persuasive speech week 4

Nurse Education in Practice 52 (2021) 103008

Available online 13 March 2021 1471-5953/© 2021 Elsevier Ltd. All rights reserved.

Review

Improving clinical experiences for nursing students in nursing homes: An integrative literature review

Hana Splitgerber *, Susan Davies, Sara Laker Winona State University-Rochester, 859 30th Ave SE, Rochester, MN, 55904, United States

A R T I C L E I N F O

Keywords: Clinical education Older adults Residential aged care Nursing home Nursing students

A B S T R A C T

Well-organized clinical placements in older adult care settings will prepare nursing students to provide care for this growing population and may influence career choices. The purpose of this integrative review is to identify strategies that can be used to provide student nurses with effective clinical education experiences in residential aged care facilities offering skilled nursing (RACF-SNs). Twenty-three studies evaluating teaching and learning models and experiences were reviewed. Four themes were identified related to effective strategies for providing gerontological clinical education to students in residential aged care environments, principally nursing homes. These were: developing a partnership, comprehensive orientation, effective supervision for students, and sup- porting staff. Eight different models were described for enhancing clinical learning experiences in these envi- ronments. These models reflect the themes highlighted in the review. Relevance of the findings to a conceptual framework for evaluating gerontological clinical placements, the Senses Framework, is considered. Strong partnerships between schools of nursing and residential aged care environments can provide well-organized clinical education to undergraduate nursing students. To be sustainable, these partnerships must be developed in ways that do not require significant additional resources. A guideline for this process based on findings of the review has been developed.

1. Introduction

As the population of the United States ages, undergraduate nursing students must acquire the necessary skills to work effectively with older adults and their families, since most nursing graduates will be caring for older adults in some capacity (Gaberson et al., 2015). In the United States, nearly 1.2 million adults aged 65 years and older used nursing home services in 2015–2016 (National Center for Health Statistics, 2018). It is estimated that after age 65, 28% of Americans will need at least ninety days of care in a nursing home during the remainder of their life (Johnson, 2019). Concurrently, it has been projected that the de- mand for registered nurses (RNs) will grow by 46% from 438,600 full-time equivalents in 2015 to 638,800 in 2030 (U.S. Department of Health and Human Services, Health Resources and Services Adminis- tration, & National Center for Health Workforce Analysis, 2018). Nursing shortages are likely to be most acutely felt in residential aged care environments, since studies have demonstrated that gerontological nursing is the least preferred career choice among nursing students (Cheng et al., 2015; Garbrah et al., 2017; Neville and Dickie, 2014).

Factors contributing to the shortage of well-prepared gerontological nurses include stereotypes of work in long-term care settings as unin- teresting, lacking in support, offering a poor work environment, and restricted opportunities for professional development (Garbrah et al., 2017; Lea et al., 2018; Neville and Dickie, 2014). Garbrah et al. (2017) reviewed 21 studies from 13 countries to determine what prevents nursing students from choosing a career in gerontological nursing. They identify lack of positive experiences working with older people and the emphasis of many curricula on the technical aspects of nursing in the context of acute and critical care as key factors. In a review of studies from seven countries, Neville and Dickie (2014) identified recruitment of nurses to work with older adults as a global issue. Findings suggest that gerontological nursing does not rate highly as a career goal for undergraduate nursing students due to uninspiring clinical activities and poor working conditions. Lea et al. (2018) identified nursing students’ reluctance to choose placements in aged residential care because of their desire to maximize their learning, considering prior experiences. Gerontological nursing is commonly perceived as offering limited learning opportunities (Lea et al., 2018). Innovative curriculum

* Corresponding author. E-mail address: [email protected] (H. Splitgerber).

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https://doi.org/10.1016/j.nepr.2021.103008 Received 27 February 2020; Received in revised form 22 February 2021; Accepted 24 February 2021

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activities that reveal the complexities of aged care are proposed as a potential solution to stimulate interest in this specialty (Lea et al., 2018; Neville and Dickie, 2014). Consequently, there is a need to understand current student clinical experiences in residential aged care environ- ments and identify strategies to improve gerontological clinical educa- tion and encourage future nurses to choose this career option.

1.1. Background

In the United States, nursing homes, also called skilled nursing fa- cilities, offer both permanent residential care and short-term skilled nursing and rehabilitation, including 24-h supervision, nursing care, assistance with daily activities, and provision of meals. Nursing homes also provide rehabilitation services, such as speech, occupational and physical therapy (Medicare Payment Advisory Commission, 2015). Nursing homes have not been considered a typical clinical placement for undergraduate students, even though there is increased demand for nurses who are competent in providing care to the older population (Xiao et al., 2012). Student learning outcomes for clinical experiences in this setting can be related to advanced critical thinking, communication, leadership, ability to develop relationships with residents, and under- standing of the nurse’s role (Ryan et al., 2018). Gaberson et al. (2015) state that, with a variety of patients, learning needs can be matched with clinical learning assignments, as students provide holistic care while also developing leadership, and delegation skills with a wide range of patients and residents. Similar to other clinical settings, students can acquire skills in physical assessment, infection control, medication administration, nutrition monitoring, and case management (Brynildsen et al., 2014).

Studies show that both positive and negative experiences during clinical placements affect student intentions to choose a career in

gerontological nursing (Brown et al., 2008a; White et al., 2012). There is evidence to suggest that clinical placements have the most important role in shaping students’ vision of gerontological nursing care (Brown et al., 2008b). In a longitudinal study examining the influence and role of students’ learning experiences in a range of learning environments in the UK, Brown et al. (2008a) found that classroom activities had a limited effect whereas clinical placements had a far greater impact. These authors propose that most students do not have a negative perception of older adults when they enter a nursing program. Rather, students develop negative perceptions when they are exposed to an ‘impoverished’ environment of care during their clinical placement caring for older adults. Students who were exposed to an ‘enriched’ learning environment commonly viewed gerontological nursing as a positive career option (Brown et al., 2008a). An enriched environment was characterized by the creation of a series of perceptual experiences or ‘senses’ for the student, including security, belonging, significance, purpose, continuity, and achievement. Known as the Senses Framework (Brown et al., 2008a; Nolan et al., 2006), this conceptual model is revisited later in this paper.

Throughout the last 40 years, a number of large-scale initiatives aimed at promoting positive student learning experiences within nursing homes have been implemented and evaluated in the United States and other advanced industrialized economies (Barnett et al., 2018; Jamieson and Grealish, 2016; Kirkevold, 2018; Loffler et al., 2018; Mezey et al., 2008). However, Norway is the only country to have successfully sustained and expanded these initiatives (Kirkevold, 2018). The Teaching and Research Aged Care Services (TRACS) program in Australia (Barnett et al., 2018; Jamieson and Grealish, 2016; Loffler et al., 2018), for example, was showing signs of developing as a com- munity of practice when funding came to an end and it became difficult to sustain this collaboration. It is therefore important to identify

Fig. 1. Steps in search process and items identified.

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successful features of clinical placements in residential aged care facil- ities that can be implemented locally, and in the absence of significant additional resources, to provide nursing students with excellent expe- riences of long-term care.

1.2. Purpose

The purpose of this integrative literature review is to identify stra- tegies for creating effective clinical learning experiences for under- graduate nursing students in residential aged care environments that offer skilled nursing, including nursing homes. Successful clinical placements in these settings may result in more students considering a career in gerontological nursing upon graduation (Nolan et al., 2006). This review focuses on pre-licensure baccalaureate nursing students and excludes post-licensure nurses studying for a post-graduate degree due to interest in students’ early exposure to the nursing role within long-term care settings for older adults.

2. Method

The following databases were included in the search: CINAHL, PubMed, Abstracts in Social Gerontology, Education Full Text (H.W. Wilson), Health Source: Nursing/Academic Edition, and PsycINFO. Databases were selected for their coverage of topics relevant to nursing and education. The search strategy focused on peer-reviewed research articles in English and published between 2008 and 2019. This time limit was set in recognition of the fact that the context for long-term care has changed rapidly over the past ten years, with older adults being supported to remain in their own homes for longer and higher levels of need among nursing home residents. Search terms included ‘aged care’ or ‘nursing homes’ or ‘residential aged care facilities’ or ‘long-term care’ AND ‘older adults’ or ‘elders’ or ‘elderly’ or ‘geriatric*’ or ‘older people’ or ‘gerontolog*’ AND ‘undergraduate nursing student’ or ‘student nurse*’ AND ‘placement’ or ‘clinical placement’ or ‘practicum’. Key- words were adjusted to account for the Major and Minor Headings in

CINAHL and MeSH in PubMed. A university librarian was consulted to help develop the search strategy.

A total of 157 results were identified from the initial searches. After removing 61 duplicates, 96 articles were initially reviewed using titles and abstracts. Studies related to clinical placements other than a nursing home, residential aged care, or long-term care setting (e.g., home health services, acute care) and studies focusing principally on students’ atti- tudes toward older people were excluded from the 96 articles. Studies that did not include nursing students were also excluded.

Preliminary reading of the selected studies identified 13 that iden- tified strategies for creating effective clinical learning experiences for undergraduate nursing students in long-term care settings for older adults. Four additional articles were identified by reviewing the refer- ence lists of the selected 13. Five additional items were identified by adding key words found within the most relevant studies into the search: ‘teaching nursing home (TNH)’ (three studies), ‘internship’ (one study), and ‘partnership’ (one study). Finally, the searches were repeated in PubMed with one additional article identified and added to the review (see Fig. 1).

Each of the 23 studies was appraised, and details were extracted and entered into a literature table by one of the authors (HS) using the process described by Garrard (2017). Details included purpose, sample, study design, methods for data collection and analysis, findings, impli- cations, and strengths/limitations. Authors SD and SL reviewed the ta- bles and confirmed that appropriate information had been entered. A theme matrix was then generated following this analysis to identify recurrent findings across the studies and aspects of methodological rigor (Garrard, 2017). This process provided a structure for the narrative, allowing studies to be compared, and informing the overall methodo- logical critique.

3. Findings

The focus of this review was on residential aged care facilities with continual access to skilled nursing. Within the literature such facilities

Table 1 Countries and settings for studies included in the review.

Authors Country Setting

Brynildsen et al. (2014) Norway Five nursing homes Campbell and Jeffers

(2008) USA Two nursing homes

Carlson and Idvall (2014) Sweden One nursing home Garbrah et al. (2017) Finland (Australia, Israel, UK, Sweden, China, Taiwan, Philippines, Portugal, USA, Norway,

Finland, Scotland, Sri Lanka) Residential aged care facilities (number not specified)

Grealish and Henderson (2016)

Australia Three residential aged care facilities

Husebø et al. (2018) Norway (Australia, UK, Norway, Sweden, USA) Nursing homes (number not specified) Jamieson and Grealish

(2016) Australia Five aged care services

Lea et al. (2017) Australia Two residential aged care facilities Lea et al. (2015) Australia Two residential aged care facilities Lea et al. (2016) Australia Two residential aged care facilities Loffler et al. (2018) Australia One aged care organization Mezey et al. (2008) USA 11 funded sites including schools of nursing and

nursing homes Mueller et al. (2011) USA Nursing homes (number not specified) Mullenbach and Burggraf

(2012) USA Five long term care facilities

Nolet et al. (2015) USA Four nursing homes O’Connell et al. (2008) Australia One residential aged care facility O’Lynn (2013) USA One long term care facility provides intermediate

and skilled care Robinson et al. (2009) Australia 12 residential aged care facilities Robinson et al. (2008) Australia Six residential aged care facilities Ryan et al. (2018) Australia One residential aged care facility Skaalvik et al. (2012) Norway Three nursing homes White et al. (2012) USA Four long term care facilities Xiao et al. (2012) Australia Eight residential aged care facilities

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are referred to using a range of terms, including nursing homes, care homes with nursing, service homes, residential care, and aged care fa- cilities. To avoid confusion, these facilities are referred to as residential aged care facilities – skilled nursing (abbreviated to RACF-SN) throughout this paper. These facilities have registered nurses on site 24-h a day. The minimum age for eligibility for residence in the RACF- SNs included in the studies is not always stated; however, most provided care for people aged 65 and over.

Findings of this review are initially presented in terms of strategies associated with positive learning experiences described by undergrad- uate nursing students in RACF-SNs. Many of the studies evaluated spe- cific models of practice incorporating these strategies. These are described and compared. The 23 studies represent evidence gathered in 13 countries, such as Australia, USA, and Nordic countries (see Table 1).

3.1. Creating positive learning experiences for nursing students in residential aged care facilities with skilled nursing

Four main themes for ensuring successful placements in these set- tings were evident in the literature. These were: developing a partner- ship, comprehensive orientation, effective supervision for students, and support for staff.

3.1.1. Developing a partnership The importance of creating an effective partnership between an

educational institution and a RACF-SN is repeatedly identified in the literature as a strategy for improving students’ clinical experiences in nursing homes (O’Lynn, 2013; Robinson et al., 2008; White et al., 2012). Studies show that a strong partnership involves sharing mutual objec- tives, goals, purpose, and vision (Jamieson and Grealish, 2016; Mueller et al., 2011). Mueller et al. (2011) state that the educational partner and the nursing home partner need to share a commitment to providing a quality clinical learning experience to students. Staff at the nursing fa- cility should be familiar with the nursing clinical curriculum, objectives, and student learning outcomes. Through building relationships with facility staff, faculty can provide access to resources and opportunities such as guest presentations, and journal clubs. These resources can in- crease nursing home staff confidence in teaching students as well as contributing to their professional development (Mueller et al., 2011).

In a report of a summit of 38 experts in geriatric education and practice, Mezey et al. (2008) identified nine principles for Teaching Nursing Homes (a specific model for clinical teaching in nursing homes developed in the United States in the 1980s and 1990s). These include articulating a vision and mission for mutual accountability and committing to a collaborative learning environment. Consistent with these principles, Jamieson and Grealish (2016) created stakeholder committees, with a shared mission and purpose, to create formal part- nerships and informal networks. Stakeholders representing nursing schools, nursing homes, non-government facilities, and a public hospi- tal, worked together to build and strengthen the network; however, engagement reduced over time and this raised questions regarding sustainability. These authors suggest that “coordination and support work is invisible yet essential to the success of complex partnership arrangements” (p. e27). They emphasize that continuous financial and human resources investment is needed to sustain a long-term relation- ship between all partners (Jamieson and Grealish, 2016).

Successful partnerships between departments of nursing and RACF- SNs have been associated with positive clinical placement outcomes (O’Lynn, 2013). Two examples are worth reporting in more detail here. O’Lynn (2013) conducted a mixed-methods quasi-experimental study to evaluate a team approach to providing students with clinical teachers and role models in nursing homes over six semesters (24 months). The team consisted of certified nursing assistants, certified medication as- sistants, nurses, and rehabilitation staff (physical therapists, rehabilita- tion aides, and speech pathologists). Students were randomly assigned to two groups, one in a nursing home setting and the other in a hospital

setting. Many students expressed that they were initially hesitant about their nursing home placement but were surprised by how much they learned from their instructors, including the non-RN instructors. Stu- dents were able to learn and practice many skills and valued the re- lationships they developed with residents and staff. Post-placement assessment revealed no statistically significant differences between the two groups for any of the research variables, including evaluation of the course, simulation scores, medical-surgical standardized exam score and adult health course grade. The results of this study suggest that a RACF-SN can be successfully utilized as a clinical placement within a medical-surgical adult health course (O’Lynn, 2013).

Loffler et al. (2018) evaluated shared clinical placements in RACF-SNs for students completing majors in nursing, medicine, phar- macy, and social work. The benefits for students included an enhanced understanding of the needs of older adults in these environments and increased insight into providing care to meet complex needs through an interdisciplinary approach. Benefits for the care facility included a positive impact on reputation as a learning institution, increased recruitment, and a range of funding opportunities as a result of collab- oration with an academic institution. Benefits for the education partners included high-quality education that addressed curriculum re- quirements. Following introduction of the scheme, the number of stu- dent clinical placements provided in RACF-SNs increased by 83.5% within four years. Patients benefited from increased access to specific services and enhanced intergenerational exchange. The main contribu- tion of this study was to demonstrate the benefits of inter-disciplinary, inter-organizational partnerships for all stakeholders.

In summary, a strong partnership between an education provider and a RACF-SN provides the context for effective clinical placement. Eval- uative studies suggest that important components of such partnerships include mutual understanding of goals and constraints, resource- sharing, the establishment of stakeholder committees, and an interdis- ciplinary focus.

3.1.2. Comprehensive orientation To provide effective clinical experiences for students within RACF-

SNs, a comprehensive, well-structured orientation to the setting is crucial (Robinson et al., 2008, 2009). Students may have considerable anxiety prior to their clinical experiences and being welcomed by staff and provided with necessary information are essential strategies for creating a supportive clinical learning environment (Husebø et al., 2018). Appropriate preparation, student orientation, and structured educational support may also affect students’ interest in working in this setting in the future (Brynildsen et al., 2014). Orientation should include a tour of the facility, information on shift routines, explanation of relevant health and safety issues, and an introduction to the organiza- tion of care within the home (Brynildsen et al., 2014; Husebø et al., 2018; Robinson et al., 2008). Such preparation can encourage students by boosting their motivation and confidence (Brynildsen et al., 2014; Husebø et al., 2018).

Robinson et al. (2009) examined student and staff perceptions of student clinical orientation in nursing homes in Australia using a quantitative cross-sectional design. A total of 12 nursing home facilities, 67 staff, and 53 students participated in this study. Findings suggest that staff members were more satisfied with the orientation process in gen- eral than students with more than half of the students (52%) reporting that they doubted that the staff were expecting them. The authors concluded that a lack of structured orientation may have negative im- plications for student clinical education in nursing homes, impacting their interest in working in this setting, and possibly even their commitment to a nursing career (Robinson et al., 2009).

Several studies report the effects of student orientation in preparing students for their clinical placement in RACF-SNs. In a mixed-methods action research study also in Australia, Lea et al. (2017) facilitated mentor support to provide better orientation and quality of clinical placement experiences to students. The mentors included RNs (46.9%, n

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= 15), Licensed Practical Nurses (LPNs) (25%, n = 8), and non-nursing care workers (25%, n = 8). Mentors participated in 10 meetings prior to student placements that were of three weeks duration. An orientation checklist for students and an orientation action plan for mentors were created prior to the first student placement period. Students reported that they felt confident and prepared for the nursing home clinical placement. Mentors reported that they had an enhanced understanding of their mentoring role (Lea et al., 2017).

Also, in Australia, Xiao et al. (2012) conducted a mixed-methods action research study that provided pre-clinical sessions and an onsite orientation day to prepare students for their clinical placement in RACF-SNs. Students were encouraged to discuss differences between a nursing home and acute care setting and to develop realistic expecta- tions for learning in nursing homes to reduce the anxiety caused by their feelings of being disadvantaged by their placement. Findings indicated that the orientation program prepared students with a better under- standing of what to expect from their nursing home placement and reduced their anxiety level (Xiao et al., 2012).

In summary, orientation to clinical placements in RACF-SNs is effective when provided for both students and staff and involving pre- clinical sessions. Using a checklist approach and creating realistic ex- pectations of the placement are also helpful.

3.1.3. Effective supervision for students Nearly half of the studies in the review specifically identify an

effective one-to-one supervisory relationship (variably referred to in the reviewed studies as mentorship, preceptorship, and supervising RN), as an essential part of clinical education in RACF-SNs (Brynildsen et al., 2014; Carlson and Idvall, 2014; Garbrah et al., 2017; Lea et al., 2016, 2017, Loffler et al., 2018, Ryan et al., 2018; Skaalvik et al., 2012; White et al., 2012; Xiao et al., 2012). In these relationships, a student is assigned to a specific nurse for continuing supervision and support throughout the placement. The reviewed studies provide evidence of the important contribution of these relationships to student learning. For example, Carlson and Idvall (2014) reported a cross-sectional study that examined students’ learning experiences during a nursing home clinical placement in Sweden. Consistent with studies in other clinical settings, findings confirm that the positive attitude of the supervising nurse was the most important factor enabling students to have effective learning experiences during a RACF-SN clinical placement. Students considered that positive clinical learning experiences are highly associated with mutual respect and trusting relationships between the supervisory nurses and students (Carlson and Idvall, 2014).

In an Australian study, Ryan et al. (2018) sought student and staff views of a gerontology clinical learning experience in a RACF-SN on two sites and emphasized the importance of students feeling supported by nursing staff who were willing to spend time with them (Ryan et al., 2018). In a mixed-methods study in Norway, Brynildsen et al. (2014) reported that students had positive experiences when their preceptors were attentive, gave constructive feedback, knew the student’s schedule, and communicated well (Brynildsen et al., 2014). Xiao et al. (2012) used a partnership model to select nurses who were passionate about caring for older adults to act as mentors. The nurses were able to contribute current knowledge of gerontological nursing to academic partners and provided strong role models for students (Xiao et al., 2012).

There is evidence that well-structured feedback from a mentor can enhance student knowledge and nursing skills. In a qualitative Norwe- gian study, Skaalvik et al. (2012) found that professional dialogue with nurse mentors is an important component of a positive student learning environment in nursing homes. Students who had experience of such dialogue reported that they were accepted and appreciated for their contribution by providing new perspectives and knowledge to the or- ganization. However, students, who did not have this experience, re- ported that they felt that they were invisible and were afraid of asking questions (Skaalvik et al., 2012). Similarly, in a cross-sectional study in Australia, Lea et al. (2016) found that students who experienced useful

feedback exchanges with nurse mentors, were more likely to consider working in a nursing home post-graduation.

Summary points relating to effective supervision for students within RACF-SNs include a positive attitude on the part of the supervising RN and ability to role-model excellence in practice, clear policies on appropriate activities for the student, and effective communication involving opportunities for reflection, dialogue, and detailed structured feedback on performance.

3.1.4. Supporting staff Structured orientation and support are needed not only for students,

but also for staff to increase their understanding of student learning in the clinical environment. Garbrah et al. (2017) state that nurse educa- tors and nurses who are specialized in older adult nursing care must act as role models for students during nursing clinical placements. Prepar- ing nurses for this role and ensuring the time commitment required have been identified as key elements in ensuring effective interaction be- tween students and nurses in RACF-SNs (Xiao et al., 2012). However, staff nurses who participate in students’ clinical learning often feel un- supported and receive minimal recognition for their contribution to education (White et al., 2012).

Studies have shown that organizational investment in building staff capacity can produce a positive learning culture in RACF-SNs (Grealish and Henderson, 2016; Lea et al., 2015, 2016, 2017). Academic partners can also support staff by sharing resources to prepare them for their role in providing clinical education in nursing homes, including information about the students’ scope of practice (Mueller et al., 2011; Ryan et al., 2018). Mueller et al. (2011) describe how faculty within a university department of nursing strengthened their partnership with nursing home staff with a half-day workshop, during which, faculty and staff learned about each other, the nursing home environment, the nursing curriculum, and student learning objectives. Nursing home staff and faculty worked together to identify effective strategies for providing positive learning experiences to the student and jointly developed case scenarios.

White et al. (2012) described an initiative in which designated staff nurses, known as clinical education liaisons (CELs), were provided with additional resources, support, and recognition in order to utilize their expertise. The CEL Professional Development Program included a four-day workshop, two-day Leading Educational Access Project (LEAP), Train-the-Trainer program, and simulation sessions in the university simulation laboratory. As a result of this professional development program, staff nurses reported that they felt they were well-prepared for the student clinical placement. Students reported that they were made to feel welcome and appreciated the complexity of the experience during the placement (White et al., 2012).

With regard to their supervisory role with students, Lea et al. (2017) suggest that nursing homes should set up a formal mentor group prior to student placement and provide opportunities to engage in a dialogue around their practice, helping them to shape how they support students. To improve mentorship and learning experiences of students and men- tors, it is important to identify the needs of mentors prior to the clinical placement and provide support to mentors throughout the experience (Lea et al., 2017).

In recognition of the fact that many RNs in nursing homes are close to retirement age, have less than full time employment status, and have received hospital-based training, Xiao et al. (2012) implemented and evaluated a two-day program to prepare RNs for their role in student learning. In this study, a ‘clinical supervision toolkit’ was introduced to enable supervising RNs to provide constructive feedback to students. The toolkit included a communication folder for RN supervisors, nursing faculty and students, and posters for the nursing station. In survey re- sponses, RNs indicated that they were satisfied with the support they received, and with teaching and learning resources. Students in this study initially expressed resistance to their placement in a RACF-SN; however, they later acknowledged that they learned about nursing

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Table 2 Models of practice.

Model/Citation Purpose Location/Sample/ Setting

Design/Framework Variables/Instruments Results Implications

Sister Model Campbell and Jeffers (2008)

To describe the sister model framework and provide an evaluation as a part of the TNHP

United States N = four NHs (two larger urban NHs each linked with a smaller rural ‘sister’ NH), Mennonite College of Nursing at Illinois State University

Qualitative, descriptiveAdaptation of TNH model

The Sister Model (communication, sharing resources, interactive learning, and nursing expertise) Anonymous survey (open-ended questions, NH administrators, directors of nursing, and assistant directors of nursing)

A practiced ‘learning approach’ was considered important to administrators. Positive outcomes include: • increased

professionalism of some staff identification of areas for growth within the homes

• awareness of how staff members’ practice methods influence new nurses.

• A clear planned, structured, purposeful communication pathway and relational aspect of the partnership cannot be underestimated.

• NH and nursing school administrators need to understand and accept the responsibility of ensuring that learning is occurring and that best practices are being used in the care of older adults.

• Clear communication is the key success indicator (expectations and support provided).

• It is crucial to have a minimum one liaison as a leader of NH staff.

Tri-Focal Model of Care O’Connell et al. (2008)

To provide an overview of the range of issues that confront different stakeholders and propose an innovative model of care termed ‘Tri-focal model of care’

Melbourne, Australia One RACF Stakeholders include residents, residents’ families, service providers, students, and staff

Report, descriptive The Tri-focal model of careReview of literature and description of program development

The Tri-focal model of care was developed based on the concepts of ‘Partnership- centered care’, ‘Positive work environment’, and evidence-based practice in aged care This model emphasizes creating a positive environment including: • team structure • processes, and

characteristics that foster accountability

• commitment • enthusiasm • motivation • social support • reduction of conflict • developing

leadership styles and characteristics

• partnership- centered care

Tri-focal model of care provides a comprehensive model of care delivery and addresses the underlying issues related to recruitment and retention, unlike the TNH modelNo evaluation reported.

Teaching Nursing Home (TNH) Mezey et al. (2008)

To report on recommendations of a teaching nursing home summit of experts To identify characteristics of successful partnerships between academia, nursing homes, and other stakeholders

United States 38 experts in geriatric education and practice

Review of literature and report of a summit

The participants considered • stakeholders

critical to achieving successful TNHs

• barriers • evidence-based

research support of TNHs

• National and state regulatory board/ monitoring health policy agendas

Eight goals of a TNH/ learning collaborative/ learning partnership were identified. Nine principles were developed representing the following themes: • Quality of care and

quality of life for residents

• Ethical learning collaborative/ partnership

• Mutual accountability

• Shared resources • Valuing, supporting,

disseminating of best practices

• Reciprocity

• Confirmed the feasibility of the TNH model

• Could help transform conceptions of nursing homes

• Could have substantial impact on the long-term care professional workforce

(continued on next page)

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Table 2 (continued )

Model/Citation Purpose Location/Sample/ Setting

Design/Framework Variables/Instruments Results Implications

• Research • A commitment to

transparency and quality improvement

Enriched Clinical Learning Environment through Partnerships White et al. (2012)

To describe the partnership between long-term care staff nurses and clinical nursing faculty to provide students with excellent clinical experiences in NHs and assisted living facilities.

United States. Nine clinical education liaisons (CELs) nurses with either an associate degree or BSN, four long-term care organizations.

Mixed-methods, Quasi- experimental (pretest- posttest design)

CELs’ experience with the professional development training, expectations about the ECLEPs program, and attitudes about working with students Pre- and post-survey (five-point Likert scale) and interview

Survey results showed changes in five items (in a positive direction in four items and in a negative direction in one item “having students around makes me proud of our center and the work we do”, p. 48). Statistical significance was not reported for these differences. CELs were satisfied with the ECLEPs program. They thought that the students will make good nurses (mean = 4.9) and they want to work with students again in the future (mean = 4.9). • CELs were satisfied

with the professional development sessions, the information sharing, and the support provided by the facility.

• The ECLEPs partnership model can help meeting the learning needs of the CELs and to develop a clinical setting that prepares nurses for the future.

Dedicated Education Unit Mullenbach & Burggraf. (2012)

To develop a clinical immersion for nursing students in LTC and to involve RNs in the LTC facility as preceptors in collaboration with faculty. Termed Dedicated Learning Unit (DLU)

United States. 61 senior students (fall semester), a five-credit stand- alone gerontological nursing course, five weeks of 6-h clinical days, five long-term care facilities.

Mixed-methods, surveys, analysis of student journals, observation

Students’ LTC clinical preparedness, assessment skills, critical incident identification, and experience Pre- and post-survey (clinical preceptors and students), student weekly journals, interviews (students, clinical faculty, and clinical preceptors)

After the fall placement, students reported that they were well prepared for: • Performing clinical

skills (Q1), t(50) = 36.67, p < .05.

• Performing a history/assessment (Q2), t(59) = 34.94, p < .05

• Identifying and writing about a critical incident (Q3) t(59) = 19.685, p < .05 in LTC.

Students progressed in: • Skill development • Understanding of

patients’ needs. • Clinical preceptors

and managers reported satisfaction with the program.

• The dedicated learning unit (DLU) model can change student perceptions of LTC from negative to positive.

• Further studies needed to replicate the use of the DLU model in LTC and also to explore transitions in care after rehabilitation.

Dedicated Education Unit O’Lynn. (2013)

To determine whether the implementation of the Portland Model DEU in the long-term care facility would provide students a setting equal in quality to the acute care setting.

United States 313 undergraduate and direct-entry master’s students (n = 76 in DEU-LTC, n = 237 in hospital DEU), team model (certified nursing assistants, certified medication assistants, nurses, and rehabilitation staff), adult health medical-surgical course

Mixed-methods, quasi- experimental The Portland Model Dedicated Education Unit in Long-Term Care (DEU- LTC) Random clinical assignment (DEU in acute care vs. DEU –LTC)

Quality and rigor of the DEU-LTC and satisfaction of stakeholders Post-operative hip simulation score, post- operative wound simulation score, gastric bleed simulation score, medical-surgical standardized exam score, adult health course grade, focus groups

No statistically significant differences between the two groups in relation to: • evaluation of the

course • simulation scores • medical-surgical

standardized exam score

• adult health course grade

Students reported that they learned many skills from their instructors (including

DEU-LTC may improve communication and collaboration with team members. Further research is needed to • replicate these

findings • determine whether

the DEU-LTC gener- ates increased student interest in a geriatric nursing career.

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Table 2 (continued )

Model/Citation Purpose Location/Sample/ Setting

Design/Framework Variables/Instruments Results Implications

non-RN) and valued the relationships with residents and staff. Instructors, staff, and DONs reported higher satisfaction with DEU- LTC than traditional clinical teaching.

Wisconsin Long Term Care Clinical Scholars Program Nolet et al. (2015)

To report on development, implementation and evaluation of The Wisconsin Long Term Care Clinical Scholars Program, a NH internship for baccalaureate nursing students.

United States. 10 junior and senior nursing students of two baccalaureate schools of nursing, 12 weeks summer nurse internship, four NHs.

Mixed-methods Paid nursing home work experience coupled with long-term care curriculum Wisconsin Long-Term Care Clinical Scholars Program (LTC- CSP)

Influence of the Wisconsin LTC-CSP on students’ perceptions and interests Focus groups, intern satisfaction survey, in- person interviews, the likelihood of working in NHs survey

The LTC-CSP • improved student

feelings of preparedness to work with older adults

• clarified the role of nurses in NHs, and

• enticed students to seek employment in NHs

Educators in health disciplines should consider how to incentivize students to explore caring for older adults in NHs through expanded practice opportunities with no financial burden. Developing partnerships with local practice sites to co-develop student opportunities and increase precepting capacity is an important first step to creating positive NH experiences.

Co-operative for Healthy Aging Research and Teaching (CHART) Jamieson & Grealish. (2016)

To describe the partnership mechanism that supported teaching and research in aged care in one of the 16 funded projects under the auspices of the Teaching and Research in Aged Care Service project

Australia five CHART liaison nurses, four facility managers, four focus groups of staff (n = 26) from a diverse range of roles (cleaners, support, and direct care staff), four residential aged care facilities (RACFs), Australia

Mixed-methods, descriptive

TRACS program Document review Stakeholder interviews (project outcomes, organizational change, and practice change and challenges)

• Maintaining engagement and collaboration required significant investment in partnership arrangements.

• Partnerships were often dependent on the motivation of individuals, and this could be difficult to sustain.

• Support for continued nursing placements was variable.

• Local practice innovation was advanced when partnership investment was aligned at a strategic and operational level.

• Continuous, and often invisible, investment in maintaining operational partnership is crucial to sustained change.

• Partnering in a private aged care service environment to achieve sector- wide changes was challenging, but the investment can result in innovation and service improvement.

• The impact of the project was dependent on the engagement of senior staff with the CHART project.

Helping Hand Student Education and Partnership Loffler et al. (2018)

To describe the national evaluation of Australia’s Teaching and Research Aged Care Services (TRACS) program (2012–2015) and provide an analysis of the Helping Hand Student Education and Participation model

Southern Australia 315 university students, 299 vocational education, and training (VET) students, 58 secondary students, a collaboration of Helping Hand Aged Care and University of South Australia

Mixed-methods, concurrent triangulation design (a review of literature, interviews and focus groups with patients, students, nursing facility, and colleges, key performance indicators (KPI) surveys, student survey, TRACS partner survey, 16 case studies)

TRACS program Structured orientation and induction, student-led clinic, a student-led project, vocational education, and training VET student education

Benefits for students • enhanced

understanding of the needs of older adults

• effective application of theory into practice

Benefits for the care facility • a positive impact on

reputation • increased

recruitment (70%– 80%) and funding opportunities

Benefits for educational institutions • being able to provide

high-quality education

• increased availability of clinical placements

Crucial factors identified include • an effective clinical

facilitator • supervisors and

mentors • well-structured

learning program with an orientation and induction

• interprofessional education

• collaboration between aged care and education providers

• mutual trust and respect

• shared values • regular

communication • a centralized student

placement system • effective student

education manager

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care needs and acquired knowledge and skills specific to older adults (Xiao et al., 2012).

In a cross-sectional study, Lea et al. (2016) found that the support- iveness of not only RNs and enrolled nurses, but also unregulated care workers, is related to student perceptions of the nursing home as a positive learning environment and possible future career choice. By supporting both nursing- and non-nursing staff in RACF-SNs with knowledge and resources, faculty can contribute to a positive educa- tional environment for students.

In summary, studies suggest that staff in RACF-SNs need orientation to the needs of nursing students, preparation to provide positive learning experiences, access to learning resources, and recognition of the contribution they are making.

3.2. Models of practice

In reviewing the evidence to identify strategies for creating effective clinical learning experiences for undergraduate nursing students in RACF-SNs, different models for establishing clinical learning environ- ments in these settings were identified. These models reflect the themes identified in this review to varying degrees. They are described briefly here to provide further illustration of the different approaches to creating effective clinical learning experiences in RACF-SNs that have been developed and evaluated. They include the Sister Model (Campbell and Jeffers, 2008), the Tri-Focal Model of Care (O’Connell et al., 2008), the Teaching Nursing Home (TNH) (Mezey et al., 2008), the Enriched Clinical Learning Environment through Partnerships (ECLEP) (White et al., 2012), the Dedicated Education Unit (DEU) (Mullenbach and

Burggraf, 2012; O’Lynn, 2013), the Wisconsin Long Term Care Clinical Scholars Program (Nolet et al., 2015), the Co-operative for Healthy Aging Research and Teaching (CHART) (Jamieson and Grealish, 2016), and the Helping Hand Student Education and Partnership model (Loffler et al., 2018). A summary of work to evaluate these models is included in Table 2. Without exception, these models rely on the creation of an effective partnership between schools of nursing and RACF-SNs, but they have slightly different emphases. The TNH and the CHART model both focus on concurrent efforts to improve student education, resident outcomes, and research, with the CHART highlighting the role of organized shared governance. The Helping Hand Student Education and Partnership Model emphasizes interdisciplinary partnerships and effective coordination of placements. The Sister Model, the Tri-Focal Model of Care, and the ECLEP focus on improving staff support to enhance the student learning environment, while the Wisconsin Long Term Care Clinical Scholars Program provides summer internship op- portunities in nursing homes, involving both additional support for staff and effective supervisory relationships. The DEU model also focuses on effective supervision, utilizing practicing nurses as clinical instructors working directly with students, with nursing faculty providing support.

Although undoubtedly influential, limitations were noted in relation to the clinical education models. The TNH model was first developed in the United States in the 1980s and later tested in other countries. Although this approach became a national clinical model in Norway (Kirkevold, 2018), not all TNH projects were sustained in the United States after funding ended (Mezey et al., 2008). Other clinical partner- ship models were tested for effectiveness, but usually in a single location using primarily descriptive methods. The DEU, although well

Table 2 (continued )

Model/Citation Purpose Location/Sample/ Setting

Design/Framework Variables/Instruments Results Implications

• using a workforce model (directly employing allied health professionals rather than outsourcing)

• adequate resources

Table 3 The six senses for students.

Sense Definition (Brown et al., 2008a, p. 1222, p. 1222) Examples of student experiences consistent with each sense

A sense of security

“The freedom to learn and explore roles and competencies within a supportive but enabling environment which recognises the physical and emotional vulnerabilities of being a student.”

Receiving comprehensive orientation to the facility and routines (Brynildsen et al., 2014)) Having access to clear policies on appropriate activities to be undertaken by nursing students (Ryan et al., 2018) Receiving necessary information to care for residents (Lea et al., 2017)

A sense of belonging

“Feeling part of a defined group with a clear and valued role to play, mainly, but not exclusively, within the clinical area. Identifying with a community of peers, belonging to a cohort of students.”

Being made to feel welcome and part of a team within the facility (Husebø et al., 2018; Lea et al., 2015) Being able to develop relationships with residents and staff (O’Lynn, 2013).

A sense of continuity

“Being enabled to forge connections and make links between nursing as taught and nursing as witnessed, having consistent relationships and advice, being exposed to good standards of care based on a clear and agreed philosophy.”

Having a consistent relationship with a mentor, preceptor or supervising nurse throughout a placement (Brynildsen et al., 2014; Carlson and Idvall, 2014; Ryan et al., 2018; Xiao et al., 2012)

A sense of purpose

“Having something meaningful and important to aim for, identifying important personal and professional goals, being able to feel that there is the potential to ‘make a difference’ to the quality of care.”

Working with staff who are knowledgeable and passionate about their work ( Xiao et al., 2012) Having a mentor who challenges them and highlights learning opportunities in relation to older adults (Lea et al., 2016)

A sense of achievement

“Being able to realize personal and professionally orientated goals, particularly in relation to developing competence as a nurse, in a way that is consistent with self and significant others’ definitions of what constitutes good care. Being able to feel that you have ‘made a difference’.”

Receiving good feedback on their performance (Lea et al., 2016; Skaalvik et al., 2012) Feeling inspired by being exposed to excellent standards of care and positive attitudes towards older adults (Xiao et al., 2012) Making progress towards a goal and being acknowledged by staff as having contributed (Skaalvik et al., 2012).

A sense of significance

“The belief that you matter as a person and as a student, and that what you do is recognized as making an important contribution, acknowledged by significant others, individually and collectively. Developing a belief that gerontological nursing and older people matter and are accorded value and status.”

Experiencing mutual respect and trusting relationships between students and facility staff (Carlson and Idvall, 2014) Feeling valued by facility staff

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established in acute care settings, has not been widely tested in RACF-SNs. One of the barriers to utilizing the DEU is the low number of baccalaureate-prepared RNs in this setting. Overall, there was little ev- idence in the studies evaluating the different models of a clear concep- tual foundation guiding their development. Undoubtedly, the challenge of creating sustainability for clinical placements for nursing students in RACF-SNs has yet to be overcome, and it is possible that new and innovative approaches may be needed that build more explicitly on conceptual and theoretical understandings of how nursing students learn to work effectively with older adults.

4. Discussion

The findings of this integrative review suggest that nursing students can learn a wide range of practical nursing skills in RACF-SNs and can also advance their clinical reasoning and critical thinking skills. Nursing students can develop understanding of the RN role in this setting, potentially impacting recruitment (Neville and Dickie, 2014). Successful placements occur when academic schools of nursing and RACF-SNs develop a meaningful, reciprocal partnership and pay close attention to preparing and supporting staff and students through comprehensive orientation, effective supervision arrangements, and provision of educational resources and opportunities.

4.1. Limitations

Several limitations of the studies considered within this review are apparent. Many have small sample sizes and were conducted on a single site, limiting the generalizability of the findings to other settings. Moreover, all were conducted in countries with advanced industrialized economies, further limiting the potential to generalize findings. Overall, study designs generated lower levels of evidence, limiting the extent to which causal relationships could be inferred. Measures to determine effectiveness varied widely, most commonly relying on self-report. Nonetheless, the review provides an overview of approaches to providing clinical placements for nursing students in RACF-SNs and describes experiences of students and staff in relation to a range of strategies for promoting learning. These findings have been integrated

into a practical guideline that can assist faculty and nurses to develop a partnership between academic nursing departments and RACF-SNs that should enable effective learning experiences in these settings (see Ap- pendix A). The search results may not include all clinical teaching and learning models that have been developed and tested.

4.2. Conceptual framework

In considering the findings of the review, the authors recognized that elements of the conceptual model known as the Senses Framework (Nolan et al., 2006), mentioned earlier, might help to further explain the findings concerning effective strategies for creating clinical placements in RACF-SNs. Originally developed to capture important determinants of care for older adults and staff working with them in nursing homes (Nolan, 1997), the Senses Framework was further developed in exten- sive theoretical and empirical work in the UK (Brown et al., 2008a, 2008b; Nolan et al., 2001, 2006), and adapted to incorporate the needs of nursing students. Six senses or experiences were identified that were needed for students to experience an enriched practice placement with older adults (Brown et al., 2008a, 2008b; Nolan et al., 2006) (Table 3). A concept map (Fig. 2) proposes how the strategies for creating effective clinical placements in RACF-SNs identified within this review might create the six senses for students.

It is important to note that the Senses Framework has yet to be fully tested in RACF-SNs, although the framework provided the foundation of an extensive funded program of work in the UK to improve quality of care and quality of life in residential care facilities for older adults (NCHR&D Forum, 2007). Further research could utilize assessment tools based on the senses, both to determine outcomes for students under- taking clinical placements in these settings and to identify RACF-SNs that are likely to provide high quality clinical placements for nursing students. Continuous efforts are required by faculty to identify nursing homes with high standards of care and promote their use as clinical placements for nursing students.

5. Conclusion

The purpose of this integrative review of literature has been to

Fig. 2. Concept map of effective clinical placement for nursing students in RACF-SNs.

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describe strategies associated with effective clinical learning experi- ences for nursing students in RACF-SNs, including nursing homes. The review revealed that students are often reluctant to undertake clinical placements at these sites. As much of the future nursing workforce will be working with older adults in some capacity, schools of nursing must invest extra effort into exposing students to this population group to increase their understanding of older adult care.

Strategies identified for creating positive learning experiences for nursing students in nursing homes include developing a strong academic and nursing home partnership, providing comprehensive student orientation, promoting positive supervision experiences, and supporting facility staff in their educational roles. Several models of clinical edu- cation were identified that emphasize different aspects of the partner- ship between academia and nursing homes and these may offer guidance for faculty and staff in RACF-SNs who are seeking to create positive clinical experiences for nursing students. The Senses Framework may provide a useful tool for conceptualizing and measuring the effective- ness of future initiatives.

Funding sources

None.

Ethical approval details

This manuscript is a literature review that did not require an approval by an Institutional Review Board.

Author statement

Hana Splitgerber: Conceptualization, Methodology, Formal anal- ysis, Writing - Original draft preparation.

Susan Davies: Conceptualization, Methodology, Formal analysis, Writing – Review & Editing, Supervision.

Sara Laker: Conceptualization, Methodology, Formal analysis, Writing – Review & Editing, Supervision.

Declaration of competing interest

None.

Acknowledgements

We are grateful to Dr. Diane Forsyth for her review of an earlier version of this paper.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.nepr.2021.103008.

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