways of providing practice education contributes to growing challenges in student clinical placement (Newberry & Mickelson, 2007).  An integrated and shared framework between academic and practice is necessary to support student placements. Factors that negatively impact the quality of clinical learning environments are: staff burnout, ill-prepared students, increased patient workload, higher patient acuity, limited availability of preceptors and lack of qualified clinical instructors (Barnett et al., 2010; P. M.   73 Smith et al., 2010). Also, in the context of this study, the impact on all levels of numerous students from different programs at different levels competing for and sharing placements. According to Hutchings et al. (2005), it is difficult to provide adequate support for the increased numbers of newly qualified staff alongside supporting student learning. With the increase in number of students on the unit there may be greater challenges in terms of workload, staff morale and patient safety. Balancing practice setting needs with educational needs is a dynamic process in order to support students in attaining appropriate experiences (Newberry & Mickelson, 2007). Clinical sites should be able to provide environments that are conducive to learning, provide evidence-informed learning experiences, support student needs and educational level, and allow students sufficient time to consolidate skills (Clark & Stevens, 2006; Murray & Williamson, 2009). To achieve this greater partnership between practice and education are required. Despite the growing concern surrounding scarcity of clinical placements there are notable facilitators that can assist in overcoming this problem. Student clinical placements are an excellent recruitment strategy for practice settings to identify potential future staff members and leads to the stimulation of experienced staff (Cummins, 2009; Thompson, 2005). Health authorities benefit from student practice education as many students are subsequently hired as employees and their practice education experience has provided them with an initial orientation. Additionally, practice education helps health authorities recruit for practice settings that have more difficulties attracting staff including, rural, remote and mental health practice settings (P. M. Smith, Spadoni, et al., 2007). According to BCAHC (2011), strong partnerships between health authorities and post-secondary institutions build a foundation for capacity and quality in practice education. Enhancing resources such as the use of clinical placement committees and   74 consortiums to find and plan clinical placements, mentorship workshops and supportive management may provide possible solutions (Murray & Williamson, 2009). 5.4 Recommendations for Nursing Research HSPnet, a web-enabled practice education management system, is currently being used to coordinate and track student clinical placements. Further analysis is required to examine longitudinal trends among other health authorities within the BCLM and across Canada. Determining the barriers and facilitators of practice settings to accept or decline student clinical placements and measuring predictive components of a quality learning environment will provide evidence to support actions that can be taken to improve the allocation of clinical placements and leverage for change as performance improvements can be measured over time (Newberry & Mickelson, 2007). 5.5 Implications for Nursing Education Strong partnerships between health authorities and post-secondary institutions can facilitate effective management of clinical capacity to accommodate the growing number of student requests to ensure students get the clinical experience necessary to meet entry-level practice competencies. Academic institutions develop, implement and evaluate the theory-based curricula while health authorities provide the practice education environments where students apply and further develop the knowledge and skills gained in the classroom (British Columbia Academic Health Council, 2011). Collaboration can assist in bridging the gap between theory and practice by standardizing decision-making processes, identifying clinical changes and maximizing clinical placement opportunities. Key health and academic stakeholders engage in continuous comprehensive assessments of practice education infrastructure, as well as practice education quality review, planning, and improvement will help ensure sustainability in an ever-   75 changing healthcare environment. Practice education has been recognized as an integral and critical component of education. Government initiatives to decrease acute care wait times and faster transition for patients back into their home accentuate the importance for clinical placements that are relevant to constantly changing work practices (Government of Canada, 2012). Student practice education must reflect the anticipated growth of the nursing profession and increasingly diverse areas of practice (Overton et al., 2009). Training programs rely heavily on clinical placements in the health care sector and on preceptors to supervise student learning. Clinical experience must be comprised of sufficient hours to meet provincial standards, yet there are no clear guidelines as to the number of hours necessary to be supervised by qualified faculty and ensure students’ ability to practice at an entry level (Diem et al., 2004). Nursing programs vary in length, duration, have specific competency outcomes and distinctive number of clinical practice hours. There are inconsistencies in reported number of clinical practice hours per day, per week and per semester that the student receives during their two to four year program of study (Canadian Association of Schools of Nursing, 2003). Typically degree programs offer 200 more didactic hours and 350-500 more lab and/or clinical hours than diploma programs (Alberta Association of Registered Nurses, 2003). According to Diem et al., (Diem et al., 2004), in Canada, nurses training requires students to spend approximately 2,000 hours in clinical practice. Moreover, registered psychiatric nursing requires a minimum of 1000 clinical practice hours, with 775 clinical hours in psychiatric nursing and 225 clinical hours in general nursing (College of Registered Psychiatric Nurses of British Columbia, 2011). The amount of time and type of clinical placements available are important considerations that determine the focus of the clinical experience and extended time in clinical can be beneficial for students in developing   76 relationships, achieving academic outcomes and obtaining life skills (P. M. Smith, Seeley, et al., 2007). 5.6 Summary and Conclusion From this retrospective descriptive analysis of the HSPnet for the academic years of 2005/06 to 2010/11 there was an increase of 77% in student hours hosted at a variety of health service sites a large health authority in BC. The main findings from this study indicate that there are increasing demands and pressures for both practice and academic sectors to secure and host student practice education. Although the majority of confirmed student hours are for the BSN programs, the number of hours for LPN programs are rapidly growing. Group and preceptorship experiences are the two predominant models of practice education used within the health authority, however, CLUs and field experiences also exist. Although greater emphasis is being placed on care provided in the community, as health authorities try to decrease wait times and increase efficiency of returning patients home, inpatient settings continue to host the most student hours as compared to community. Medicine and surgical areas host the majority of students and these practice hours have increased over time. Practice education is a strategic issue for health care organizations, and improving capacity for student practice learning is of critical importance to health human resource development (British Columbia Academic Health Council, 2011; Newberry & Mickelson, 2007). Significant research supports the importance of clinical experience for both education and practice: students’ benefit from having real world experiences, while healthcare providers benefit by identifying potential new workforce members who have relevant experience (Levett-Jones, Fahy, Parsons, & Mitchell, 2006; Newton, Jolly, Ockerby, & Cross, 2010). Further research is needed to determine the relationship between quantity and quality of the practice environments   77 to develop an organizational culture that celebrates student learning and supports practice education for staff and students, and to evaluate the appropriateness of practice settings to provide the necessary skills and knowledge to achieve professional practice outcomes.    78 References Alberta Association of Registered Nurses. (2003). Baccalaureate nursing degree as minimum education requirement for entry to registered nursing practice in Alberta (pp. 67). Edmonton, AB: Alberta Association of Registered Nurses. Baglin, M. R., & Rugg, S. (2010). Student nurses' experiences of community-based practice placement learning: a qualitative exploration. Nurse Education in Practice, 10(3), 144- 152. doi: 10.1016/j.nepr.2009.05.008 Barnett, T., Cross, M., Jacob, E., Shahwan-Akl, L., Welch, A., Caldwell, A., & Berry, R. (2008). Building capacity for the clinical placement of nursing students. Collegian, 15(2), 55-61. Barnett, T., Cross, M., Shahwan-Akl, L., & Jacob, E. (2010). The evaluation of a successful collaborative education model to expand student clinical placements. Nurse Education in Practice, 10(1), 17-21. doi: 10.1016/j.nepr.2009.01.018 BC Ministry of Advanced Education: Technology and Innovation. (2012). B.C. Post-secondary Education Facts.   Retrieved December 23, 2012, from http://www.aved.gov.bc.ca/mediaroom/facts.htm Beal, J. A. (2012). Academic-service partnerships in nursing: An integrative review. Nursing Research and Practice, 2012(1), 1-9. Benner, P. (1984). From novice to expert: Power and excellence in nursing practice. Palo Alto, CA: Addison-Wesely. Bourbonnais, F. F., & Kerr, E. (2007). Preceptoring a student in the final clinical placement: reflections from nurses in a Canadian Hospital. Journal of Clinical Nursing, 16(8), 1543- 1549.   79 British Columbia Academic Health Council. (2004). Practice education survey final report. Vancouver, BC: British Columbia Academic Health Council. British Columbia Academic Health Council. (2011). About BCAHC.   Retrieved April 3 2012, from http://www.bcahc.ca/ British Columbia Academic Health Council. (2012a). HSPnet Data Report for 2010-11. Vancouver, BC: British Columbia Academic Health Council. British Columbia Academic Health Council. (2012b). What is Practice Education?   Retrieved March 31, 2012, from http://practiceeducation.org/index.php?option=com_content&view=article&id=1&Itemid =6 Brown, J. S., Collins, A., & Duguid, P. (1989). Situated cognition and the culture of learning. Educational Researcher, 18(1), 32-42. Budgen, C., & Gamroth, L. (2008). An overview of practice education models. Nurse Education Today, 28(3), 273-283. Callaghan, D., Watts, W. E., McCullough, D. L., Moreau, J. T., Little, M. A., Gamroth, L. M., & Durnford, K. L. (2009). The experience of two practice education models: Collaborative learning unit and preceptorship. Nurse Education in Practice, 9(4), 244-252. Canadian Association of Schools of Nursing. (2003). Clinical Practice Education Survey 2003 Ottawa, ON: Canadian Association of Schools of Nursing. Canadian Association of Schools of Nursing. (2010). Nursing Education in Canada Statistics 2008-2009. Ottawa, ON: Canadian Association of Schools of Nursing. Canadian Federation of Nurses Union. (2012). The Nursing Workforce (pp. 1-8). Ottawa, ON: Canadian Federation of Nurses Union.   80 Canadian Institute for Health Information. (2011). Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa, ON: Canadian Institute for Health Information. Canadian Institute for Health Information. (2012). Types of Care.   Retrieved December 5, 2012, from http://www.cihi.ca/CIHI-ext-portal/internet/EN/Theme/types+of+care/cihi000002 Canadian Institute of Health Information. (2010). Regulated Nurses: Canadian Trends, 2005- 2009 (pp. 1-217). Ottawa, ON: Canadian Institute of Health Information. Canadian Nurses Association. (2009). Tested solutions for eliminating Canada's registered nurse shortage. Ottawa, ON: Canadian Nurses Association. Carrière, Y., & Galarneau, D. (2011). Statistics Canada: delayed retirement: a new trend? Ottawa, ON: Statistics Canada. Chan, D. (2003). Validation of the clinical learning environment inventory. Western Journal of Nursing Research, 25(5), 519-532. Chan, K., & Chan, C. (2004). Social workers' conceptions of the relationship between theory and practice in an organizational context. International Social Work, 47(4), 543-557. doi: Doi 10.1177/0020872804046260 Chouinard, N. T. (2009). HSPnet: A Canadian national student placement system…and more. Journal of Diagnostic Medical Sonography, 25, 121-124. Clark, C., & Stevens, C. (2006). A web-based programme for hospital and community student placements. British Journal of Community Nursing, 11(1), 23-28. Cleary, B. L., McBride, A. B., McClure, M. L., & Reinhard, S. C. (2009). Expanding the capacity of nursing education. Health Affairs, 28(4), w634-w645. College of Registered Nurses British Columbia. (2012a). Education and Examinations. from https://http://www.crnbc.ca/crnbc/Documents/Centennial/education-examinations.html   81 College of Registered Nurses British Columbia. (2012b). What Nurses Do.   Retrieved December 5, 2012, from http://www.crnbc.ca/Whatnursesdo/pages/default.aspx. College of Registered Psychiatric Nurses of British Columbia. (2011). Guidelines for education assessment of internationally educated psychiatric nurses. Vancouver, BC: College of Registered Psychiatric Nurses of British Columbia. Collins, A., Brown, J. S., & Holum, A. (1991). Cognitive apprenticeship: Making thinking visible. American Educator(Winter), 1-18. Collins, A., Brown, J. S., & Newman, S. E. (1989). Cognitive apprenticeship: Teaching the crafts of reading, writing, and mathematics. In L. Resnick (Ed.), Knowing, learning, and instruction: Essays in honor of Robert Glaser (pp. 487). Hillsdale, NJ: Lawerence Erlbaum Associates. Croxon, L., & Maginnis, C. (2009). Evaluation of clinical teaching models for nursing practice. Nurse Education in Practice, 9(4), 236-243. Cummins, A. (2009). Clinical supervision: The way forward? A review of the literature. Nurse Education in Practice, 9(3), 215-220. Currens, J. B. (2003). The 2:1 clinical placement model: Review. Physiotherapy, 89(9), 540-554. Darcy Associates. (2009). A new model of clinical placement governance in Victoria: Final report. Victoria, Australia: Council of Victorian Health Deans and the Department of Human Services. Diem, E., Cragg, B., Moreau, D., Lauzon, S., Blais, J., McBride, W., & Idriss, D. (2004). Educational Preparation Objective C and D Clinical Placement (pp. 155). Ottawa, ON: Canadian Nurses Association.   82 Engestrom, Y. (2001). Expansive learning at work: Toward an activity theoretical reconceptualization. Journal of Education and Work, 14(1), 133-156. Eraut, M. (2000). Non-formal learning and tacit knowledge in professional work. British Journal of Educational Psychology, 70(1), 113-136. doi: 10.1348/000709900158001 Fraser Health Authority. (2011). Taking action to reduce hospital congestion and improve patient care Retrieved December 23, 2012, from http://www.fraserhealth.ca/about_us/quality- and-safety/ Ghefaili, A. (2003). Cognitive apprenticeship, technology, and the contextualization of learning environments. Journal of Educational Computing, Design & Online learning, 4, 1-27. Government of Canada. (2012). Canadians in Context - Aging Population.   Retrieved April 3, 2012, from http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=33 Greeno, J. G., Collins, A. M., & Resnick, L. (1996). Cognition and Learning. In D. C. Berliner, R. (Ed.), Handbook of educational psychology (pp. 15-46). New York, NY: Macmillan. Hall, W. A. (2006). Developing clinical placements in times of scarcity. Nurse Education Today, 26(8), 627-633. doi: 10.1016/j.nedt.2006.07.009 Health Canada. (2006). Nursing Issues: Education. Ottawa, ON: Health Canada. Health Sciences Placement Network of Brisith Columbia. (2011). Health Science Placement Network Overview and Benefits.   Retrieved November 21, 2011, from http://www.hspcanada.net/ Henderson, A., Heel, A., & Twentyman, M. (2007). Enabling student placement through strategic partnerships between a health-care organization and tertiary institutions. Journal of Nursing Management, 15(1), 91-96. doi: 10.1111/j.1365-2934.2006.00634.x   83 Hoe Harwood, C., Reimer-Kirkham, S., Sawatzky, R., Terblanche, L., & Van Hofwegen, L. (2009). Innovation in community clinical placements: a Canadian survey. International Journal of Nursing Education Scholarship, 6(1). doi: 10.2202/1548-923x.1860 Holmlund, K. , Lindgren, B. , & Athlin, E. (2010). Group supervision for nursing students during their clinical placements: its content and meaning. Journal of Nursing Management, 18(6), 678-688. Hutchings, Andy, Williamson, Graham R., & Humphreys, Ann. (2005). Supporting learners in clinical practice: Capacity issues. Journal of Clinical Nursing, 14(8), 945-955. doi: 10.1111/j.1365-2702.2005.01239.x Hutchins, E. (1995). How a cockpit remembers its speeds. Cognitive Science, 19(3), 265-288. Ishida, D. N., Ako, M. M., & Sekiguchi, L. D. (1998). Cooperative Education in Nursing: A Strategy for Increasing Marketability. Journal of Nursing Education, 37(6), 260-263. Jonson, K. (2006). Developing Clinical Teaching Units in Fraser Health Authority (pp. 1-7). Vancouver, BC: Fraser Health Authority. Kerridge, J. L. (2008). Supporting student nurses on placement in nursing homes: the challenges for the link-tutor role. Nurse Education in Practice, 8(6), 389-396. doi: 10.1016/j.nepr.2008.03.003 Kirkham, S. R., Hoe Harwood, C., Terblanche, L., Hofwegen, L. V., & Sawatzky, R. (2007). The use of clinical placements in nursing education: A national survey. Langley, BC: Trinity Western University. Lambert, V., & Glacken, M. (2005). Clinical education facilitators: A literature review. Journal of Clinical Nursing, 14(6), 664-673. doi: 10.1111/j.1365-2702.2005.01136.x   84 Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge, UK: Cambridge University Press. Lave, J., & Wenger, E. (1999). Legitimate peripheral participation in communities of practice. Learning and Knowledge, 21-35. Lennon, B. (2005). Medical workforce expansion in Australia: A commitment and capacity. Paper presented at the International Medical Workforce Collaborative, Winnipeg, MB. Levett-Jones, T., Fahy, K., Parsons, K., & Mitchell, A. (2006). Enhancing nursing students' clinical placement experiences: a quality improvement project. Contemporary Nurse: a Journal for the Australian Nursing Profession, 23(1), 58-71. doi: 10.5555/conu.2006.23.1.58 Luhanga, F. L., Billay, D., Grundy, Q., Myrick, F., & Yonge, O. (2010). The one-to-one relationship: is it really key to an effective preceptorship experience? A review of the literature. International Journal of Nursing Education Scholarship, 7(1), 1-15. Mannix, J., Faga, P., Beale, B., & Jackson, D. (2006). Towards sustainable models for clinical education in nursing: An on-going conversation. Nurse Education in Practice, 6(1), 3-11. doi: 10.1016/j.nepr.2005.05.004 Massachusetts Department of Higher Education. (2012). Massachusetts Centralized Nursing Clinical Placement System (MCNCPS) Retrieved June 4, 2012, from http://www.mass.edu/mcncps/welcome.asp Murphy, G. T. (2009). Tested solutions for eliminating Canada's registered nurse shortage. Ottawa, ON: Canadian Nurses Association.   85 Murray, S. C., & Williamson, G. R. (2009). Managing capacity issues in clinical placements for pre-registration nurses. Journal of Clinical Nursing, 18(22), 3146-3154. doi: 10.1111/j.1365-2702.2008.02693.x Nersessian, N. J., Kurz-Milcke, E., Newstetter, W. C., & Davies, J. (2003). Research laboratories as evolving distributed cognitive systems. Paper presented at the 25th Annual Meeting of the Cognitive Science Society, Boston, MA. Newberry, J., & Mickelson, G. (2007). Indicators of practice education quality in health care organizations: A literature review BC Practice Education Initiative (pp. 30): British Columbia Academic Health Council. Newton, J. M., Jolly, B. C., Ockerby, C. M., & Cross, W. M. (2010). Clinical learning environment inventory: Factor analysis. Journal of Advanced Nursing, 66(6), 1371-1381. doi: 10.1111/j.1365-2648.2010.05303.x Nursing Education Program Approval Board. (2005). Standards for Alberta nursing education programs leading to initial entry to practice as registered nurse (pp. 18). Edmonton, AB: Nursing Education Program Approval Board. O'Connor, S. J. (2007). Developing professional habitus: a Bernsteinian analysis of the modern nurse apprenticeship. Nurse Education Today, 27(7), 748-754. doi: 10.1016/j.nedt.2006.10.008 Overton, A., Clark, M., & Thomas, Y. (2009). A review of non-traditional occupational therapy practice placement education: a focus on role-emerging and project placements. British Journal of Occupational Therapy, 72(2), 294-301. Pollard, C., Ellis, L., Stringer, E., & Cockayne, D. (2007). Clinical education: A review of the literature. Nurse Education in Practice, 7(5), 315-322. doi: 10.1016/j.nepr.2006.10.001   86 Rodger, S., Webb, G., Devitt, L., Gilbert, J., Wrightson, P., & McMeeken, J. (2008). Clinical education and practice placements in the allied health professions: an international perspective. Journal of Allied Health, 37(1), 53-62. Rogoff, B. (1990). Apprenticeship in thinking: Cognitive development in social context. Oxford, UK: Oxford University Press. Ross, S., & Marriner, A. (1985). Cooperative education: experience-based learning. Nursing Outlook, 33(4), 177-180. Rudman, A., & Gustavsson, J. (2011). Early-career burnout among new graduate nurses: A prospective observational study of intra-individual change trajectories. International Journal of Nursing Studies, 48(3), 292-306. Scheckelhoff, D. J., Bush, C. G., Flynn, A. A., MacKinnon, G. E., Myers, C. E., Kahaleh, A. A., . . . Sheaffer, S. L. (2008). Capacity of hospitals to partner with academia to meet experiential education requirements for pharmacy students. American Journal of Health- system Pharmacy: AJHP, 65(21), e53-71. Service Canada. (2012). Registered Nurses.   Retrieved March 13, 2012, 2012, from http://www.servicecanada.gc.ca/eng/qc/job_futures/statistics/3152.shtml Smith, M. K. (2009, 2009). Communities of practice: The encyclopedia of informal knowledge. Retrieved March 31 2012, from http://www.infed.org/biblio/communities_of_practice.htm Smith, P. M., Corso, L. N., & Cobb, N. (2010). The perennial struggle to find clinical placement opportunities: A Canadian national survey. Nurse Education Today, 30(8), 798-803. doi: 10.1016/j.nedt.2010.02.004   87 Smith, P. M., Seeley, J., Sevean, P., Strickland, S., Spadoni, M. , & Dampier, D. (2007). Costing Nursing Clinical Placements in Canada (pp. 45). Ottawa, ON: Canadian Association of Schools of Nursing. Smith, P. M., Spadoni, M., Seeley, J., Sevean, P., Dampier, S, & Strickland, S. (2007). An Inventory of Strategies to Deliver Nursing and Interprofessional Clinical Placements in Canada (pp. 52). Ottawa, ON: Canadian Association of Schools of Nursing. Stalmeijer, R. E., Dolmans, D. H., Wolfhagen, I. H., & Scherpbier, A. J. (2009). Cognitive apprenticeship in clinical practice: can it stimulate learning in the opinion of students? Advances in Health Sciences Education: Theory & Practice, 14(4), 535-546. doi: 10.1007/s10459-008-9136-0 StudentMAX. (2012). Student Max an Oregon Clinical Placement System.   Retrieved June 4, 2012, from https://http://www.studentmax.org/ Taylor, K. L., & Care, W. D. (1999). Nursing education as cognitive apprenticeship. A framework for clinical education. Nurse Educator, 24(4), 31-36. Thompson, L. (2005). Clinical placement capacity review: Final report and recommendations (pp. 41). Saskatoon, SK: Saskatchewan Academic Health Sciences Network (SAHSN). Tony, B., Louise, B., Christine, J., & Majda, P. (2008). Wicked spell or magic bullet? A review of the clinical supervision literature 2001-2007. Nurse Education Today, 28(3), 264-272. Wolff, A., Pesut, B., & Regan, S. (2010). New graduate nurse practice readiness: Perspectives on the context shaping our understanding and expectations. Nurse Education Today, 30(2), 187-191. doi: 10.1016/j.nedt.2009.07.011 Zilm, G. (1977). The trend in nursing education and what it means in health care delivery. Canadian Medical Association Journal, 116(8), 936, 941-932, 945-936.

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.24.1-0071865/manifest

Comment

Related Items