Report From a National Survey of Health Service Facilities

Health facilities were asked a number of questions relating to their experience taking undergraduate BN students for clinical placements. These included their reasons for not doing so, support mechanisms provided by them to universities and those provided by universities to health facilities and issues which arise from placing undergraduate students.

4.1 Clinical Placements

Of the 432 questionnaires analysed, 278 facilities reported that they have agreements to provide clinical placements for undergraduate students.

Table 8 indicates that 90% of the public hospitals that responded have agreements to accept undergraduate students for clinical placement. Just over half (56%) of the private for-profit hospitals that responded also have agreements. Lowest is the charitable category at 43% of respondents.

To determine whether health facilities faced difficulties dealing with large numbers of universities with different program requirements, they were asked to indicate the number of Australian universities that currently send clinical practicum requests through their office. Of the 278 respondents who indicated that they have agreements to accept undergraduate students (Table 8), 267 indicated the number of universities from whom they accepted undergraduate bachelor of nursing students for clinical placement at the time of the survey. Results appear in Table 9.

All categories of institution currently deal with a minimum of one university (except one respondent in the public category) and a maximum of up to 14 universities in the public category when placing BN students (Table 9). A more realistic response might be found in the median where except for the charitable category, the median is 2. There is a large standard deviation in the public category which reflects results from area-wide responses.

Table 10 indicates the facility type (service focus) for those institutions which currently place undergraduate students for clinical practicum. As with Table 6, respondents may have indicated more than one service focus. The numbers in this table include every response to this question even those indicated as 'other' previously. As respondents selected multiple areas of service focus, no percentages are given.

Table 10 indicates that a large number of acute care facilities accept undergraduate BN students (182). Also large numbers of nursing homes (69), community care facilities (48) and maternity hospitals (38) which responded are currently placing undergraduate students, but less so than acute care facilities. Of concern is the small number of day only facilities which do. These facilities are expected to provide a large proportion of care in the future, but relatively fewer students are exposed to this type of experience. Despite the large number of aged care facilities which do take undergraduate BN students, a large number do not take them.

Universities function on a semester basis and most frequently, student clinical placements would occur within these times. Increasingly though there are indications that some universities are running three and four semesters in any given year. While this might spread out the 'student load' it may also extend the time during which clinical facilities have students. Health institutions were asked to indicate the number of weeks per year for which they had BN students for clinical placement (Table 11) - again not all institutions placing undergraduate students responded.

Table 11 - Number of weeks/year health facilities have undergraduate BN students for clinical placement (n = 250)

The responses indicate that some facilities are taking students for more than the 28 - 30 weeks which most frequently comprises a two-semester academic year. If the median is used, the public category takes more students (Table 12) for more weeks per year. The charitable category only has students for four weeks (median). Note the large standard deviation, particularly in the public category.

Of those institutions reporting that they accepted undergraduate students, Table 12 indicates the number of students they place in a week. Note that only 233 (54%) of those surveyed answered this question. The survey asked respondents to provide data on first, second and third year students. Table 12 presents the data as a total number of students and Table 13 presents data stratified by year.

From Table 12, the maximum number of students placed is 282 in the public category. However this result must be viewed with caution, as some responses from this category were provided on a regional or area-wide basis rather than by individual institutions. (Note the large standard deviation that reflects the wide variation within organisational categories). Across all categories the median ranges from 10 in the charitable to a high of 15 in the private non-profit category; higher than the median for the public category. When mean numbers are considered, the public category is higher than the remaining three but this result is inflated by the area/regional responses. The number of students placed as first, second or third year BN students is presented below.

Some students enrolled in nursing programs may obtain additional clinical experience through employment as an assistant in nursing (AIN). To this end organisations were asked whether or not they employ undergraduate BN students as assistants in nursing (AINs) (Table 14).

Table 14 indicates that a total of 171 institutions indicated they employed BN students as AINs. Public institutions are less likely to do so than either the private for-profit or not-for-profit categories. The remaining three categories utilise AINs at fairly similar levels (45.8% to 51%) compared to only 24% for the public category.

Health facilities were also asked whether they employed overseas trained registered nurses awaiting registration as assistants in nursing. This question was asked to determine whether this placed an additional teaching responsibility on staff since, while they are registered nurses in their country of origin, language and skills deficits may require additional supervision and/or support from staff. However across all categories of health facility only 28 overseas registered nurses were employed in this category.

4.2 Support For Undergraduates

Health facilities were asked to indicate the support they provide to undergraduate BN students while on clinical placement. Table 15 indicates the support mechanisms for all organisations that have undergraduate BN students ranked in decreasing frequency of response (n=278). For instance, 87% of respondents indicated that they had a ward or unit nursing staff person to buddy the BN student nurse.

Table 15 indicates that respondents provide a range of support services and facilities for students. When analysed further by category differences emerge (Table 16).

Public institutions are more likely to provide subsidised meals, accommodation and internet access than the other three categories. However a greater percentage of private for-profit institutions provide time to attend class. Overall the charitable category provides support mechanisms for students less often except for paid orientation and time to attend class. The private for-profit category like the public category, provides considerable support for undergraduate students. They are slightly more likely to use a buddy system than an educator than is the public system which may be a reflection of size, staffing or a philosophical approach to student learning.

Respondents were asked to indicate reasons why they did not provide clinical placements for undergraduate students. Seven potential reasons were provided and respondents could select more than one option. Results appear below in Table 17 in ascending rank order based on the public institutions which was the category with the greatest number of responses. Only those institutions which indicated that they do not provide undergraduate clinical placements were included in the analysis. Respondents could provide more than one response.

For the public and private for-profit categories, small size is the most frequently nominated reason for not accepting undergraduate bachelor of nursing students for clinical placements. Not being asked is the most frequently cited reason in the charitable and private not-for-profit categories and the second most frequent in the public and private for-profit categories. Lack of infrastructure support (insufficient senior and supervisory staff, suitability of learning situations) are uniformly important across all categories of institution. Compromise to the quality of care is cited last or second to last by all institutional categories. Only the private category (both for-profit and not-for-profit) indicated that liability issues played a role in decisions not to accept students.

4.3 The Managerial Impact Of Providing Clinical Experience To Undergraduate BN Students

Concern had been expressed that some institutions experienced a variety of problems when accepting undergraduate students for clinical placement. Organisations were asked to indicate, using a four point Likert scale, how often they experienced: 'too many placement requests'; ' inadequate supervision from the university'; and 'competing requests for the same period'. The Likert scale used '1' to represent 'never', '2' - 'occasionally', '3' - 'usually' and '4' - 'always'.

Table 18 provides aggregated data (for all respondents irrespective of category of institution) for these three questions for each of the four Likert responses.

Table 18 - Extent to which respondents experience difficulties with BN placements

Table 18 indicates that 27% of respondents 'never' experience too many placement requests and 33.5% do 'occasionally'. Approximately 34% responded they 'usually' or 'always' experienced too many placement requests.

The results are similar with respect to 'inadequate supervision'. Approximately 25% 'never' and 37% 'occasionally' experience this as a problem. Approximately 31% 'usually' or 'always' experience this problem indicating a perception that some institutions do not believe universities provide sufficient supervision of their students.

In terms of 'competing requests' more indicated 'usually' or 'always' for this question than for previous items. This may reflect constraints imposed by academic year patterns and perhaps, the specialist nature of some hospitals. An example may include specialist paediatric or mental health institutions where placement in a curriculum may limit flexibility of clinical placements.

Responses to these items were then analysed according to category of institution to see whether there were differences given variable numbers in students accepted. Figures 3, 4 and 5 indicate the responses across the four categories of institution for each of the individual items.

Figure 3 - Extent to which respondents experience too many placement requests (by category of institution)

Figure 3 indicates that there is little real difference between the public and private for-profit institutions in terms of experiencing too many placement requests. Despite the number of responses indicating institutions 'never' or only 'occasionally' experience few problems in this regard, there are 10 to almost 25% of respondents in the public and private for-profit categories which 'always' or 'usually' have too many placement requests. This may occur because of the number of students they place (Table 12) and the number of institutions with whom they deal (Table 9). The charitable category has a very high response of 'never' but they have less students. The private not-for-profit category has the highest frequency of response to 'always' and 'occasionally' which may relate to the type of institution and organisational size (see Figure 6).

Figure 4 - Extent to which respondents experience inadequate supervision (by category of institution)

In terms of the provision of supervision, across all categories of institution (Figure 4) the most frequent response is 'occasionally' (except for 'never' in the charitable category). Nevertheless there are many respondents who believe they 'always' or 'usually' have inadequate supervision. This may reflect unsatisfactory supervisory arrangements but it may also relate to organisational size (it may be difficult providing supervision to smaller institutions (see Figure 6). Additional factors may include the degree of geographical separation (distances between the university and health facility), lack of awareness of arrangements (member of staff from the health facility seconded to act as supervisors/clinical educators while students are on their wards). Some institutions provide payment and/or other incentives to a ward/unit for supervision rather than a visible supervisor or clinical educator. From Table 15, 87% of respondents provide a 'buddy system' for undergraduate BN students on clinical practicum across all categories of institution while only 36% provide a clinical educator. This finding may impact on the results in Figure 4.

Figure 5 - Extent to which respondents experience competing requests for the same periods (by category of institution)

Figure 5 indicates that the charitable category responded they more frequently 'never' or only 'occasionally' have competing requests for the same period. For the other three categories of institution the results are similar. Of interest is the number which responded 'never' or 'occasionally' in the public and private for-profit categories given the number of affiliations with universities (Table 9) and the number of students they place (Table 12). Up to 20% in the public and private (for-profit and not-for-profit) categories indicated that they 'always' experience difficulties with competing requests and 20-30+% responded that they 'usually' do. These results indicate that the potential for conflict between universities and health facilities in balancing priorities and competing demands is a real issue.

When the nursing home service focus with institutions having less than 100 beds is analysed (Figure 6), some explanation may be found for responses in the charitable and private not-for-profit categories. Most of the nursing homes were found in these categories.

Figure 6 - BN student placements in metropolitan and non-metropolitan nursing homes with less than 100 beds

The constraints of organisational size and geographical location (non-metropolitan) may make it difficult for universities to provide supervision or an educator in this instance: nor may it be financially viable.

4.4 Clinical Outcomes Associated With Providing Clinical Placements For Undergraduate BN Students

Institutions were asked to indicate whether they experienced an increase in various factors when undergraduate BN students were on clinical placement in their facilities. This question arose from concerns expressed by institutions that these factors may be present.

The questions were 'indicate the extent to which you believe the following occur when you take undergraduate BN nursing students for clinical placement':

The Likert scale used was 'never' (1), 'occasionally' (2), 'usually' (3) and 'always' (4)'. Figure 7 provides results according to Likert responses for these four items irrespective of category of institution.

Figure 7 - Experiences when BN nursing students are on placement (n = 278 who responded that they take BN placements)

In terms of patient complaints 80% of all respondents indicated this 'never' occurred and a further 20% indicated it was an occasional occurrence. A similar result is found for a decrease in quality and an increase in adverse events. The results do not support the concerns expressed.

Over 40% of respondents reported an increase in staff complaints 'occasionally' and a small number 'usually' (approximately 5%) and even less 'always'. While 45% reported that they 'never' experienced an increase in staff complaints, there are indications of a potential stressor for staff having students on their wards. While staff may complain more when they have students, there is little evidence to suggest that students are adversely affecting patients and quality. Reasons for staff complaints may require further study.

Tables 19 - 22 present the data according to organisational category to see if there are differences between categories given differences in the numbers of students provided clinical placement. In terms of an increase in patient complaints and a decrease in quality of care, no institution responded 'usually' or 'always' (Tables 19 and 21). Similarly, an increase in adverse events has responses grouped around 'never' and 'occasionally', but the greatest frequency of response overall is 'never'.

Table 19 - Extent to which respondents believe there is an increase in patient complaints when taking undergraduate BN students

	Never n (%)	Occasionally n (%)
Public	90 (79)	24 (21)
Private for-profit	64 (78)	18 (22)
Charitable	18 (90)	2 (10)
Private non-profit	33 (79)	9 (21)
Total	203 (79)	53 (21)

Despite the relatively large number of students provided clinical experience in the public and private for-profit categories, there is little difference in responses (78-79%) across all categories of institution (except for the charitable category with 90% responding 'never'). As patient satisfaction is an important outcome measure it is important that most institutions reported they 'never' experienced an increase in patient complaints when students are provided clinical placements.

Table 20 - Extent to which respondents believe there is an increase in staff complaints when taking undergraduate BN students

Overall, few respondents indicated they 'usually' or 'always' experience an increase in staff complaints and there is little real difference between the categories of institution. Responses to 'never' and 'occasionally' in the charitable and private not-for-profit categories are similar, whereas those in the public and private for-profit categories are almost mirror images of each other. More public facilities indicated 'occasionally' (57%) and more in the private for-profit category responded 'never' (57%) for this item.

Table 21 - Extent to which respondents believe there is a decrease in quality of care when taking undergraduate BN students

	Never n (%)	Occasionally n (%)
Public	99 (87)	15 (13)
Private for-profit	69 (84)	13 (16)
Charitable	18 (90)	2 (10)
Private non-profit	33 (80)	8 (20)
Total	217 (85)	38 (15)

While the majority (minimum 84%) of respondents in all categories of institutions indicated they believe they 'never' experience a decrease in the quality of care when students are on clinical placement, there are some 10-20% which believe they 'occasionally' do.

Table 22 - Extent to which respondents believe there is an increase in adverse incidents when taking undergraduate BN students

Again, there is little real difference in these results between the categories of institution. Despite providing clinical placements to more undergraduate students the public and private for-profit categories do not report any greater increase in adverse events.

4.5 Summary

In summary, of those who responded, more public institutions take undergraduate BN students for clinical practicum than any other category of institution. In addition they place more students for more weeks across a wider range of service foci than do the other respondents. The most frequent service focus is acute care. The health facilities are providing a wide array of support mechanisms and facilities for undergraduate BN students across all categories of institution. Lack of infrastructure support (insufficient senior staff, suitability of learning situations) was a frequently cited reason for not accepting undergraduate BN students for clinical placement.

In terms of some of the outcomes of accepting BN students for clinical placement, 10-15% of institutions 'always' experience too many placement requests, inadequate supervision, and/or competing requests for the same period. 20-27% indicated they 'usually' experience these difficulties. Both these results reflect a 'load' on the system, particularly too many requests and for the same period and a 'load' on staff if inadequate supervision is provided. However at the other end of the scale 23.7% to 27% responded 'never' to these three questions. For all three aspects, 'occasionally' was the most frequently selected response.

When responses are analysed by category of institution, the charitable sector indicated 'never' as a response to all three questions more frequently than did the others. However, fewer charitable institutions accept student placements than do the other categories (see Table 12). In the public category, where the majority of BN students are placed, 14-16% responded 'always' to the three questions, and 23-33% for 'usually'. This may reflect large student numbers with a resultant load on institutions, but also may provide a source of friction between universities and health agencies. The private category (both for-profit and non-profit) responded in a manner similar to the public category for many items. Interestingly, they are more likely to indicate they 'never' received inadequate supervision from the universities than the public category. However, student numbers, organisational size and the more likely availability of an educator in the public category (Table 13) may be significant in these findings.

When asked whether they experienced an increase in patient and staff complaints, a decrease in the quality of care or an increase in adverse incidents, few respondents indicated that taking undergraduate BN students resulted in adverse effects with respect to these outcomes. At least 70% of all respondents indicated there was no increase in patient complaints, a decrease in quality of care or an increase in adverse events. In addition, 45% of all respondents said there was no increase in staff complaints while 40% said this occurred 'occasionally'. There were few differences in the results across all categories of institution despite the fact that the public and private for-profit categories take more students.

Report From a National Survey Of Health Service Facilities for the National Review of Nursing Education 2001

4. Bachelor of Nursing Undergraduate Students

4.1 Clinical Placements

4.2 Support For Undergraduates

4.3 The Managerial Impact Of Providing Clinical Experience To Undergraduate BN Students

4.4 Clinical Outcomes Associated With Providing Clinical Placements For Undergraduate BN Students

4.5 Summary