Dedicated Education Units: Strengthening a Learning Culture

Innovation in Care Delivery: Advancing a Professional Practice Environment

History of the Dedicated Education Process

Initial Implementation at MGH

The Interprofessional Dedicated Education Unit Experience at MGH

Overview

Why Clinical Education Must Change

(Ard & Valiga, 2009; Benner, Sutphen, Leonard, & Day, 2010, IOM-Future of Nursing Report, 2011; Ironside & McNelis 2010; NLN Think Tank of Transforming Clinical Education, 2008; NLN National Survey, 2009)

Obstacles to achieving quality clinical education experiences have been reported.

Recommendations to optimize clinical learning have been articulated: Align learning and engagement in clinical practice realities

Focus on achievement of students’ clinical learning goals

Address quality and safety improvement

Develop clinical reasoning and a spirit of inquiry

Visit by Kay Edgecombe, Flinders University So. Adelaide, Australia

September 2010

The History

blog.questia.com

Edgecombe’s DEU model for nursing clinical education represents a dramatic shift in focus on staff nurses assuming the clinical instructor responsibilities for individual students per semester, as well as the entire clinical unit and all staff focused on student learning and immersion into the clinical setting.

Clinical Education Partnerships Shared Vision and Goals

Quality Education and Innovative Practice Nursing Faculty and RN Shortages Diverse Workforce Patient Care Unit Development Professional Nurse Formation Quality & Safety Competencies Continuous Improvement

Coordination and Relationship-building Processes

Resource Commitment

A Partnership: University of Massachusetts Boston, Massachusetts General Hospital, and Brigham and Women ’s Hospital

A model where nursing practice informs nursing education and nursing education influences nursing practice

Dedicated Education Unit is…. An innovative model of clinical nursing

education.

An entire patient care unit is transformed into an optimal teaching/learning environment.

The DEU model strives to address the mechanisms that help alleviate the faculty shortage while providing enhanced nursing education and improving practice.

Defining the Roles of the DEU Model

CI = Clinical Instructor. A BS prepared staff nurse with five years of clinical experience is granted an adjunct faculty appointment at UMASS Boston. The staff provides direct clinical instruction, supervision, and evaluation of two nursing students.

CFC = Clinical Faculty Coordinator. A course professor at UMass Boston who collaborates with nursing management to support the CIs in their education and evaluation of the students.

Features of the DEUExclusive use of the DEU by University of

Massachusetts Boston students.Staff nurses would serve as clinical Instructors

for two nursing students over the course of the semester.

Orientation and faculty enrichment days provided to the CIs by the College of Nursing.

University faculty expertise to support the CIs.Commitment by all parties to build an optimal

learning environment.

2012

DEU IMPLEMENTATION TIMELINE

2011

2010

2007

2006

UMass Boston with MGH and BWH of Partners HealthCare Partnership formed

UMass Boston with MGH and BWH of Partners HealthCare Partnership formed

Jan 2008 Began Two DEUs Pilot Study focused on Quality/Safety competency development, Staff Nurse Satisfaction RWJF Grant QSEN Phase Two, Project School

Jan 2008 Began Two DEUs Pilot Study focused on Quality/Safety competency development, Staff Nurse Satisfaction RWJF Grant QSEN Phase Two, Project School

RWJF Grant (Jan 2010) Evaluating Innovations in Nursing Education Program Project PDQ First randomized control DEU study, Expanded number of units/students at MGH and BWH

RWJF Grant (Jan 2010) Evaluating Innovations in Nursing Education Program Project PDQ First randomized control DEU study, Expanded number of units/students at MGH and BWH

Additional DEU Study site beganGood Samaritan Medical Center, Brockton, MASteward Health Systems

Additional DEU Study site beganGood Samaritan Medical Center, Brockton, MASteward Health Systems

Two -yearEIN Study completed

Two -yearEIN Study completed

Overarching Research Question

“How does the DEU intervention develop new instructors (thus building capacity), enhance faculty work-life (thus sustaining recruitment, retention, and productivity), and promote educational quality, functioning within a shared DEU partnership structure and within local contexts, amidst nursing unit similarities and differences?”

STU

DY

D

ES

IGN

14 Week Semesters

4 Cohorts (Students)

Surveys, Interviews, Activity Logs

4 Clinical Rotations

CFCs: Coach CIs and provide clinical instruction guidance

CNHS Faculty: Provide classroom-based instruction; Colleagues with CFCs in academic service partnership

Junior Year: NU310 Senior Year: NU455 UMB CNHS Juniors, Good Academic Standing

Random Assignment

X O X O X O X O X O X O X O X O X O X O

DEU 2:1

Control 8:1

Control 1:1

DEU 1-2:1

Clinical Instructors: Provide clinical instruction to students

Data Collection Processes

SA

MP

LE D

ETA

ILS Students n = 162

4 Semester Cohorts 2010-2012

Comparison of Educational Quality:DEU vs Traditional Students (Mean Scores)

P < .001 SECEE; P < .01 GCL; QSENP < .001 SECEE; P < .01 GCL; QSEN

RES

ULTS

P<.001 QI, Informatics, TeamworkP<.001 QI, Informatics, Teamwork

Comparison of QSEN Competency Development: DEU vs Traditional Students (Mean Scores)

RES

ULTS

DEU Students Spend More Time on InstructionTime spent on instruction (2x) compared to other

activities, by group remainder: same time spent on patient care/management of care activities

CO

NC

LU

SIO

NS

DEU clinical education model is as effective as traditional model. Exceeds students’ perception of clinical learning in almost all items. Clinical learning is optimized.

DEU model provides more clinical learning opportunities and focus on QSEN competency development.

DEUs provided similar total direct patient care time; however, DEU students reported more instructional time, especially during patient care

Opportunity for teamwork experiences exceeded those available in the traditional model.

WORK LIFE:

CIs report benefits from working with students

DEU CIs Exhibit Enhanced

Spirit of Inquiry and Motivation “So I think it has helped me realize that there is so much still to learn. It keeps you fresh. You keep going back to your basics, you know. Because you kind of get lost in the fact that you’ve been doing this for so long that it becomes old hat to you…”

“It keeps me up to date with my knowledge. I feel like, you know, you’re kind of molding the brains of new nurses. It makes you learn about yourself, how you learn, positives and negatives.”

WO

RK

LIF

E

DEU Student

Presentation:

Learning Styles

of the Next

Generation

DEU Cycle

of Sustainab

ility

Program Growth (per semester)

2008 (Spring): 12 junior students 2009: 16 juniors, 12 seniors 2010: 30 juniors,12 -16 seniors *additional DEU unit started 2011: 24 - 28 juniors, 16 - 28

Seniors 2012: 20 juniors,16 - 28 Seniors

Recruitment 2008 – 2012 PCA – 31 RN – 16

Orientation Savings

Traditional 3 - 4 weeksDEU student 1.5 weeks

Traditional 8 -12 weeks DEU student 6 - 8 weeks

PCA

RN

Professional Development

ASN – BSN Enrollment 4 Staff Nurses have enrolled in BSN completion

program within the last two years.

BSN – Masters 4 Staff Nurses have enrolled in Masters program

within the last two years.

Masters-level Enrollment 8 -12 vouchers per year utilized by DEU staff

members.

Recommendations for Further StudyDeeper dive into:

Unit sustainability (mix of staff, rotation patterns, CI retention, max./min. student numbers.)

Student performance

CI development and CFC coaching

Transition to practice

Interprofessional Dedicated Education Unit Experience at MGH

Carmen Vega-Barachowitz, MS, CCC-SLPDirector MGH Speech, Language & Swallowing Disorders

IPDEU Member Steering Committee & IPDEU Faculty

OverviewThe purpose of this part of the presentation is to:

Discuss current evidence indicating that interprofessional collaborative practice are essential to safe, high quality, patient-centered care

Discuss the rationale for interprofessional education as precursor to interprofessional collaborative practice

Discuss the Interprofessional Dedicated Education Unit (IPDEU) including the evolution, structure and outcomes evaluation

IntroductionHealthcare Reform:A great moment to re-examine interprofessional approaches with the goal of addressing:

QualitySafetyEfficiencyEffectivenessPatient Centeredness

Evidence to Support Interprofessional Education

System is fragmented, silo-filled and more discipline-centric than patient-centered

Incidence of medical errors; 66% attributed to interprofessional communication breakdown

Coordination across complex systems, especially with multiple co-morbidities, requires expert collaboration across all members of the team.

Traditional HP education still occurs in silos; exposure to other disciplines is random and not purposeful

Quality & Safety Implications

Decreased medical errors and near misses:

attributed to IP communication

by increasing comfort with direct communication through standardized language

by improving understanding of roles,

responsibilities and the abilities of team members

JC Sentinel EventsContext Patient Safety ConcernsRoot Causes of Sentinel Events (all categories,

1995 – 2005)

We need to foster better communication between healthcare professionals as an approach to improving patient safety

We need to foster better communication between healthcare professionals as an approach to improving patient safety

Percent of 3548 events

Strong Collaboration Leading to Better Outcomes

Association Between Nurse-Physician

Collaborationand Negative Patient

Outcomes in ICU

The higher the level of nurse-physician collaboration, the lower the risk of a negative patient outcome

The higher the level of nurse-physician collaboration, the lower the risk of a negative patient outcome

Med-Surg ICU

Surgical ICU Medical ICU

Source: Definitions.net, STANDS4 LLC, 2012. http://www.definitions.net/definition/communication, accessed January 17, 2012; Fagin CM, Collaboration Between Nurses and Physicians: No Longer a Choice, Academic Medicine, 1992; 67(5):295-303; Baggs, et al., “Association Between Nurse-Physician Collaboration and Patient Outcomes in Three Intensive Care Units,” Critical Care Medicine, 1999, 27(9):1991-1998.

Interprofessional Collaboration

Interprofessional Education

Interprofessional Collaboration is a patient-centered approach to health care delivery that synergistically maximizes the strengths and skills of each contributing health worker to optimize the quality of patient care.

Interprofessional Education occurs when learners from two or more professions learn with, from and about each other to enable effective collaboration and improve health outcomes.

Background: IPE as precursor of IPC

Create a coordinated effort across health professions

Guide professionals and institutional curricular development of learning approaches & strategies

Provide a dialogue to evaluate the fit between education and practice demands

Provide a foundation for a learning continuum in IPC for lifelong learning

A process which includes but is not limited to communication and decision-making

Collaborative practice includes: Responsibility Accountability Coordination Communication Cooperation Assertiveness Autonomy Mutual trust and respect

Interprofessional Collaboration

Interprofessional Education

World Health Organization. 2010. Framework for Action on Interprofessional Education & Collaborative Practice. WHO, Geneva. p. 9

Framework for Action: Interprofessional education and collaborative practice

Sponsors American Association of Colleges of

Pharmacy American Association of Colleges of

Nursing American Association of Colleges of

Osteopathic Medicine American Dental Education

Association Association of Schools of Public

Health Association of American Medical

Colleges

Goal: Interprofessional Collaborative Practice as the key to safe, high-quality, accessible patient-centered care

Goal: Interprofessional Collaborative Practice as the key to safe, high-quality, accessible patient-centered careIP Competency DomainsA generally identified cluster of more specific interprofessional competencies that are conceptually linked, and serve as theoretical constructs.Values/ethics for IP PracticeRoles/ResponsibilitiesIP CommunicationTeams and Teamwork

IPDEU BackgroundCollaboration between

Massachusetts General Hospital & MGH Institute of Health Professions

Model & disciplines involved

1. Staff nurses become CIs

2. CIs become more skilled in

clinical instructionwith CFC coaching.

3. Students, nurses,the nursing unit and educational

unit benefit.

4. DEU studentsare hired as RNs

on DEU units,Supporting the

DEU model: RNs return for advanced

degrees.

Model of DEU for nursing

USED TWICE(see remake version on slide 23)

Physical Therapy

& SLP Model

MGH Experienced Clinicianbecomes

clinical supervisor

1:1 disciplinespecific clinical education

at the bedside or ambulatory setting

MGH staff in clinical educator (PT) role or senior staff (SLP)

is a mentor and coach to less experienced

clinical supervisors

Interprofessional

Education: IP-DEU

Interprofessional Clinical Education

Clinical interaction;Debriefings, Seminars

Interprofessional Collaboration:

Team partnershipCommunication

CoordinationUnderstanding of roles

Patient CenteredCare

IPDEU Goals & Objectives Deliver effective interprofessional clinical education that has

potential to lead to effective interprofessional collaborative practice and improved patient outcomes

Integrate both professional and interprofessional activities and competencies in the clinical experience

Generate interest in practicing in the acute care environment Offer professional development opportunities for clinical

instructors Increase the understanding of discipline specific contributions

leading to appropriate consults and referrals

Clinical Day

Structure

Interprofessional Dedicated Education

Units Clinical Site: Massachusetts General Hospital

Ellison 8: 36-bed in-patient Cardiac Step-down unit

Bigelow 11: 24-bed General Medicine unit

The StudentsTwenty-four students from CSD, Nursing, PT are placed

into mixed discipline pairs (dyads) per semesterNursing students are in the Accelerated BSN program or

Direct Entry Nursing (DEN) programPhysical therapy students are in the Doctor of Physical

Therapy programCommunication Science and Disorders students are in the

Masters of Science in Speech and Language Pathology program.

The FacultyClinical Faculty Coordinators MGH IHPClinical Instructors RNs, PTs, SLPsCI Staff Educators PT & SLPCI training

Teaching across disciplinesOne hour simulated session mandatory for all

clinical instructors

The Clinical DayEach student does clinical preparation prior

to clinical day

Dyads present prep to each other as well as nursing CI on the morning of clinical- allows for awareness of varied approaches of chart review as well as importance of roles

Engaging Students Across Disciplines

PATIENT & FAMILY

CENTRIC CARE

Balance/Fall Prevention

Vital Signs/Physiologic

ResponseEdema Management

Activity Instruction/Sternal Precautions

Communication

Cognition Positioning SwallowingVentilation/Gas Exchange

Integument

Endurance

Consultations

Medications

Patient & Family Education

Ethical IssuesPatient & Family Values

Interdisciplinary Rounds

Medical Management

Weekly Debriefings Common themes within the

objectives are discussed; facilitates self reflection and critical thinking

Bi-monthly Reflections Reflections read by

coordinators, comments provided

Final Seminar “Interprofessional Rounds” Held at the end to

demonstrate growth of the student, as well as awareness of value of other team members

Debriefings & Reflective

Component

Evaluation PlanCase based analysis of student experiences

Evaluation plan awaiting IRB approval

Generation of additional research questions

Able to communicate to patient with more knowledge and expertise

Improved understanding of patient because they understand team members and their roles

Having dyad partner and primary CI allows for creation of ‘safety net’ where they can ask questions, receive feedback, non threatening environment

Seeing things from a different perspective forced you to think about the patient and how they are affected

Qualitative Comments

Qualitative Comments All of the disciplines blend in a way that supports patient

care and the patient would not receive the best care if it weren’t for the interprofessional practice.

I have a better understanding of what my role is with PT and SLP

I think the debriefing sessions were…influential. It was great having all of the disciplines present and hearing their perspectives and contributions to difficult problems.

Future Directions/ConsiderationsInvolvement of other disciplines including

medical learnersExpansion of the IPDEUs beyond the current two

clinical units; the model may need to be adaptedAssess impact of this model to patient outcomesLongitudinal implications on interprofessional

practice