Determining faculty clinical competence - page 2

My hospital is having an issue with the competence of some of the faculty members that are sent by the schools to supervise student clinical experiences. We are considering the establishment of a... Read More

  1. by   llg
    Quote from vickynurse

    I'll agree that not every clinical instructor is proficient at the bedside. But, to be fair, not every bedside nurse is a good teacher. Nursing education is a unique specialty. We are not baby sitters for baby nurses!

    And by the way, how is it that I can supervise and educate nine students who are caring for nine patients, and not be competent? Students beg to be in my group even though I have very high expectations. Of the 40+ students I have in clinical over 12 months, I rarely have anyone fail boards.
    If you have gotten the impression that I think that you, personally, are incompetent, I am sorry for the misunderstanding. I don't know who you are and do not know anything about your level of expertise. I just know that some of the people sent to my hospital to supervise clinical experiences know almost nothing about inpatient pediatrics. Some have never even worked on an inpatient peds unit before. They make many mistakes in their care and we hear them tell the students the wrong things, etc. and it has us very worried. Sometimes, the faculty are not hired until the very last minute and have no time for orientation to the unit unless we make a fuss about it and insist and/or register an official complaint to the school.

    The whole purpose of the thread was for me to find out what is done in other parts of the country to assure that faculty are clinically competent to supervise care. I am interested in hearing about orientations required, check-offs, etc. that are not required in my region of the country.

    I also agree wholeheartedly that not every bedside nurse is a good teacher. In order to be a good clinical teacher, the nurse has to be competent in BOTH the care of the patient and in teaching.
    Last edit by llg on Mar 12, '07
  2. by   VickyRN
    It has been very difficult for schools of nursing in our area to find qualified pediatric clinical instructors.

    I am a clinical instructor overseeing BSN students on a very acute tertiary pediatric ward in the local teaching hospital. I have been on this same floor for almost 5 years now with groups of students (first ADN and now BSN) and feel comfortable and competent. I also conducted clinicals for ADN students in a longterm care pediatric facility.

    I have to admit that I have not "officially" worked on an inpatient peds unit. I do have experience with mother-baby nursing and especially with newborns. I have also worked on general med-surg floors in small community hospitals, in which there are a few pediatric patients added to the mix. I study and research the patient assignments the day before and ask lots of questions. During my 4 years as a faculty member in the ADN program, I extensively taught pediatric content in the classroom, and so am familiar with most of the diseases and even the odd syndromes on the floor.
  3. by   llg
    Quote from VickyRN
    I am a clinical instructor overseeing BSN students on a very acute tertiary pediatric ward in the local teaching hospital. I have been on this same floor for almost 5 years now with groups of students (first ADN and now BSN) and feel comfortable and competent. I also conducted clinicals for ADN students in a longterm care pediatric facility.

    I have to admit that I have not "officially" worked on an inpatient peds unit. .
    We would be quite happy with those sorts of qualifications. We have a couple of instructors like that. They are not employee's of the hospital, but they have been in the hospital working with students on a regular basis. They know the type of patient population we have and the type of care we need. They also know the staff nurses and the nursing leadership team -- and can use them as resources as needed.

    What worries us are the instructors who are hired at the last minute who have never set foot in our hospital before -- and have never worked on a pediatric inpatient unit before. They suddenly show up with a group of students and want to give meds, change dressings, etc. They do things to our IV pumps, keep the doors open to the negative pressure rooms, give parents wrong information, violate infection control policies, etc. They (and/or their supervisors) believe that because they have MSN after their name and have a little outpatient peds experience as an FNP, that they can come right in and start doing patient care in our hospital without an orientation.

    Our contracts with the schools do not mandate specific qualifications or orientation requirements. They just say that the school will send "qualified faculty" and leave it up to the schools to assess the competence of their teachers. We are finding that we can not trust the schools' judgments and need to set some specific guidelines. That's why I started the thread. I am grateful to everyone who has participated in it and welcome any more input anyone has to offer.
  4. by   barb4575
    llg,

    I do understand your concerns and they are valid. This is where I believe nursing education and practice need to come together. We all know that the real problem with the nursing shortage is the severe faculty shortage. It would be terrific if the nurse practice experts would teach clinical, but most either don't want to make the low salary or don't want to teach or both. What has happened in nursing education is that if one has an advanced degree and is breathing, he/she gets hired and yes, much of it is occurring at the last minute. The Director/Dean may have one standard, but the reality is that these days, you have to take who you can get...often times, there is only one applicant.

    As far as the board approving someone in MO, I know personally that I cannot rely on that method. I hired someone from another well-known, large college and three of those faculty gave this applicant glowing references. Once hired, I realized that working on a doctorate does not equate with knowing the fundamentals of nursing and people are afraid to tell the truth on reference checks. You would not believe what this individual did and I won't reveal it here...incredible really.

    I have decided about the time that I retire, nurse educators will have a great salary and this will attract more experts into education. But, we also will be having more faculty who are working for the money and not have the passion for education. There are many terrific nurse educators who do keep active in practice via various methods, but like practice, there are many that are not competent or caring.

    The solution lies with both groups: nursing practice leaders and nurse educators. I do not think the nursing practice leaders should only be admin-types, I am referring to including those who are actually working actively in practice.

    Regardless if I remain active in practice, it is my 25 years of experience that gives me the insight to ask the expert when I need to do so and to quickly realize who the experts on the unit really are...usually takes me one day to figure it out.

    Thank you,

    Barbara
  5. by   vickynurse
    Quote from llg
    What worries us are the instructors who are hired at the last minute who have never set foot in our hospital before -- and have never worked on a pediatric inpatient unit before. They suddenly show up with a group of students and want to give meds, change dressings, etc. They do things to our IV pumps,....
    No offense taken, just want to point out that some very desparaging remarks have been made about nursing instructors on this thread. BTW, ditto with everything Barb said in her post. Those of us who specialize in education really take a hit in the wallet.

    The above quote may be a contributing factor to your problems. We have contracts with five peds hospitals / units STL and NONE allow students to give meds or do anything with IVs. This is written in the contracts. Some facilities also dictate the student / teacher ratio.

    Just trying to throw out some ideas. Take them or leave them.
  6. by   barb4575
    Hey Vicky,

    I was worried that you would take offense to my post and I am happy that you did not...afterall, we are both educators and employed in the same state. I do know that what llg is saying is absolutely right on, but I don't have any specific solutions, other than practitioners and educators must work together to promote quality care and a good learning experience for students. They are our future and if we can give to them just as my preceptor gave to me, we will be ahead. I will never forget my preceptor and I was lucky that she had the diploma, work experience, and patience of Job. There was no way that I was ready to lead an evening Med-Surg unit. Not once did she make me feel that I was ignorant or that my education as a BSN was inadequate...even though at that time, I felt it was very inadequate. I do not think it matters what program one graduates from, most do feel this way as a new grad. What concerns me most of all is how very difficult nursing on these Med-Surg units has become and I applaud those nurse administrators who are standing up for their nurses and won't allow more than a 4:1 ratio. The patients are that acutely ill and require that much attention.

    You know the old saying about educators, they teach because they cannot do. I can finally see some truth to it today. I am doing some PRN Med-Surg because it is challenging and I love to learn. But, there is absolutely no way that I am going to do it FT with 9 patients per shift. I know I would be unhappy because I could not give the care they deserved. My question is how do staff nurses today cope with those feelings? I could never be ok with saying, I did the best I could, because over the past two years--it was never good enough and I just could not uphold my standards in that situation.

    llg, I realize you are talking about Peds, but that is not my background. I can say that when I was an agency nurse, the staff nurses did not allow the agency nurses to accept peds patients and trust me, that never hurt my feelings. I am an adult health nurse and I don't pretend to know much about Pediatrics. One time I worked in a small hospital as a PRN nurse and I had to take Peds patients, but the difference was that the house supervisor was an expert in Peds and she was willing to answer questions and assist us. That was the only way I felt safe.

    I will work on some problem-solving for this issue and see what I can come up with for resolution. It is an excellent, thought-provoking thread.

    Thank you,

    Barbara
  7. by   vickynurse
    Yes, this has been an interesting thread. I agree that educators and industry need to work together toward solutions. BOTH must be willing to contribute to the solutions. I feel my suggestions to you, llg can be a start. Orientation is an obvious need. Evals on all instructors, written by hosp staff and sent to the education program director are helpful as long as they are objective and not rants / personal attacks. Guidelines for acceptable student teacher ratios can be stipulated in contracts. Restrictions such as 'no med administration' can also be contracted. Facilities can also recruit instructors from within as I've mentioned before. A facility could also request documentation of instructor experience in a specific area, such as peds. (Although that is no guarantee of competence, either.)

    Since each nurse has unique education and experience, I doubt that it will be possible to come up with a simple list of qualifications. Barb, you've been in a position to hire instructors and I have not. Is it even legal for a hospital to interview or have input into who the hiring process on a college campus? I'm not sure of the privacy and labor laws related to this situation.

    I agree that the shortage of professional FT nurse educators (different from PT clincal instructor) is contributing to the shortage. We cannot loose sight; however, of the way industry is chewing up and spitting out nurses by the tens of thousands every year. I see this as analogous to fluid volume deficit: too little fluid in AND too much out. Education can only address the infusion of new nurses. Industry must address the hemorrhage. Yes, med surg is hard. Too physically hard for the > 40ish nurse and more demanding than the < 40ish nurse is willing to give to a job. Burnout is an industry problem. The only thing I can do as an educator is to toughen them up while they are students by having high expectations.

    Anyway, I've probably contributed as much as I can on this thread. See you on another thread!
  8. by   llg
    Thanks, vickynurse, for your participation ... and to you, too, Barbara.

    I've been a FT clinical instructor in the past and am now teaching in the classroom part time. So, I do sympathize with the schools' problems. However, as I am now working for a hospital coordinating our school contracts, I can't allow the schools to send faculty members who can't be trusted to use good judgment regarding patient care as they supervise their students.

    Unfortunately, we have 3 local schools who have terrible problems with their internal management. As a result of their troubles, they have serious problems attracting and retaining qualified faculty. Because we deal with 8 different RN programs, it's hard for us to "play favorites" with one or two schools -- and whatever we require for one (or offer in support of one), we have to do for the others. The good news is that I have recently learned that the state's BON is considering the establishment of some additional standards/requirements for nursing programs that if adopted, would force these schools to either address some of their problems or shut down. That would be a blessing either way.
  9. by   barb4575
    llg and Vicky,

    I agree with all of Vicky's suggestions. I also know that a thorough agency orientation is necessary and if the agency doesn't provide it, this becomes the responsibility of the educator to get the orientation. Shadowing a RN for at least one shift does help to familiarize oneself to the facility and their procedures/policies/routine. I can say that most of the orientations I have received have not been helpful until I shadowed that staff RN. Even if the staff nurse did not enjoy teaching, I would get the information I needed by asking questions and stressing that I needed to know how they did things so I could be consistent with them. Suddenly, their attitude would change. Many staff RN's have negative views of faculty and this only helps to change those views.

    Just as staff RN's have to complete skill competency exams, the educator should have to do this local credentialing as well. The hospital Staff Education and Development representative can learn a great deal about the faculty member prior to him/her ever reaching the unit. I did have one hospital call me about two of my faculty members--one before she started and the other was after her first clinical day teaching. The dilemma was that both nurses were "no rehires" at those institutions.

    When the Chief Nursing Officer informed me of this, I also informed her that I had received excellent references on them from her nursing staff and told her how difficult it was to find faculty and I could not teach every course.

    I then went to the clinical area and spent the day; I did regular rounds (often times being present the entire shift) so she was not suspiscious. I spent hours talking to this faculty member afterwards and she then became the best clinical instructor I had...she had no idea that she was coming across to students and nurses in the manner that she had been up to that point. To this day, there has been no other faculty member as skilled in clinical education.

    I do believe that if the instructor is confident in his/her clinical skills, most nurses will pick this up immediately. If the staff nurse or manager does not find that the instructor is competent, it is their responsibility to report it to the Dean/Director and hospital nursing administration. Afterall, they are responsible for the quality care delivered by all which includes students and instructors.

    With the board of nursing, it is imperative that their Minimum Standards for nurse administrators and educators address this dilemma. The process of getting a faculty member approved does not appear to be adequate and is too rushed. The standards are so vague and this is something that the board staff need to rectify. They do need to close colleges that are not offering quality education. What I have found in my experience is that the board would like to put that responsibility on the Dean or Director and they may be fearful about acting due to their liabilities. I had no idea how political a board of nursing was until I worked for a not-for-profit new college organization and couldn't seem to close it down. There was no one in education who did not agree that they needed closed either, but the politics of it all, kept them partially in business. This is where my current doctoral research lies: with the professional nurse educator who becomes a whistleblower.

    I do not think that nurse practice employees should be involved in the hiring of faculty other than providing references for them. When these references are offered, they should be honest or not provided at all. A great deal can be said on the phone reference check without saying much at all.

    Many colleges are partnering with the hospitals to obtain qualified, experienced nurse clinical educators. The more we involve ourself in this process, the better we will be in the professions of nursing and education. We want them to help us.

    Thank you for this thought-provoking thread,

    Barbara
  10. by   llg
    Thanks, Barbara,

    I suspect my hospital will begin requiring some specific orientation process to the units for faculty prior to their first day of clinical. We have always offered such an orientation -- and the better schools take us up on it. However, some of the schools that are struggling often hire their faculty only a day or two before the start of a rotation. That makes it impossible for us to bring the new faculty together at the beginning of a semester and have some sort of group session -- or even a planned class once per month. It has to be thrown together at the last minute without notice each time a faculty member quits and a replacement is hurriedly found.

    We also have the problem that the clinical groups usually rotate through several different units during a single rotation, thus requiring more than a day or two of clinical orientation. The range of units and the types of care needed, the unit routines, etc. are significantly different and many clinical groups only spend 2 or 3 days on each unit. Thus the schools don't want to "waste time" orienting to a unit that will only be used so briefly. But I see no choice in that.

    The schools will complain that it is an undue hardship to have to hire faculty ahead of time ... and provide them with paid time to get oriented ... and tell us that we are being unfair. The political ramifications may be significant if those schools complain about our "unfairness" publically. But I think it is something we have to do -- for safety's sake.

    Thank you for letting me know what it is like in your neck of the woods.
  11. by   barb4575
    Hi llg,

    I was wondering if the hospital director has spoken to the director for the college about these issues? There may be much more to the story than you are all aware of--I do agree with the rule you will be making that they need to be oriented by a certain time frame. The director of the college will have to realize that if she doesn't hire by that date, they won't be able to use your site for clinical. It is amazing how people tend to make deadlines when forced to do so.

    I also have some empathy for the director because I know how difficult it is to attract faculty especially to an organization that does not advertise, offers poor salary and benefits, and the word does get around about their reputation. I was doing three FT roles at once because of these very reasons and I only stayed as long as I did for the students. The organization is not-for-profit, yet trust me, it was all about money. Once the board of nursing approved the start-up date, the President did what she wanted and had absolutely no respect for the regulatory power of the board of nursing. She terminated a large majority of individuals because quite frankly, she had no money to pay them and she had some people who were employed and would do anything for the students...including working many roles for the price of one.

    Spyder has a thread about a new LPN school in IL and I am sorry to hear what is going on with her as it reminds me of the same situation I was in- I fought it for 1.25 years. The President did leave me alone for the first year as she was so busy micromanaging the LPN Director. I wanted to resign in the summer, but when I informed the board, I was told that they would close both of my programs like they did the LPN programs due to the instability. I knew that no other school would accept them and they would have wasted one year of their lives and $10k, so I stayed awhile longer. One month after I resigned, one campus was closed. The other branch campus is still open to allow these students to actually graduate. I am curious to see if they will close their branch campuses completely down when these students are finished. I hope the board of nursing and accrediting body will act appropriately. There are also some very powerful, wealthy men involved and politicians too--so it is unclear of what will happen at this time.

    I had a reporter tell me that it is a great story. I find it to be the saddest story in nursing education.

    I had to laugh when you said, my neck of the "woods" because trust me, these are woods here

    Good luck in the new policy development and the implementation of such changes. I would guess that the director of these colleges will follow suit because they need you as a clinical site. I would also question if they come to your hospital so infrequently, perhaps the entire experience could be observational?

    Barbara
  12. by   traumaRUs
    I was a staff nurse in a level one trauma center for 10 years and while there, I went back to school and got my MSN and continued to work as a staff nurse afterwards. Anyway, since we were the "big" hospital in town, the nursing schools in the area (4) sent students to the ER. I liked having students so I volunteered often to precept. One day I had a chance to talk with an instructor because I wanted to scope out the opportunities in academia. Anyway, I found out that she had only worked as an RN for 2 years over 15 years prior and then went back for an advanced degree and her doctorate and had taught during the intervening years. However, she told me that she was very scared being in the ER because she had no experience with critical care.

    So, my concern is the lack of current experience for these educators. This educator was very nice, polite, well-liked on the unit and respected by her students. Yet, she couldn't show anything to the students - the staff nurse preceptors were providing the education.

    And...I do know about the shortage of instructors. I am currently clinically competent because I work as an APN, but can't take a cut in pay in order to teach.
  13. by   llg
    Quote from barb4575
    Hi llg,

    I was wondering if the hospital director has spoken to the director for the college about these issues? There may be much more to the story than you are all aware of--I do agree with the rule you will be making that they need to be oriented by a certain time frame. The director of the college will have to realize that if she doesn't hire by that date, they won't be able to use your site for clinical. It is amazing how people tend to make deadlines when forced to do so.
    ........ (snip, snip) ...
    Good luck in the new policy development and the implementation of such changes. I would guess that the director of these colleges will follow suit because they need you as a clinical site. I would also question if they come to your hospital so infrequently, perhaps the entire experience could be observational?

    Barbara
    I am the person responsible for coordinating the activities of the 8 RN programs who use my hospital, and yes, I have spoken with the school directors many times. I have told them many times over a period of about 4 years that we will be forced to create and enforce strict requirements if they don't voluntarily takes steps themselves to address some of the issues, but it hasn't done much good. Slowly, I have started to enforce increasingly strict policies -- but I think it is time for a bigger change. Thus, my interest in requiring adequate faculty preparation and my willingness to consider actually not allowing those who don't comply to continue coming.

    The politics are complicated because we are a charity hospital with the only really good pediatric inpatient units in the region. There are also racial and social class issues that could be brought into the situation. It could get really messy. It could also effect our fundraising efforts long term -- and as a charity hospital, that's a major issue.

    The "just observation" idea is one we have used to help tide us over temporarily. However, I doubt we can continue to rely on that approach much longer and/or on a much larger scale. We do have some schools that have qualified faculty and who provide and an excellent education and who would like to expand. They need the clinical slots to expand -- slots that are now being filled by schools without qualified faculty. It would be in the community's best interest to allow those good quality schools to expand and to consolidate the community's resources within the better quality programs. There needs to be some reorganization and "shake out" of the nursing education programs in the region. But how we get there is difficult ... and it's hard to figure out where my hospital fits in the dynamics.

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