After reading here on allnurses for some time and observing the amount of questions from potential students regarding what hallmarks identify quality nursing programs, I thought I would draft this article.
I did considerable research on programs based on the specialties I was interested in, the structure, and the clinical experiences provided when I was school shopping. I really wish there had been more information available to me regarding the importance of quality clinical experiences. I was extremely lucky to attend an outstanding program, and because of my experiences I wanted to share information regarding the education model used and equip you all with a few more tools to use when considering your future school. With the advent of so many for-profit, poorly designed programs out there, the stories of students being taken advantage of are more and more common, and that is something I hate to see.
Another recurring theme I see here on allnurses is that students are struggling during their clinical experiences. There seem to be many, many horror stories of clinical nightmares ranging from the professional team dynamic on a nursing unit, to personality clashes with faculty and staff, and difficulties with nurse preceptors. While I'm sure that these are multi-faceted issues, I wanted to share my experiences in a nursing program that utilizes the DEU or Designated Education Unit model of clinical teaching.
In many "traditional" nursing programs, clinicals are structured something like this:
- Students have assigned clinical "days" of the week based on their faculty's schedule (or the school's schedule)
- Students visit the hospital the night before to receive patient assignments
- Students must look up pertinent information on their patients: chart, meds, history, allergies, etc in preparation for the next day's clinical.
- Students are assigned to a nurse preceptor who is in charge of the care for the patient to whom the student has been assigned; often the faculty assigns the patient to the student.
- Students may work a short shift or have limited hours on clinical days as paperwork may be due *that* day, which limits time at the bedside and may result in students spending time in the "break room" instead of hands-on learning.
- The student arrives to clinical, completes a day's work (or in some cases, shadows)
- The student turns in a care plan for their assigned patient, oftentimes the same day.
There are a few limitations to the "traditional" model. Many of the students I know who attend programs that utilize this model spend hours of the night before clinical trying to complete paperwork and looking up medications, and arrive at clinical exhausted. Additionally, these students often do not attend report, get their assignment, and take charge of their day as they would in a normal work setting. Reading a patient history, getting a summary, and proceeding with care requires a very different learning skillset and level of critical thinking than poring over the patient's chart and looking up meds for hours. You simply do not have this kind of time when you begin to work as a nurse. Sometimes, the nurse preceptor to whom the student is assigned may not know they are getting a student that day, may be a new nurse themselves, or may not enjoy teaching. It seems that this is where a lot of conflict begins between student and preceptor.
The DEU model takes place on units that are specifically designated as teaching units. In my area, these units have relationships with the local nursing schools, and policies and procedures are well developed and clear. The student's scope of practice, do's and don'ts, and learning objectives are well established. Nurses from DEU's volunteer to be preceptors, and in the case of my program, attend classes through the University that orient them to the nursing program's objectives, precepting methods, policies, procedures, teaching styles, etc. Most of our preceptors are extremely experienced nurses with a wealth of experience who truly enjoy teaching. Students are paired with preceptors that appear to be compatible with their personality, skill level, and the like. While this might not always be possible, efforts are made to ensure a good fit between student and preceptor, and both are fully instructed on protocols for handling any conflicts which may arise.
In a DEU program, the students follow the schedule of their assigned nurse preceptor for the entire rotation. This may include day shifts, nights, evenings, weekends, 8 hour shifts, 12 hour shifts, etc. Also, the students are not required to visit the hospital the night before to receive assignments; the student is assigned to a nurse, not a specific patient. The student arrives early, attends report, reviews the patients' charts, and sets up their day alongside their nurse preceptor, just as a licensed nurse does on a daily basis. Many times, in the later semesters of the programs, the clinical faculty is not even present for the entire shift. A mid-term and final evaluation is conducted between the student, nurse preceptor, and faculty, and this evaluation is exactly like a professional performance review. Clinical paperwork, such as care plans, are turned in weekly to the clinical faculty, typically via email; generally only one care plan is due per week. Post conference takes place during a typical class day, not during clinical.
Students are still expected to know their meds, know their skills, and know their patient's backgrounds before administering any medications or initiating care. Technology is welcomed; medications can be looked up in a variety of software programs if the student needs a refresher prior to administering the med, but everything is done on the unit, just as a licensed nurse would do. The first two semesters of the program are weighted very heavily for lab time. Before the student performs skills in the hospital setting, they have become proficient in the lab; lab equipment is purchased based on the brands and models used on the DEU to ensure familiarity. Pharmacology is also heavily front weighted, and competency expectations are clear and quite high. Excellent reference materials are provided in the classroom, including commonly encountered med "cheat sheets" based on DEU protocols and preferences.
Overall, my experiences with the DEU model have been outstanding. During my first medical rotation, my cohort actually was not able to participate in this model because of a massive overhaul of the hospital's electronic medical records system. For this rotation, we were assigned nurse preceptors on the fly, more like the traditional model. While I still had a terrific experience (especially because the hospital had tons of float and travel nurses to facilitate the EMR change), I could definitely see how problems could occur. The advantage was that I was able to observe many different approaches to nursing. The disadvantage to the traditional model is that the student must establish rapport, "prove" their skillset, and review what they are allowed to do each time they meet a new nurse, which can be a hindrance to skill development, time management development, and autonomy.
By the "advanced" rotations that took place during the second to last semester of my program, all of the students were expected to carry a full patient load of 4-5 patients (depending on the unit's policy. ICU =2, for example), complete assessments, administer all meds, draw labs, communicate with physicians, and complete all charting on time and accurately. Charting was cosigned by the nurse preceptor but was part of the patient's actual medical record. 85% of this work was conducted independently or with stand by assist. This second to last semester served as preparation for the student's final practicum in the specialty of their choice, if accepted.
The DEU model overall allows for tremendous growth, student confidence, and truly prepares students to enter the "real world" of nursing. While all students enter the profession with a great deal to learn, the flexibility of this model truly helps students to become functional team members and lets them work at the pace of the unit. Students who are ahead and demonstrating more advanced skills are pushed and provided with additional challenges and responsibilities; those who need a bit more time are accommodated and brought along more slowly.
The DEU model provides excellent networking opportunities for students. Throughout all of the rotations, the student has the chance to develop relationships with not only their nurse preceptor, but their nurse managers, physicians, support staff, and even HR in some cases. Many students in previous classes have obtained employment prior to graduation. This goes both ways, however. If a student is not meeting benchmarks, constructive feedback is given and consequences are made abundantly clear.
My program wasn't perfect. I had a lot of gripes (mainly about a lot of petty things, I know now!). After reading so many student horror stories on AN, speaking to my peers who are completing their degrees at a variety of different schools, and doing some basic research, I took every complaint back. I feel tremendously privileged to have attended this style of program. I feel that my time management and critical thinking have grown exponentially, and I was able to secure a coveted final practicum slot on a specialty unit that offers limited access to students.
The DEU model strives to improve upon the traditional model by meeting the needs of both the seasoned preceptor and the student nurses who are anxious to learn, all the while keeping patient care in the forefront. I hope this information will assist you when you are evaluating your program options. I cannot emphasize enough the importance of choosing a program with good NCLEX pass rates, good completion statistics, and that is (most importantly) full accredited. Don't be afraid to take your time when evaluating schools; ask questions and dig in to the school's stats, get feedback from other students, talk to hiring managers in your community. (Be professional, of course!). How are clinicals conducted? How many hours does the program include? What type of technology does the simulation lab offer, and how often can you get in to the lab to use it? The job market continues to be tough, and equipping yourself with the best education possible is one step you can take on the road to achieving your dreams.
Here is some more information on DEU as well as a link to one of the school's utilizing this model:
Implementing Quality and Safety at the Unit Level in an Innovative Clinical Education Model
Dedicated Education Unit: An Innovative Clinical Partner Education Model
University of Portland (Not my school, but a nice summary)
Thanks for reading, have fun, and get out there and own your nursing school experience!
