"I've never done this before."
These words, from the lips of the young nurse at bedside wielding an IV, line could evoke a hospital patient's worst nightmare. Of course, in reality this would never occur. No RN. would voice that thought even if it were true. And it would not be true: all nursing students, whether in diploma, associate, or baccalaureate programs, receive some clinical experience (Kelly, 1987). The question is, what is the quality of this experience? How intensive is the training?
At The University of Tennessee at Chattanooga (UTC), a collaborative effort between the School of Nursing, the Office of Cooperative Education, and several local hospitals ensures that new nursing graduates are adequately prepared-before the diploma is awarded. UTC nursing students undergo intensive, in-hospital clinical training that requires them - under the direct supervision of a nurse mentor or preceptor - to function as registered nurses for a period of five weeks.
But these students acquire more than the clinical basics. Beyond learning how to administer medication, start intravenous fluids, read doctors' orders, and relate effectively to clients and families, they encounter many of the more subtle nuances of the job. They discover that philosophical differences exist between what they've been taught in school-that care of and loyalty to the client and the client's family are paramount-and what the service agency expects: loyalty to that agency and conformity to its rules and administrative structure above all else (Ford, 1977). They realize that hospital personnel are as susceptible as employees anywhere to company politics. Most importantly, however, these students learn the value of teamwork; and teamwork "is, or must become, a lifelong professional work pattern" for nurses (Ford, 1977,p. 21). The competence and confidence the UTC nursing student gains through the close team relationship with a nurse preceptor cannot be overstated. How, then, does the nursing preceptorship work at UTC? And where does cooperative education come in?
The brainchild of nursing professor Dr. Cherry Anderson, the clinical preceptorship came into being in 1988. At the outset, one large medical center agreed to participate by assigning preceptors and paying stipends to the first group of students, who also received three semester hours credit for the course. Other local hospitals, seeing the advantages, soon followed suit. In similar fashion to Northeastern's School of Nursing, which started out in 1965 with five hospitals and six years later had twenty (Knowles, 1972), UTC's program has increased hospital and student participation five-fold since its inception. The class is no longer optional. Successful completion of this course is now a requirement for graduation from UTC with a BSN degree.
The UTC clinical preceptorship is a five-week summer course offered to rising seniors. Each student must work a minimum of 170 hours, and must conform to the preceptor's shift schedule. So that the learning experience is not compromised, double shifts are strongly discouraged. (However, straight 12-hour shifts are not uncommon.) The student is paid a stipend by the hospital, half on the front end and half at completion, whether or not the hospital has also offered a scholarship to that student (efforts are made to place students in hospitals where they already have scholarships, although this is not always possible). All students have malpractice insurance and are certified in CPR. Students who request placement on an intensive care unit must first receive a recommendation from the UTC faculty member who trained the student in medical/ surgical procedures.
There is an academic component to this intense clinical course, as well. One afternoon each week, all preceptorship students meet with nursing faculty for five hours of discussion, debriefing, and case presentation. More than two absences from these seminars-usually due to work schedule conflict-are not allowed. The student must demonstrate progress towards meeting the eight course objectives, which stipulate that the student will:
The nurse preceptor also evaluates the student's performance on an ongoing basis, and turns in a formal assessment at the end of the five weeks. If, at that time, even one of the 27 technical, communication, accountability, or nursing process skills evaluated is rated less than satisfactory, the student fails the course. To make an "A" (a student can contract for less), the student must exhibit above average performance in the clinical setting; keep a written log of all clinical experiences; attend weekly seminars with faculty; achieve an "A" on a concept paper, project, or article; and present a clinical case study. All students assume responsibility for planning of patient care and the increasingly complex responsibilities of handling a multi-patient caseload.
This program is a glove-fit for cooperative education. "The on-campus laboratory, unfortunately, is too often an artificial, unthinking, and mechanical set of procedures," observes co-op practitioner Asa Knowles, "and not a meaningful educational experience" (p. 230). In nursing, as in most technical fields, the validity of the cooperative education concept integration of classroom learning with practical experience-is so clearly evident that garnering support from faculty, hospital staff, and students is not difficult. But prior to implementation of the preceptorship, co-op placements were hit-and-miss, with the quality of the work experience varying widely. The sequential nature of nursing courses at UTC prevented alternating work assignments, and part-time co-op openings in local hospitals (nurse aid or nurse intern positions) were rare. Moreover, the co-op coordinator had to contend with ever-changing supervisory personnel and consequent repetitious delineation of co-op expectations. The preceptorship provided the perfect vehicle for drawing hospitals into a structured cooperative arrangement, one that allowed hospital co-op supervisors to appreciate the "big picture."
Generally, only two semesters of coursework remain after the clinical preceptorship. Preceptorship students register for co-op (a non-credit course that provides academic documentation of work experience) each semester of employment, beginning with the five-week preceptorship, and thus can acquire the three semesters normally expected of co-op students. Nursing students may remain at the same hospital, transfer to another, or elect to treat the preceptorship as a one-semester "field experience" if juggling work and school schedules proves unworkable. Those who continue to work are paid an hourly rate by the employing hospital. However, the job description changes significantly: no longer under one-on-one supervision by an R.N., students cannot dispense medication, perform invasive procedures, or otherwise function as nurse graduates, although they continue to provide assistance in other ways.
What do hospitals get from this program? First and foremost, significant cost savings. The new graduate who has completed the clinical preceptorship generally requires far less orientation time. Nurse and author Lucie Young Kelly writes, "For the director of nursing with fiscal restraints, a lengthy orientation and in-service program is a strain on the budget.. .. " (1987, p. 204) Friesan and Conahan (1980) and Sovie (1980) estimate that the cost for orienting a new graduate ranges from $1500 to $5000. This is because, while a new graduate is in training - for time periods that range from nine weeks to six months (Spees, 1977) - the ward must do without him/her, causing veteran nurses to work overtime at time-and-a-half wages or the hospital to hire nurses from the registry at a much higher rate. Thus the hospital is providing costly education that could have been secured at much lower cost via the preceptorship. Spees goes on to say, "The providers of nursing care [education] are failing the employers and failing their graduates by not providing sufficient experience in basic nursing skills. What the employer is looking for primarily is a qualified, experienced nurse ..... " (1977, p. 15) This experience has become a precious commodity in these days of ever-expanding medical knowledge. Nurses today carry out an enormously wide range of tasks, and "many believe that present nursing school curricula do not prepare the nurse to function in an expanded role" (Bullough, 1977). Others believe that the term "expanded role" itself is a nonsensical cliché that does not begin to define the difficulties facing modem nurse graduates (Montag, 1975). Certainly roles for nurses have changed since the establishment of the first baccalaureate program in nursing in 1909, and nurse educators bear the burden of conveying larger and larger amounts of technical knowledge and clinical expertise. Although "the question of how nurses should be educated to enter the nursing field ... has been going on for almost 100 years" (Kelly, 1987), almost all agree that a combination of liberal education and intensive practical experience is the ideal.
The preceptors themselves draw gains from this program. Learning by teaching is an old concept, but nonetheless valid, and working with young, fresh minds-with thousands of questions-all but assures professional growth of the supervising nurse. Most receive some financial compensation from the hospital; for many, the raise is permanent. Thus the preceptorship allows the hospital to doubly reward nurses who have displayed expertise, dedication, and teaching skill, since they are carefully chosen based on those abilities.
For most new nursing graduates, the first experience in the work setting is the most difficult (Anderson, 1989). After leaving an educational institution that places more emphasis on cognitive and affective processes than on content and techniques, they find themselves in an untenable situation. The values of the university and the health care agency are often at odds; the former rewards contemplative skill and ideas, while the latter seeks technical and organizational competencies, particularly time-management skills (Ford, 1977). Too many new graduates have not been able to work on these.
Jobs today require greater skill and more complex knowledge. The argument for cooperative education, "a very sophisticated extension ... of the college laboratory,'' (Ryder, 1985, p. 309) is more compelling than ever, especially in health professions, where the stakes are so high. The Cooperative Education Research Center reported 8,265 co-ops in the health majors will participate in a clinical nursing preceptorship, and many of those will work two more semesters in local hospitals before graduating. These students will emerge into the job market with broadened clinical expertise, a knowledge of "real world" nursing, well-developed time-management skills, enhanced clinical self-esteem, realistic job expectations, and the confidence derived from having already managed several adult patients at once (Anderson, 1989). And they will have documented cooperative education experience, proof of marketability in an increasingly experience-oriented world.
Clearly, the UTC clinical nursing preceptorship is a win-win situation. The students receive ideal preparation for the challenges of nursing along with enhanced job marketability; the School of Nursing, besides the achievement of providing "functional, competent graduates" (Spears, 1986), enjoys strengthened ties with hospitals and real-world clinical instruction labs; the cooperative education coordinator meets with supervisors who are well-versed in the co-op concept, and benefits from the tighter bonds with faculty, employers, and students ensured by the collaboration; and the hospitals realize cost savings, marketing benefits (via student word-of-mouth), an early look at potential nursing hires, and valuable training/ skills enhancement of veteran R.N.s who serve as preceptors. This is cooperative education in a state of perfection.