Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Capacity building:

professional staff and student development/preparation for DEU teaching roles

ANMC Competencies :

Australian Nursing and Midwifery Council competencies required for registration as a nurse (RN) or midwife (RM) (ANMC n.d.)

Principal Academic (PA):

an academic lecturer in clinical (nursing school faculty member) who visits the clinical setting prior to student placement to facilitate clinical staff preparation for working with the students and thereafter visits the clinical setting regularly throughout each semester; communicates and liaises with students, the LN and the CNC, and utilises their ongoing expertise to facilitate students’ learning

Dedicated Liaison Nurse (DLN)/Clinical Liaison Nurse (CLN):

an experienced Registered Nurse (RN) selected from the practice area who takes on extra responsibilities, including overseeing clinical learning in the DEU and liaising between staff, students and academics/faculty the liaison between the unit and the University Academic Liaison Nurse (ALN) a permanent clinical lecturer at the University who provides consistent support to students and clinicians

Registered Nurse (RN):

College- or University-qualified nurse licensed by a nursing registration body to undertake all facets of nursing in accordance with the body’s regulations

Enrolled Nurse (EN):

Diploma-qualified nurse working under supervision of a RN to provide nursing care

Clinical Instructor (CI):

a staff nurse who wants to teach

Clinical Faculty Coordinator (CFC):

nursing faculty from the University who plans students’ experience and informs Clinical Instructors (CI) what is covered in University classes each week

Introduction

The Dedicated Education Unit (DEU) is a set of principles and concepts that enable change in curriculum and clinical learning contexts while maintaining increased student time and opportunity for clinical learning throughout their journey to becoming professional nurses. DEUs are designed to encompass clinical and academic staff capacity building through designating DEU-specific roles and responsibilities, such as Liaison Nurse/Dedicated Liaison Nurse (LN/DLN), Clinical Nurse Consultant (CNC) or Principal Academic (PA), as described in Chaps. 2, 4, 5, 6, 7, 8, 10 and 11 (this volume). The basic design whereby clinical staff act as nursing students’ primary clinical instructors in the clinical setting generates clinical staff capacity building as they go about their day-to-day work with students in the DEU (see Craig and Moscato, Chap. 6, this volume). However, it is still essential to provide clinical staff with enhanced opportunities to learn how to teach students, as recommended by Benner et~al. (2010), in the interests of improved nursing education and patient safety.

It is not only clinical staff who need these opportunities to learn how to teach nursing students. Academic staff benefit by maintaining the currency of their clinical knowledge and skills to inform their classroom teaching. Students develop further educative skills in the DEU context of peer teaching and learning. Curriculum and assessment are key considerations when designing formal capacity building strategies/events, considerations based on the fact that patient safety is paramount. Reshaping the timing of clinical placements to privilege clinical equally with the theory of classroom work (Bail et~al., Chap. 5, this volume) as a curriculum design strategy, for example, engenders greater integration of the two, and greater sharing and valuing of clinician and academic knowledge, thus supporting capacity building for all DEU staff.

Capacity Building and Curriculum: The Influence of Learning Outcomes, Graduate Attributes and Competencies

Achieving the formal and incidental learning outcomes, reflected in graduate attributes and nursing competencies relevant to the country in which a DEU is operating, is a goal for which students, clinicians and academics strive. In the DEU, the outcomes surpass the designated learning objectives. There is a need to build student, clinician and academic capacity in DEUs to ensure they meet the goals. The original Flinders University School of Nursing philosophy statements reflect the need to design the curriculum to take account of two potentially conflicting goals in nurse education: to prepare students ‘for beginning level practice as registered nurses … [and] to develop cognitive skills, values and attitudes which will prepare them for lifelong learning and reflective practice’ (FUSON 1991: 20). Curriculum design, including peer teaching and learning in DEUs, and other ways of engaging students as partners with academics and clinical staff in learning theory and practice, such as student feedback sessions, have a direct influence on students’ achievement of their goals. The value of student feedback sessions is evidenced in a statement by DEU students Anj Taylor and Vandhana Nand (Story 1, Chap. 10, this volume): ‘We’ve changed a lot already through the feedback sessions and these changes have been put in place for the next DEU. We feel so valued; our voices were heard’.

Capacity Building in Assessment and Feedback

As identified by Grealish et~al. (Chap. 3, this volume), the area of clinical assessment remains a challenging component of nursing education for clinicians and academics (Cowan et~al. 2005; McAllister 1998). The never-ending question of how to assess the student’s progress towards becoming a competent novice RN leads to a critical focus on forms of assessment and who is best placed to undertake them. Therefore, much capacity building for DEU clinical and academic staff has an assessment focus. The argument is put forward in Taylor and Nand (Story 1, Chap. 10, this volume) that ‘assessments are harder in DEUs because the tutors are there all the time. With other students, assessment is just a process. It is not going on all the time’.

Clinicians and academics need to be equipped with the capacity to understand and acknowledge the possibility that the different biases of employer expectations and academic expectations can influence the way students are assessed. Clinical facilitators (academics) assess students as beginning practitioners, whereas clinicians may assess students from a workplace perspective—how ready students are to start work—rather than from the perspective of students as learners.

Building Capacity in the Language of Assessment

The language of assessment is explained in formal capacity building strategies such as workshops. This language must reflect the clinical learning environment—learning assessment tools (competencies)—and this language is not common to nurses’ clinical situation. Therefore, it is necessary to build clinicians’ capacity to have a greater understanding of the meaning of academic language and to modify the assessment criteria/language to better reflect the clinical learning environment meaning and context. For example, a highly experienced nurse, using the intuitive knowledge that comes with their experience, might say to a clinical facilitator, ‘That student will make a good nurse’, or ‘That student is going to fail’. Capacity building involves giving clinical staff a language to describe this and to use the language in an informed way. Developing the language of assessment in clinicians may be as simple as asking for specific details such as time, place, what, when and how when someone says, ‘This student has a problem’. When someone says, ‘This student is achieving well’, they need to give a specific description, for example, ‘The Student looked after x patient and was able to…’ (specific details of what they did well and how they did it well, ‘They did this, this and this’). Then the nurse needs to identify what difference the student has made to the patient outcome or the clinicians’ outcomes. This detail is needed when assessing students in terms of registration board competencies.

Understanding and practising the language of assessment helps clinicians and academics validate their assessments. It gives them the language needed to stand up in front of their colleagues and validate what might otherwise seem to be nuanced assessment, a subjective judgement based solely on the assessor’s level of practice expertise (Benner 1984), without objective explanation. The language also enables clinicians and academics to identify and talk about the biases and noise (e.g. culture and other distractions from the objectives of the assessment) that might impact their assessment. It enables them to identify the criteria for accountability of their assessment as a way of evaluating the effectiveness of the approaches to teaching and learning in different clinical contexts. Particularly important in capacity building for DEU staff is assisting them to assess in a progressive manner because students are in the unit over an extended time. The different structure of DEUs requires assessors to validate specific concepts being addressed over time. For example, when they see a student doing something, assessors need to look back to what the student did previously, rather than simply assessing the students’ current performance. Looking back to the student’s previous performance is an important step in establishing rigour in the assessment process and evaluating the student’s progression in both their learning and labour force practice.

Building Capacity in Understanding Different Types of Assessment

Understanding the different types of assessment and their benefit or limitations is also a necessary part of capacity building for staff and students in DEUs. Therefore, sessions are needed for clinicians, academics and students on understanding formative, summative and self-assessment. In the DEU, constructive ongoing feedback and constant assessment add rigour to the whole assessment process. ‘Assessors (clinicians) are right there all the time with the students’ (Taylor and Nand, Story 1, Chap. 10, this volume); they become familiar with the students so they can observe progressions or regressions and effectively intervene to optimise students’ progress or step in to address any problems. Students’ learning is not limited—students progressing well can be given increased opportunity for autonomy, while those requiring greater support have the support on hand. Peer teaching plays an important role in students being able to facilitate each other’s learning, assess each other’s progress and audit self-assessments.

As described by Bail et~al. (Chap. 5, this volume), students are supported to self-assess as a component of their formative assessment part way through their placement. Students are provided with the ANMC Competencies (ANMC n.d.) (utilised for registration of nurses in Australia) and asked to describe examples where they have demonstrated components of nursing practice, such as ‘practices within an ethical nursing framework’ or ‘establishes and maintains therapeutic relationships’. The students self-assess performance against the standards, utilising the Bondy Rating Scale (1983).

Formative assessment is provided informally in meetings with the Principal Academic (PA) and/or the Dedicated Liaison Nurse (DLN) and includes discussion, feedback and feedforward. The PA and/or the DLN conduct summative feedback, which is part of the final assessment. This is again graded against the ANMC Competencies (ANMC n.d.) using the Bondy Rating Scale. The final assessment takes place at a meeting with the student and is based on three major sources of evidence: student self-assessment, PA judgement on attitudes and knowledge based on critical conversations over the semester, and specific feedback about clinical skills and attitudes from clinicians with whom the students have worked. This ongoing summative assessment contributes to progressive learning across placements throughout the students’ degree. The meeting also has a formative aspect, and students are encouraged to identify their learning needs for the next months of their careers. The ongoing and collaborative nature of assessment acts as a capacity building tool, enabling clinicians, academics (clinical facilitators) and students to learn to assess through practice.

In the Canterbury, New Zealand, DEU model described in Chap. 7, the Clinical Liaison Nurse (CLN) and Academic Liaison Nurse (ALN) undertake students’ formative and summative assessments. They introduced this process to promote the role of the DEU staff as clinical teachers and to provide a consistent and valid assessment process because students work with multiple nurses. The student completes their self-assessment and gives it to the CLN or ALN the day prior to assessment. The ALN and CLN discuss the student’s self-assessment and their own estimation of the student’s progress, after which the student joins the meeting to discuss their progress and set goals for the remainder of the placement. Summative assessments follow a similar format. Thus, the way assessment is undertaken is a capacity building strategy.

In the Swedish DEU (Ekebergh, Chap. 8, this volume), emphasis is placed on learning progression. Each DEU has a certain educational level (some may have two) in relation to the education programme as a whole. The level for each DEU should have a pronounced awareness of the students’ learning processes during their clinical studies and should relate this to their individual study plans. The DEU should take an active lead in developing and creating structures and other strategies to ensure that the learning progression is in line with the lifeworld perspective as a basis for learning.

Capacity Building for Feedback in the Clinical Setting

Clinicians, academics and students need capacity building for feedback processes in clinical settings. Feedback is very contextual and more immediate than assessment, spanning complex or simplistic and linear experiences. As Bail et~al. explain in Chap. 5 (this volume), the restructured Canberra University nursing curriculum placed added emphasis on the feedback students gain in both clinical and theoretical components of their learning and how it ‘feeds forward’ to affect their professional development. Feedback contains the crucial ‘sandwich component’, telling the student what they’ve done well, where they can improve and giving them some insight into how they can improve. This component is also about assessment.

Workshops, as described in the next section, are key structured events for building the capacity of clinical and academic staff in DEUs. Preliminary face-to-face preparation sessions for DEU students detailing peer teaching and learning are a strategy used to build students’ capacity for self- and peer assessment as part of overall preparation for learning and working in the clinical context.

Formal Capacity Building Strategies for DEU Clinical and Academic Staff

Formal, structured, scheduled activities designed to build DEU staff capacity include clinical staff completing clinical feedback forms and evaluation surveys; involving clinical staff in student orientation to DEUs; involving academics and students in ward team meetings; academic and clinical staff liaison regarding student behaviour and performance; and inviting clinical and academic staff to become members of a practice development working party (Bail et~al., Chap. 5, this volume). However, workshops have become the most common form of structured capacity building for clinical and academic DEU staff (Gonda, Chap. 4, Bail et~al., Chap. 5 and Casey et~al., Chap. 7, this volume). They have been proven successful as capacity building strategies.

Workshops

Workshops, held predominantly at Universities but sometimes in clinical venues, are designed to help clinical staff understand what the students are learning in the classroom and what their expected learning objectives are at a particular year level. The formal and incidental learning outcomes are also explored in the context of specific DEUs. The workshops are also designed to help academics keep in touch with the latest changes in the clinical setting. They aim to develop clinicians’ and academics’ capacity to integrate the University and clinical curriculums, to share knowledge and experiences, develop firm relationships and be well prepared to teach and assess students in DEUs. One of the greatest benefits of holding workshops at the Universities is that clinical and academic staff from all DEUs can attend, whereas workshops held in a clinical venue only accommodate clinical and academic staff from that venue. For example, University of Canberra (UC) holds a ‘Mega DEU’ once a year. All Dedicated Liaison Nurses (DLN) and DEU clinical managers are invited to a forum as an opportunity to develop collaboratively and learn from each other. Clinicians working with health students on clinical placements provided by UC are also invited to twice-yearly free workshops (Bail et~al., Chap. 5, this volume). In Canterbury, New Zealand, CPIT/CDHB runs workshops each semester to educate clinical and academic staff undertaking key roles in the DEU for the first time, and to update existing DEU staff on curriculum changes and provide opportunities to problem solve issues and look for quality assurance and research opportunities (Casey et~al., Chap. 7, this volume).

The original workshop concept resulted from staff feedback to the PAs after the Flinders University School of Nursing DEU pilot. It arose in response to expressions of interest and comments from DEU staff. One-day workshops were made available to all nursing staff (Registered Nurses-RNs and Enrolled Nurses-ENs) in the DEU. Workshops were offered strategically at the beginning of the year in the 2–3 weeks prior to clinical commencing to ensure workshop participants are still in the DEU when the students arrive. The workshops were also offered on 6 days to enable as many nursing staff as possible to attend on different days without disrupting the nursing rosters. Initially, staff members were seconded. The school paid this cost as well as catering costs; lunch, morning and afternoon tea provided irreplaceable networking opportunities for clinical and academic staff and a valuable extension of the whole workshop experience. These breaks were invaluable for both professional and personal networking and informal brainstorming of ideas about DEUs, how this one did it differently from that one, and shared support for concerns clinicians raised. The DEU venues considered the workshops to be a valuable professional development for their staff. Today it would count towards the 20 h mandatory professional development they are required to complete.

One significant DEU venue chose to have a workshop on their site as an alternative arrangement. This was carried out in order to meet the staff capacity building objective. However, having the workshops on-site minimised the opportunities for networking with DEU staff from other sites.

Whenever a new DEU was developed, maximum numbers of staff were encouraged to attend the workshops. Any new staff members in long-established DEUs were encouraged to attend. Clinical facilitators (PAs) employed by the University who would go to hand over time several times prior to the students’ arrival in the DEU also attended the workshops.

A Flinders University School of Nursing one-day workshop programme is given here as an example of a clinical and academic staff capacity building opportunity.

  1. 1.

    Meet and greet. The workshop begins with a meet and greet, where clinical and academic staff can meet each other, identify which DEUs they are in, what their roles are and get an overview of different DEUs. This introductory time also enables staff to meet the course coordinators and clinical placement coordinators with whom they will be in contact.

  2. 2.

    Overview of the DEU experience: the nature of the team. After meeting and greeting, the DEU coordinator presents a brief overview of the DEU experience: the nature of the team. The coordinator explains the principles behind the DEU and how it came to be, then gives a brief presentation of how it works in the clinical setting. Workshop participants see a variety of DEU configurations (e.g. mental health, acute surgical) to demonstrate how the DEU adapts to the particular learning environment.

  3. 3.

    Undergraduate nursing programme. Course coordinators give a short presentation outlining the undergraduate nursing programme. This is essential to the clinicians’ understanding of what students are learning across the entire programme; it gives a whole of the curriculum picture and helps build another bridge between the University and clinical learning contexts.

  4. 4.

    Specific semester topics, clinical direction and assessment. Topic coordinators give the final presentation before morning tea in which they explain specific semester topics and talk about clinical direction and assessment. Topics covered included facilitating theory to practice transfer of students’ learning; fulfilling the topic objectives in the clinical setting; assessment details related to the clinical experience; and who is to do assessment (clinical staff or the PA). In the final semester, assessment is a formal process between the PA and a clinical staff member who is in a position to have informed input.

  5. 5.

    Supporting clinical learning. This session details teaching and learning strategies staff can use, including thinking aloud, small blocks of knowledge building into larger knowledge or having an umbrella to hook pieces of knowledge into relevant practice, situated learning, principles of reflection in practice, and peer learning and teaching—explaining the theory behind the clinicians’ practice of teaching the students in clinical.

  6. 6.

    Lunch. personal and professional networking between work colleagues, previous clinical contacts and academics. This casual capacity building enables academics to catch up on what is happening regarding development and changes in clinical venues.

  7. 7.

    Clinical coaching and the Liaison Nurse (LN) role. A short presentation about clinical coaching and the Liaison Nurse (LN) role follows lunch. It focuses on facilitating optimal learning outcomes for students by identifying their strengths, supporting ongoing development/identifying areas of concern and initiating appropriate interventions. One intervention DEU clinical and academic staff need to understand is the clinical learning contract; a contract designed to provide students at risk of failing the clinical component of a nursing practice topic with the opportunity to focus on areas of unsatisfactory practice identified by clinical staff. Students work collaboratively with clinical coaches and PAs to successfully complete the contract and the clinical component of their course. The contract consists of clearly stated clinical practice issues that need attention, student learning objectives, learning strategies and clinical practice evaluation criteria. It is signed by the PA and the student.

  8. 8.

    English as a second language (ESL) teaching strategies. This is included in response to clinicians’ requests. Increasing numbers of ESL students participating in clinical cause concern. The session is about strategies for minimising confusion, understanding cultural nuances of different students, providing effective feedback to those students, understanding ‘face-saving’ issues, ensuring participation in the clinical area, emphasising that the onus for learning was on the students and highlighting adult learning principles for ESL students. This session is followed by an afternoon tea, allowing time for lively discussion among clinicians and academics about strategies to help ESL students with their communication skills.

  9. 9.

    Feedback and assessment of competence. The final session focuses on the critical issue of feedback and assessment of competence. This topic is fraught with hard questions and angst for clinicians, academics and students. The session focuses on assessment for competencies. It is particularly oriented towards more senior students effectively achieving their registration competencies. It is emphasised that in the second part of 2nd year and all of 3rd year, students are expected to meet the ANMC Competencies (ANMC n.d.) for their year level. At the end of 2nd year, students are expected to be using competencies for practice but only have a quarter of a workload. At the end of 3rd year, students are expected to meet the competencies in anticipation of registration and manage the full workload for a novice RN.

  10. 10.

    Participant feedback. At the end of the workshop, participants are asked for feedback to identify the workshop’s strengths, where improvement is needed and suggestions for future workshops. Some examples of strengths identified from workshops are as follows: ‘This really helped consolidate my knowledge and how to run the DEU’; ‘Overall more understanding and appreciation of difficulties facing students—good session on supporting clinical learning’; ‘Enjoyed ideas on giving feedback to students’; ‘The Helpful Gatekeeper and feedback/assessment of competence’; ‘The ease of interacting with the Lecturers’; ‘Being able to discuss apprehensions of DEUs’; ‘Great strategies to deal with specific problems’ (Edgecombe 2010).

  11. 11.

    Areas for improvement. Examples of areas for improving the workshops include the following: ‘More time on using competencies for feedback—important area’; ‘Possibly have a student spokesperson’; ‘Interaction with students (present and past graduates) who can give us some suggestions about how to deal with problems in the wards’; ‘I would like to see the laboratories and increase my knowledge of how the students learn there and the content of each course stage’; ‘More role plays in how to provide feedback’. There was also a request to ‘know where all the DEUs are and who are the PAs on my worksite, not just my area’; ‘To maintain regular short courses/seminars for nurses who want to participate as a DEU in the future’ (Edgecombe 2010).

Feedback resulted in advanced workshops for clinicians and PAs who were experienced in DEUs and later LN-specific workshops covering topics including how to deal with difficult students, clinical teaching strategies, providing constructive critical feedback and developing clinical learning contracts. Workshops were followed up periodically (fortnightly or several times per semester) with meetings/debriefings with clinical staff separate from the students.

Incidental Capacity Building for DEU Clinical and Academic Staff and Students

Reshaping the timing of clinical placements to privilege clinical equally with the theory of classroom work (Bail et~al., Chap. 5, this volume) assists in incidental capacity building for all DEUs. The DEU structure sustains incidental as well as planned learning strategies. Incidental capacity building is a constantly evolving process that includes clinicians, clinical facilitators, students and patients in a collaborative learning process. For example, ‘I have learned from the CLN and ward staff, and they have learned from me’ (Elaine Horn, ALN, Manukau, Story 9, Chap. 10, this volume). The formal, planned structures (roles) in the DEU enable incidental learning in that they give a reason for maintaining a focus on the learning agenda. They generate increased research opportunities for academics and clinicians, opportunities for joint conference presentations and publications, and increased collaboration re curriculum and student assessment (Gonda, Chap. 4, this volume). The structures maintain guided feedback to students and academic guidance to clinicians for formative and summative assessment.

Clinical and Academic Staff: Support

Incidental capacity building can occur through informal staff meetings and PAs discussing with clinical staff topics such as current practice and research, student education, and standards and scope of practice (see Bail et~al., Chap. 4, this volume). PAs may also discuss opportunities for learning strategies within the ward, such as visiting other departments or having clinicians run mini-tutorials. As discussed by Craig and Moscato (Chap. 6, this volume), at the University of Portland DEUs, Clinical Instructors (CI) became more confident through their role as teachers and the support they received from academics undertaking the role of Clinical Faculty Coordinators (CFC); practice informed education and education influenced practice. CIs certified as expert clinicians gave scholarly presentations and assumed leadership roles on the unit. Some returned to school for a Master’s degree or were promoted to leadership positions within their hospitals.

Students: Peer Teaching

Incidental student peer teaching across and within year groups, resulting from accommodating students across all 3 year levels in the same space at the same time, develops students’ capacity as teachers and learners, guided by clinicians and clinical facilitators (academics). Thus, while the DEU is structured so that peer teaching is an intentional and supported strategy, peer teaching also happens to some extent by osmosis due to the students being together. The quality of the peer teaching is dependent on the quality of support. If the clinical staff and academics have the necessary knowledge and confidence to encourage and support students’ peer teaching, it will become self-sustaining as students develop it more broadly: ‘We were lucky because the CLN recognised the need for peer learning’ (Taylor and Nand, Story 1, Chap. 10, this volume).

Conclusion

Clinical and academic staff capacity building is an integral part of the DEU design. As such, it is spoken about more as ‘preparation’ for or ‘staff/faculty development’ in the DEU. However, capacity building is greater than merely preparing clinical and academic staff, and students, for their roles within the DEU learning environment. It is about equipping them with professional skills that enable clinical staff to develop teaching as well as clinical expertise, enter academia or gain promotion within their organisations; academic staff to keep up to date with clinical knowledge and practice; and students to develop teaching as well as learning capabilities through peer teaching in DEUs. Clinical staff, academics and students develop the capacity to value each other’s knowledge and to work collaboratively with an expanded diversity of peers and colleagues across academic and clinical settings/organisations. This type of capacity building underlines the possibility of interprofessional DEUs. Capacity building would extend across clinical and academic staff and students from different professions. Workshops expanded to include professions other than nursing could formalise the incidental cross-professional interaction that already happens in clinical settings. Student capacity building through peer teaching across different year levels achieves a variety of learning outcomes (formal and incidental). Therefore, a logical hypothesis would be that peer teaching in a DEU environment could accommodate the different learning objectives of different professions within that environment. Interprofessional collaboration is already implemented in one DEU in Sweden, where ambulance service personnel work alongside nursing personnel. However, research is needed into further interprofessional DEU possibilities.