Implementing dedicated education units in 6 European undergraduate nursing and midwifery students clinical placements

The nursing and midwife learning process integrates theory, simulated practice and clinical placement (CP) into study programs. Although the main goal of the Bologna Declaration was to standardize European Higher Education, differences still exist in nursing curriculum implementation in Europe. There are both 3 and 4 year programs, inconsistent adoption of the European Credit Transfer System and wide variation in CP models and students’ experiences [1, 2]. As students’ CP represents more than 50% of nursing degree hours [3], it is vital to assist institutions and participants to deal with these issues.

The clinical learning environment includes the characteristics of the physical space, psychosocial factors, organizational culture, teaching and learning elements and everything that influences the student experience in achieving educational outcomes and developing knowledge and skills, behaviors and confidence [4, 5]. However, the literature describes differences in the quality of clinical environments and in students’ CP experiences, and shows that not all clinical sites are optimal learning environments which can, in some cases, have a negative impact on student learning [5, 6].

The main goal of the Dedicated Education Unit (DEU) clinical education model is to create an optimal clinical learning environment through educational-service partnering. The DEU model allows nursing/midwifery students to achieve practical knowledge and skills and develop their professionalism and balances the demands of student learning and professionals roles, ensuring patient comfort and safety by improving quality of care. The DEU model strengthens the teaching role of the clinical nurse in instructing students’ clinical skills in the clinical setting. It also emphasizes the role of the faculty nurse in ensuring student knowledge acquisition and supporting the clinical nurses’ teaching role. In addition, the collaboration of educational and health institutions allows the optimization of training resources, enhances theory and practice integration, facilitates the student’ acquisition of competencies, and responds to professionals’ needs to provide appropriate nurse training [7‐11]. Successful students and nurses’ outcomes in the DEU model are well documented [7‐9].

The DEU model was implemented in the 1990s by nursing faculty from Flinders University in Australia. Then, in 2003, the University of Portland adapted the Australian DEU in an effort to improve the clinical learning environment and address a shortage of nurses. Since 2003, several educational and healthcare organizations in Australia, New Zealand, the United States of America and Europe have successfully implemented DEU units [7, 8, 10]. The essencial elements of DEU [11] are as follows:

A multi-center qualitative study carried out in five European countries to identify facilitators, barriers and factors associated with DEU implementation in 6 European undergraduate nursing/midwifery students CP settings.

An innovative academic-service partnership between 6 European academic organizations and 6 European health care institutes in 5 European countries (Belgium, Portugal, Poland, Spain, Turkey) was established. University Colleges Leuven collaborated with University Hospital Leuven, University Colleges Limburg with Oost-Limburg Hospital, Medical University, Warsaw with Holy Family Hospital, Polytechnic Institute, Setúbal with Centro Hospitalar de Setúbal, Escola Infermeria de la Facultat de Medicina i Ciències de la Salut de la Universitat de Barcelona with Hospital Clínic de Barcelona and Ege Üniversitesi with Izmir University Medical Center. The Characteristics of the 6 countries’ educational contexts and nine selected clinical units where the DEU model was implemented are described in Table 1.

This study includes the perceptions of 21 key professionals from academic and service organizations who had an active role in DEU implementation: Belgium (n = 4), Poland (n = 5), Portugal (n = 5), Spain (n = 4) and Turkey (n = 4). Participants roles were: hospital and faculty managers and associate managers, faculty professors, and LT, responsible for coordinating DEU implementation and evaluation of each student’s CP. These professionals worked daily with various stakeholders, including clinicians, staff nurses-midwives, other health workers and the community, and this provides opportunities to deliver feedback during regular meetings. Assessing implementation from diverse perspectives ensured vital aspects (economic, organizational and human) were captured to contribute to fruitful implementation.

A research team for each country was formed with a study coordinator designated for each team. The DEU unified guidelines for carrying out implementation and assessment were registered in a protocol [12]. Meetings with universities and healthcare directors were held, contracts and agreements were signed to arrange the educational-service partnerships and to adapt the DEU to each setting. Each organization selected the appropriate units based on students’ academic level, interest, motivation and the availability of nurses/midwives, or other institutional preferences. HN, LT and CM roles and responsibilities were identified, written into the implementation guidelines and given to all participants. The DEU mentoring course was imparted by experts to at least four members of each country’s research team. Afterwards, each member country was responsible for giving the course to HN, LT and CM project participants. This course provided global and specific per-country theoretical and practical knowledge, skills and strategies for dealing with potential issues arising during students’ CP. Staff from selected units were informed about the model and objectives. The first day of the students’ CP, trained CM and students were paired in one-on-one relationships and the LT was incorporated into the student and unit health team. Follow-up meetings and evaluation of the DEU implementation process and outcomes were conducted weekly and at the end of the program, respectively.

To evaluate DEU implementation, we used quantitative and qualitative measures, including structured and semi-structured interviews, focus groups, and observation with the aim of assessing organizational context attitudes and behaviors. In this part of the study, aiming to identify DEU implementation facilitators and barriers, we used the Consolidated Framework for Implementation Research (CFIR). It is considered that use of the CFIR may help to advance implementation science [13, 14]. The CFIR describes constructs related to the Process of implementation: Planning, Engaging, Executing, and Reflecting and Evaluating [15]. It is composed of five domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved and process implementation. The CFIR has been applied in many studies and uses practical comprehensive taxonomy of constructs with the potential to influence implementation effectiveness and to encourage consistency in evaluation and reporting of translational efforts [16, 17]. We used the interview questions from the CFIR website [17] before and after the DEU implementation process. Likewise, we used the same authors’ criteria to qualify each item’s influence on implementation. For each construct, ratings were assigned that reflected the influence. Valences of + 2 + 1 reflect a positive influence, − 2 and − 1 a negative influence while 0 indicates that this construct had no influence on DEU implementation [16] (Table 2).

Participants ratings for every CFIR construct were analized to determine if the construct had a positive, neutral, or negative influence on DEU implementation performance, and the degree of its influence. The five CFIR domains were used as a framework for identificable codes and constructs for categories. Two researchers read and re-read the participants’ answers and organized the data. The participants verified the data to ensure isomorphism between the data collected and reality and to maximize the validity of findings. Computer software (ATLAS-ti version 8.2.1) was used for exploration, management and evaluation of data. During the investigation, standards of quality and scientific rigor; credibility, transferability, dependence and reliability described by Lincoln and Guba (1985) were applied [18].

The Ethics Committee at Hospital Clinic, Barcelona granted approval for this study (approval number: HCB/2017/0053). Staff received both written and oral information about the study aim and methodology. Written informed consent was signed before data collection and participants could withdraw from the study at any time. Participants’ data were kept confidential and their identifying information was removed and cannot be connected to them.

Participants thought this domain had less positive impact on DEU implementation. In relation to patient needs and resources, all participants strongly agreed on the quality of the patient care guarantee because in the DEU model, at all times, students and patients were supervized by a qualified registered nurse/midwife. Participants in Belgium added: “Because the students are always supervized by an experienced nurse, the quality of care could remain guaranteed. Because they were trained in total patient care, and because they were able to make time for the patient, it might even increase the ability to meet the needs.” Turkish participants believed implementation of the DEU model in their units could increase the quality of nursing students’ education and the quality of patient care. They stated: “They (patients) were happy about it because that intervention was to educate the nurses better and these nurses will attend them in the future.” Further, coordinators in Portugal agree that “The intervention will emphasize a closer approach to the assessment and follow-up of patients’ needs and preferences.”

All project coordinators believed their organizations had higher quality networking, and the option to keep in contact with other organizations where the DEU is already implemented was an additional benefit at the time of collecting, sharing and comparing experiences. Belgium participants stated: “We talk about the DEU with all other DEUs on a formal basis. To evaluate the DEU, but also to exchange experiences. We do this with other DEUs in the hospital, but also with other partners from other hospitals, even from other schools. Then, of course, also with our international partners.” Spain participants stated: “We promote transversality between different organizations and departments to promote team work and professional involvement.”

Participants considered the inner setting the most positive influential CFIR domain at the time of DEU implementation. They highlight leadership engagement from the project’s coordinators and declared that the educational and health teams and management were open-minded, included innovations and engaged people at all levels. They also stressed the freedom of the learning climate in allowing people to demonstrate their capacities and creativity to improve any intervention or innovation. Portugal participants added: “ The institution is an “open door hospital“, which values the partnership relationship with the various community structures, with established protocols with the city’s existing dynamism.” and “There is a creative freedom within the institutional rules on quality.” Poland coordinators agree: “Our university tries to be up-to-date with new methods, because they are very important in medicine.”

Questions in this domain were answered after DEU model implementation. Engaging, Intervention participants and Reflecting & Evaluating constructs were considered by participants to be the most influential positive factors during the DEU implementation process. DEU coordinators and implementation teams’ effective leadership were strategic advantages for participants and helped to overcome difficulties in DEU implementation.

Portugal participants stated: “Motivated and experienced ones (leaders), both in nursing care and student mentoring.” They also added: “Choose available and experienced CM. Project marketing at the unit. Adequate training and involvement in the project. Continuous assessment of the project.”