Preparing Tomorrow’s Nursing Home Nurses: The Wisconsin-Long Term Care Clinical Scholars Program

Abstract

Preparing future nurses to care for the growing population of older adults has become a national priority. The demand for long term care services is expected to double between 2000 and 2040, yet the field remains stigmatized as an undesirable place for highly-skilled nurses to work. Recent efforts to increase student preparation in geriatrics have been shown to improve student attitudes toward working with older adults and increase knowledge, but long term care settings remain unattractive to students. This paper reports on development, implementation and evaluation of The Wisconsin Long Term Care Clinical Scholars Program, a nursing home internship for baccalaureate nursing students. The program couples a paid nursing home work experience with an evidence-based long term care nursing curriculum. The program increased student preparation and interest in working with older adults and in nursing homes, while concurrently increasing the capacity of nursing homes to provide a positive student experience.

Introduction

Nursing homes are a fundamental component of the long term care system serving older adults in the United States. An estimated 1.6 million people use nursing home services each year (Institute of Medicine, 2008); however, this number is expected to rise as nursing homes increasingly provide post-acute and skilled nursing care to older adults (CMS Nursing Home Data Compendium, 2010). Older adults are living longer with increasing multimorbidity, have more challenging care needs and are discharged from hospitals faster with higher levels of acuity than they did in the past (US Census Bureau, 2010; CDC, 2009; CDC, 2010). Evidence suggests that high Registered Nurse (RN) staffing can improve the care of, and outcomes for, nursing home residents with complex needs (Castle & Anderson, 2011; Lerner, Johangen, Trinkoff, Storr & Han, 2013; Shin, 2013). However, research has shown that it is difficult to recruit and retain qualified RNs to nursing home settings (Hunt, Probst, Haddock, Moran, Baker, Anderson, Corazzini, 2012; McGilton, Boscart, Brown & Bowers, 2013; Prentice & Black, 2007).

Geriatric nurse educators have used a number of educational strategies to prepare and entice baccalaureate nursing students to work with older adults. Nursing education programs have used increased exposure to older adults in clinical placements, paid work experiences in settings with high levels of older adults, intensive mentoring by geriatric prepared nurses, and dedicated gerontological course work (Fox, 2013) to teach appropriate care of older adults and motivate students to work with this population. While some of these programs have been reported as increasing student knowledge of appropriate care for older adults, research has consistently shown that students still prefer not to work in nursing home settings (King, Roberts & Bowers, 2013).

Many nursing programs use nursing home settings as placements for learning about older adults (Chen, Brown, Groves, Spezia, 2007), but few programs emphasize the nursing home setting as a viable career options for students, nor provide integrated education that would simultaneously prepare students to care for older adults and take positions in nursing homes after graduation. Furthermore, nursing students have recognized strong leadership and supervisory skills as essential for nurses working in nursing home settings because RNs are commonly the highest credentialed staff on premises and are responsible for managing and directing certified nursing assistants (CNAs) and licensed practical nurses (LPNs) who provide the majority of hands on care. However, research has shown students feel that traditional nursing programs do not always adequately prepare them for these roles (Siegel, Young, Mitchell, Shannon, 2008; King, Roberts and Bowers, 2013).

The rapidly changing needs of older adults demand that nursing educators continue to seek creative solutions for better preparing future nurses to meet the challenges of caring for clinically complex older adults and motivate students for careers in nursing home settings (Institute of Medicine, 2010). To meet this aim, the Wisconsin Long Term Care Clinical Scholars Program (LTC-CSP) was developed as an innovative, intensive nursing home practice experience for undergraduate nursing students with the goal of better preparing students to care for older adults and increasing interest and confidence in working in nursing home settings. Innovations included coupling multiple, concurrent educational strategies (e.g. coupling a paid work experience and didactic education), content tailored specifically to the unique role of the nurse in a nursing home setting (e.g. education on supervising and focus on resident quality of life) and experiences in supportive environments (e.g. high quality nursing home partners and enthusiastic program staff and preceptors). This paper describes development, implementation and evaluation of the LTC-CSP over the first and second years of the program.

Program Development and Implementation

The LTC-CSP, which is currently in its third cohort, was developed in 2010-2011 through the collective efforts of two Schools of Nursing, the State of Wisconsin, and four nursing homes in south central Wisconsin. It was designed as a 12-week summer nurse internship for either junior or senior nursing students. The program integrated preceptor education (to build nursing home capacity to educate students), didactic workshops for nursing students, and supported clinical learning opportunities for students. Past research has shown stipends entice students to participate in summer clinicals and gerontological programs (Souder, Beverly, Kitch & Lubin, 2012), so the LTC-CSP was designed as an employment model in order to: (1) be appealing to students, thus increasing student interest in long term care nursing, (2) demonstrate the value and rewards of long term care nursing, (3) provide a high quality, challenging work experience, going beyond traditional student clinical rotations, (4) remove the barrier of tuition charges that may decrease the appeal, and (5) provide employment, eliminating the need to juggle multiple jobs over summer.

Successfully developing and implementing the LTC-CSP was contingent upon an intensive preparation phase which involved; (1) thorough stakeholder recruitment and involvement to identify necessary program features and implementation strategies, (2) recruiting participant nursing homes and developing preceptors, (3) developing the intern curriculum, including required work experiences, with the help of content experts, and (4) recruiting interns.

Intensive Stakeholder Involvement

To prepare for the LTC-CSP, input from multiple stakeholders was solicited. A stakeholder advisory group was convened with representatives from the State’s Departments of Health Services and Workforce Development, nursing and medical director associations, nursing home provider associations, an ombudsman, local nursing homes, long term care nursing experts, new graduate nurses working in nursing homes, and a nurse residency program developer. The stakeholders met twice during the planning phase to discuss program goals, to identify specific educational needs for nurses taking positions in nursing homes, as well as to anticipate challenges in program implementation. The advisory group identified goals that would ensure the program provided a unique, supportive, and meaningful experience for interns and also met the needs and expectations of participating organizations. The advisory group determined the LTC-CSP should include a curriculum with closely matched didactic and clinical experiences, clinical topics tailored to fit the context of nursing home care, preceptor development and support and provision of novel, supplementary gerontological and leadership education.

Selecting and recruiting nursing homes

Past research has reported that nursing home sites used for clinical placements must be high quality facilities in order to best support students and not deter them from future work in the environment (Mueller, Goering, Talley & Zaccagnini, 2011). Therefore the CSP staff worked with Wisconsin Department of Health Services to select four ‘high quality, innovative’ nursing homes that were thought to have resources to pay a student intern for twelve weeks. Two additional nursing homes were added based on proximity and quality reputation. All nursing homes are Medicaid certified and provide skilled nursing care to long and short stay residents.

Five nursing homes agreed to meet with our staff during the first year of the program. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were both asked to be present for each meeting, but this only occurred at two of the five nursing homes. A handout with program rationale, benefits for the students and the organizations, and requirements for the organizations’ participation was provided to the nursing homes during the meeting. Requirements for participation included: (1) hiring an intern as a nurse tech, a Wisconsin position allowing nursing students certified as nursing assistants to perform licensed nurse duties under the supervision of a licensed RN, (2) identifying two nurse preceptors who would participate in a preceptor training program and work directly with the intern, (3) scheduling the intern for at least three paid shifts per week on the same shift as their preceptors, and (4) paying the preceptors for time spent in a half-day workshop to teach them how to effectively coach new nurses. One nursing home declined participation. However, another participant offered their second location as an additional site, bringing the final total to five. In cohort two, eight nursing homes were invited to participate, and three agreed. Most cited Medicare cuts impacting their budgets as primary reason for declining. Facility, preceptor and intern information is in Table 1.

Table 1.

Internship Participant Information for Clinical Scholars Program Cohort 1 and 2

College Student Intern Participants
	Juniors	Seniors
Cohort 1	3	2
Cohort 2	3	2
Nursing Home Preceptor Participants
	ADN	BSN
Cohort 11	5	2
Cohort 2	5	3
Nursing Home Facility Participants
	Not for profit	For profit
Cohort 12	3	2
Cohort 2	3	0

¹One preceptor in cohort 1 was a Licensed Practical Nurse.

²Only one for-profit home completed program participation

Note. ADN=Associate’s Degree in Nursing, BSN=Bachelor of Science in Nursing

Building capacity with preceptor development

Research has shown that a major barrier to using nursing homes as clinical sites is a lack of appropriate nurse role models who are trained to serve as preceptors (Aaron, 2011; Chen, Brown, Groves, Spezia, 2007). DONs at each nursing home were asked to recruit a primary and alternate preceptor to supervise, coach and mentor the interns. The primary preceptor was required to be licensed as an RN; however, due to the low number of RNs employed in nursing homes, LPNs were accepted as support preceptors (Table 1). Nursing homes with two interns could assign the same preceptors to both interns.

The LTC-CSP required preceptors to complete an online preceptor training course that reviewed responsibilities and effective strategies of precepting and attend a half-day precepting workshop at one of the participating universities. Each preceptor was paid $100 by the LTC-CSP to complete the online course outside of work time, and because they were particularly interested in developing preceptor skills, the nursing homes allowed preceptors to be in paid status during the required half-day preceptor workshop. Preceptors received copies of all intern readings and assignments and a tool to assist in providing feedback and evaluating intern progress. LTC-CSP faculty initiated phone or face-to-face check-ins every two weeks with preceptors to explore preceptors’ experiences, concerns and challenges. Feedback from preceptors was integrated into subsequent workshops.

Intern recruitment

Junior and senior level students of two baccalaureate schools of nursing were recruited for the internship. Two LTC-CSP faculty presented the internship opportunity during junior and senior level nursing classes, distributing informational flyers. A website was developed for students to find more details. Posters and announcements were posted in key places to gain student attention. An internship “question and answer” session for potential applicants was held during the semester in the late afternoon during the first year of recruitment. This was not well attended and was discontinued for subsequent cohorts. Despite discontinuing the information session, there were more applications the second year (cohort 1= 13, cohort 2 = 23). All candidates with complete applications were forwarded to participating nursing homes for review. Each nursing home selected at least one intern from the applicant pool, forming the cohort (cohort 1= 5 interns, cohort 2 = 5 interns).

Intern curriculum development

Two PhD prepared nursing faculty, each from a different nursing school, shared responsibility for leading the internship curriculum development and implementation. Both faculty had experience working with and in nursing home settings and recognized the high level of skill required to work in nursing homes. Three PhD students and one Master’s prepared nurse, all with nursing home practice experience, were recruited to help with writing the curriculum and conducting intern workshops. The study team carefully considered stakeholder feedback in developing the curriculum. Particularly, some stakeholders wanted the curriculum to focus on the most common nursing home quality survey citations. The LTC-CSP team felt this should not be a primary focus because it both duplicated existing, widely available staff development resources and could potentially encourage working from the minimum regulatory perspective, rather from the broader nursing perspective.

The team developed the following six priorities for the intern curriculum: (1) non-redundancy with existing coursework in the BSN program or with ongoing educational programs in use by partnering nursing homes (examples included infection control, falls, pressure ulcers), (2) emphasis on person-centered care, (3) content contextualized to the nursing home, (4) application of evidence-based nursing practices, (5) clear integration of preceptorship and (6) utilization of active teaching strategies. Following identification of curriculum goals, the study team identified priority topics for weekly intern workshops (Table 2). Workshops took place once weekly throughout the program and were 90-120 minutes in length.

Table 2.

Intern Workshop Curriculum and Sample Assignments

Curriculum Topics	Sample Assignments (each workshop has multiple assignments)
Nursing Home Systems	Discuss with the social worker what happens when a resident no longer qualifies for Medicare.
Achieving and maintaining function	Meet with admissions nurse to review and discuss a resident’s activity/ambulatory status and how a plan of care is developed, implemented and monitored.
Medication use in older adults	Review a residents medication list for possible side effects, drug-drug interactions, and duplicate drug classes. Discuss findings with preceptor.
Developing a culture of safety	Discuss with preceptor how mistakes or near misses are handled in the nursing home. Is there an example he/she can share? What are the policies? Are they consistent with how things are actually handled? What actions are proactively taken to reduce errors in the nursing home?
End of life care	Review and describe the nursing home’s protocols for end of life pain management, nutrition management, supportive care, and post-mortem care.
Resident comfort and pain management	Examine the nursing home’s pain management practices and protocols. What is the process for distributing controlled substances? Describe how these items influence resident care and pain management.
Communicating with team members and families	Observe interactions between a nurse and colleague when there is a difference of opinion. Describe how they interacted, what messages they conveyed, and consequences for themselves and others.
Changes in condition: Recognition and follow through.	Attend a care conference. Identify any changes in condition discussed or potentially missed. Follow up with the care team to learn how information and plans discussed are translated into practice.
Changes in cognition	Describe a challenge you have had caring for a resident with cognitive impairment. What might the resident be feeling at that moment? Any changes in medications or health recently? Any changes in the person’s environment? Ask others about successful strategies they have used in improving interactions with that resident. How are those shared with other staff? Are they documented, and if they are, do all staff have access?
Diabetes and nutritional decision making	Ask preceptor how the interdisciplinary team is used when a resident is identified as having a swallowing problem. Discuss interventions. Meet with the dietician to review the plan of care for a resident currently with swallowing difficulties. How is quality of life addressed in the plan of care?
Nursing leadership in long term care	Meet with the Director of Nursing to review recent quality survey findings. Select one citation or another quality issue the nursing home has recently tried to address. Discuss the plan of correction/improvement, how it was developed, who was involved, how it was communicated to staff, follow up, successes and challenges. Compare notes to problem solving steps in assigned reading.
Innovations in Long Term Care and Quality of Life	Explore the Advancing Excellence resources on person- centered care. After you have reviewed the tools, have a conversation with a resident about what quality of life means to them, or what makes life meaningful to them. Plan ahead how you will start the conversation and how you can effectively respond if answers such as “nothing” or “I don’t know” are given. Identify strategies to support this person’s meaningful life/quality of life.

Integration of work experience and workshops

Integration of clinical work and didactic workshops was accomplished through intern assignments each week. Assignments required attention to organizational systems, applying evidence based practices, and examining issues from the resident’s perspective. Assignments were focused on collecting and synthesizing information from a number of places and people and across multiple aspects of a resident’s trajectory in the nursing home. For example, in the “Achieving and Maintaining Function” workshop, interns were required to review pertinent history and medical records of a non-ambulatory resident; speak with admission staff about an admission functional assessment; and explore the impact of function on the Minimum Data Set (MDS) assessment and care planning process. Then, working with the preceptor, the interns synthesized knowledge gained from these experiences with evidence from assigned readings and other resources to identify, develop, and implement interventions. Finally, the intern shared the outcome of these activities in the weekly workshop for peer discussion and guidance.

An evidence based project was added to the curriculum for the second year based on feedback from nursing homes that they wanted more “value” for participating in the internship. Interns were asked to complete a project that was jointly selected by the intern and DON. Examples of projects included creation of a simple-to-read patient education brochure on chronic heart failure, a brief literature review of nursing home staff orientation practices and outcomes, and revision of catheter bag cleaning procedures based on best practice guidelines.

Evaluation

The goals of the evaluation were to examine the program’s influence on intern perceptions of, and interest in, nursing homes and the care of older adults. We also aimed to understand whether the program influenced the capacity of nursing homes to coach and mentor. Because this was an educational program evaluation used for quality improvement, this project received an exemption from the University of Wisconsin-Madison Institutional Review Board and no informed consent was required. The evaluation combined qualitative data collected from interns, preceptors, and administrative staff in the first year of the program (cohort one) and quantitative data collected from interns in both the first and second years of the program. Specifically, the qualitative data we collected included a) focus group data exploring program influence on interest in and preparation for long term care work and care of older adults; b) focus group and individual interviews with preceptors and DONs exploring program influence on nursing home capacity to educate new staff; and c) survey data assessing intern interest in long term care.

Qualitative data collection procedures varied for various participants. See Table 3 for details. Both interview and focus group data were analyzed using content analysis (Hsui-Fang & Shannon, 2005) by three members of the study team. Directed content analysis focused on coding factors that led to preparedness and intent to work in long term care, value of the program, as well as necessary changes to the CSP program content. The codes were compared among team members and disagreements discussed until consensus was reached regarding the appropriate code for the text. Similar codes were then collated into higher level categories according to those that represented ways the CSP facilitated positive changes and those that the CSP prompted null or negative changes. The findings were presented to the full project team for review and assessment of credibility and trustworthiness.

Table 3.

Qualitative Data Collection Procedures (Cohort 1)

Participants	Method	Location	Length	Data Recording	Topics addressed	Convener
Interns (n=5)	Single focus group	Universi ty classroo m	62 min	Audio recorded	Preparedness to work in LTC Intent to work in LTC Feelings of support during program	Qualitative researcher outside study team
Preceptors (n=5)	Single focus group	CSP nursing home	~ 60 min	Detailed notes	Precepting challenges Factors that influenced working relationship with interns Usefulness of CSP support	CSP team
Preceptors (n=2)1	Email survey	n/a	n/a	Written	Precepting challenges Factors that influenced working relationship Usefulness of CSP support	CSP team
DON/ADM pairs (n=4)	In- person intervie ws	CSP nursing homes	~25-40 min	Detailed notes	Value of CSP Factors that facilitated implementation	CSP team

¹Two preceptors were unable to attend the focus group but were willing to provide feedback about the program via email.

Note. LTC = long term care, DON = Director of Nursing, ADM = Administrator, CSP = Clinical Scholars Program

For the quantitative portion of the evaluation, a 27-item intern survey was developed by the project team to address program content and structure for formative purposes as well as feelings of preparedness, likelihood of working in nursing homes, and satisfaction with preceptors. Twenty-one formative questions asked interns to rate usefulness of each of the twelve workshops and CSP program supports (e.g., CSP website, availability of CSP staff, the “pre-workshop”). Survey results specifically regarding program satisfaction from cohorts one and two are presented in Table 4.

Table 4.

Survey on Satisfaction with CSP experience (n=10)

Question	Strongly Agree or Very Satisfied	Agree or Satisfied	Disagree or Dissatisfied	Strongly Disagree or Very Dissatisfied	Undecided
Overall, the internship experience was worthwhile.	90%	10%	0%	0%	0%
Overall, the workshops were worthwhile.	60%	40%	0%	0%	0%
Overall satisfaction with your primary preceptor.	80%	20%	0%	0%	N/A
I would highly recommend the internship to a friend.	70%	30%	0%	0%	0%
I feel prepared to take a nursing job in a nursing home or assisted living.	70%	20%	0%	0%	10%
I am likely to take a nursing job in a nursing home or assisted living.	30%	40%	10%	0%	20%

Interest in Long Term Care

Interns primarily reported positive experiences in the program. Seven out of ten interns reported that their views of nursing home care had changed positively because of the program (Table 4). Two interns reported no change and only one intern reported a more negative view after the program (Table 4). Interns described the nursing home environment as more positive than they expected it to be, generally disconfirming stereotypes about the environment and the care. One intern stated,

It was a lot more enjoyable than I thought it was going to be. The staff enjoys being there, activities are enjoyable and there are choices provided (to residents).

The internship was also an important experience for solidifying future work preferences. The survey showed seven of ten interns agreeing that they would be likely to take a job in a nursing home after the program (Table 4). Two interns were undecided, and only one student indicated she was unlikely to take a job in a nursing home after the program (Table 4). One intern said,

When people would ask what kind of nursing I wanted to do, I used to say ‘well, maybe geriatrics,’ but now I say, ‘yeah, I could definitely work in a nursing home’.

In fact, interns were interviewed after graduation, and three of ten students had taken positions in nursing homes, another in a local Veteran Affairs medical center with a high percentage of geriatric patients, and another pursuing an advanced nursing degree, specializing in gerontology.

During the focus group, interns described experiences that were particularly positive, possibly influencing shifts in attitudes about long term care nursing. Having responsive and supportive preceptors, was key. One intern said,

I was always working with [my preceptor], I was never put on the spot to do anything I didn’t feel comfortable doing. We’d do nurse report and look at the patients. She’d ask how many I wanted to take today. She’s always there to help me or remind me of things. My preceptor made a big difference to really have a positive experience.

Other interns described their preceptors as a highly valuable resource, or as an advocate when they were having problems with workload or scheduling.

A welcoming environment was important for a positive experience and essential for positive views of nursing home work. Interns suggested they would be enticed to work after graduation in their nursing home because nurses were kind, excited for the interns to be there, and interested in the intern as a person. Witnessing successful teamwork was also cited as important. For example, one intern said,

I’ve never seen a group of CNAs work so well together.

Along with positive experiences with the care team, interns also described developing relationships with residents as important as they made the internship personally meaningful, in addition to useful.

Preparation to Work in Nursing Homes & Care for Older Adults

In addition to promoting interest in the care of older adults, interns discussed the program’s benefit for improving their confidence and feelings of preparedness to work in a nursing home setting. Nine out of ten interns indicated they agreed or strongly agreed that they were prepared to take a position in a nursing home by the end of the program and the other intern indicated she was undecided (Table 4). During the focus group one intern said,

I feel so much more prepared to graduate and I still have a year of school left. Unlike after the first year of school where I felt uneasy. Because of the internship, I feel like I can tackle a lot more and have more confidence because of that.

Another said,

I think [the program] made me more confident to [care for older adults].

Furthermore, after the program, students reported feeling clearer about the nurse’s role in nursing homes and felt more prepared to fill that role.

Interns suggested during focus groups that the nature of the work experience in the nursing home was essential for preparing them for work in a nursing home and to care for older adults. In particular, when students felt they successfully mastered the high level of autonomy, the fast-paced environment, and the typically heavy workload demands, they felt prepared to be a nurse. Over the course of the program, each of the interns progressively took on more responsibility for resident care. Interns often started out shadowing a nurse. Then they would take responsibility for the care of three or four residents. Toward the end of the program, some of the interns were comfortable taking on the responsibility of a unit, administering medications and treatments and performing assessments on residents. This level of responsibility was important for preparing them for the expectations of a permanent position. One intern said,

Being more independent was so valuable. I learned so much more than I did in my two clinicals.

Furthermore, interns noted that this intensive experience allowed them to reconcile theoretical knowledge with everyday practice challenges. The interns described applying the theoretical gerontological nursing content they received in their nursing program and indicated that in some situations, their prior education suited the situation quite well. However, in others, such as the care of persons with dementia with challenging behaviors, they found their theoretical knowledge had limitations.

Interns generally found great value in the internship for fostering their interest related to working in a nursing home, care of older adults, and for preparing them to be nurses. Ten out of ten interns reported they agreed or strongly agreed that the internship was worthwhile and ten out of ten interns agreed or strongly agreed that they would highly recommend the program to a friend (Table 4). In fact, as previously mentioned, applications increased the second year of the program despite scaled back recruitment efforts. The increased exposure and the intensity of the clinical work in the program were cited as benefits. The interns generally suggested that the internship was an important experience that provided unique and essential opportunities over those offered in typical clinicals. One intern said,

It’s nice to have geriatric and long term care clinicals, but it was really helpful to go more often than a clinical where you are only there two days a week. I felt like I always had to relearn things in clinical.

Intern Challenges

Interns experienced some challenges throughout their program. In particular, the interns repeatedly discussed administrative issues in terms of scheduling. Interns often lacked control over their schedule and were not always informed about their workloads in advance. Changes were implemented in the program for cohort two to address this issue and it is no longer a commonly reported challenge. Another major challenge was ensuring the appropriate balance of autonomy and support. Some interns reported being asked to take on more responsibility then they were ready for; to take on responsibility they had not planned for; or to take on major responsibility without advance notice such as in the case of taking charge of a unit in the event of a call-in. This resulted in a feeling of ‘being thrown in’ and was a very negative experience.

“I was thrown on my own and I didn’t know it would happen. Throwing me on a floor where I didn’t know anyone [residents or staff] was really stressful. I didn’t want the internship to be this stressful.”

In addition, some interns worked in facilities in which teamwork was low; management seemed unresponsive, uninvolved, or generally unsupportive; and there was a perceived high level of disorganization or chaos in the environment. Furthermore, interns noted that the scope of practice between registered nurses and licensed practical nurses seemed blurred in the nursing home setting and they were uncomfortable with that. New guidelines were developed for nursing home staff around the progression expectations (including suggested resident care load) after the first and second years to address this.

Building Capacity in Nursing Homes

Preceptors and DONs reported several benefits associated with the internship program. Preceptors generally enjoyed the experience of teaching and reported that they learned new knowledge along the way. In particular, some preceptors indicated they acquired new teaching skills and others acquired new practice knowledge. For example, there were situations in which preceptors were unable to answer an intern question and then the pair would investigate to find the answer together. As one DON reported,

When an intern wasn’t sure of something, she’d ask the preceptor, then we’d find out the preceptor wasn’t sure either, so we all learned together.

This practice of investigation and learning had another important effect of shaping the culture in the facility as well. As the DON stated about the process,

It is important … to see a culture of asking for help and supporting each other.

Furthermore, despite the un-recouped costs associated with the intern hourly wage, most DON’s saw benefit despite this cost. In particular, DONs reported the value of seeing preceptors grow as nurses and teachers. DONs reported preceptors became more organized and developed new skills and confidence. One DON said,

I saw growth in [the preceptor] in her confidence. It brought her teaching skills to another level and you can see that in how she works with other staff.

The additional skills the preceptors gained during the program were seen as an asset that could be used for training future new employees. DONs also saw potential value in the program for improving the nursing home’s image in the community, retaining the intern as staff after graduation and recruiting new nurses to their facility. One DON said,

[The intern] will likely tell her fellow students about her positive experience … This can help position us as a desirable place to work.

Preceptors and DONs also reported challenges. In particular, there was clear lack of direction regarding the degree of autonomy the interns should have over the course of the program. Some preceptors and DONs felt strongly that interns should be able to work independently on a unit fairly quickly. In this case, working independently on a unit was viewed as a level of work that would justify the cost of the intern’s hourly wage. In other nursing homes, determining the appropriate level of autonomy and workload expectations was also somewhat problematic; however, staff in these nursing homes did not see independent workloads as essential. Staff that did not see early workload independence as the final goal were more likely to report more benefits from the program than staff who felt the marker of success was independence. More structure has been developed via a weekly progression guide around independent practice benchmarks to reduce this issue in future cohorts. For example, a week two goal is “to develop skills in organizing and prioritizing direct care of 4-6 residents with preceptor coaching and assistance.” A worksheet provides a goal-related assessment activity for preceptor use along with behaviors or actions to look for during the intern’s shift.

Discussion

The LTC-CSP is a program that was carefully and collaboratively designed by industry stakeholders in order to provide a unique educational experience that could prepare nursing students to care for older adults in nursing home settings. The LTC-CSP was generally viewed positively by interns, preceptors, and facility administration. Interns felt more prepared to care for older adults. Preceptors generally enjoyed their roles and some gained new knowledge or skills. Administrative staff saw value in the program for recruiting future employees and building the skill set of their current workforce.

Despite decades of evidence that nursing homes are the last choice place of employment for baccalaureate nursing students (Henderson, 2008; King, Roberts & Bowers, 2013; Moyle, 2003; Stevens, 2011), seven out of ten LTC-CSP interns felt that they would consider taking a job in a nursing home in the future. However, interns in the LTC-CSP self-selected to be in the program, making them potentially more interested in working with older people, and in nursing homes, than the average nursing student. Interns did report the intensive clinical experiences and positive faculty, preceptor, and nursing home staff attitudes, helped them learn how to appropriately care for older adults and motivated them to desire a job in a nursing home setting. Some interns did take jobs in nursing homes after the program and others took jobs in other settings in which older adults were the primary clientele. Further research is needed to determine if pre-program interest, attitudes, and knowledge influence outcomes.

Research on transitions from student to professional nurse indicates many newly registered nurses suffer ‘transition shock’, leaving their jobs because they lack confidence and experience in nursing (Casey, Fink, Krugman & Propst, 2004; Zinsmeister & Schafer, 2009). The enhanced confidence interns reported after participating in the LTC-CSP, as a result of intensive and robust workloads, may serve as a protective factor against the shock they otherwise might experience as they transition to newly registered nurses. The employment model, along with supportive preceptorship and additional education related specifically to the intern’s role, makes this program similar to a nurse residency program, which is an effective transition model used by many hospitals (Anderson, Hair, & Todero, 2012). Further research is needed to determine whether the LTC-CSP might improve intern transitions to newly registered nurses and reduce turnover.

Despite positive experiences and successes of the program, there were a number of challenges. One of the largest challenges threatening the positive work environment for interns was reconciling the goals of the LTC-CSP and the goals of the nursing homes. In particular, there were often differences in expectations and understandings regarding the scope of the intern’s work. Firstly, clarity about the role of the intern in the facility as a learner rather than an independent worker often needed to be negotiated and advocated for throughout the course of the program. The intern’s role often shifted from learner to worker, particularly during times of crisis when staffing was low. Clarifying expectations for the interns among facilities, preceptors, interns, and the program, particularly in terms of the expected workload, was found to be paramount to ensuring appropriate support for the interns. Secondly, the scope of practice for a Nurse Tech had to be clarified so that facilities could understand the range of nursing activities interns could and could not be responsible for. To facilitate understandings of the scope of practice, the LTC-CSP staff arranged a conference call between facility administrative staff and the state nursing regulation office. The call was intended to increase confidence among all parties that the program and practices were safe and acceptable to regulators.

Another challenge that threatened the implementation of the program was administrative staff turnover. Two nursing homes had administrator turnover during the program. This nursing home had not integrated other key leadership, administrative, and nursing staff (e.g., staff educators, human resources) in planning, and key implementation steps were missed, such as assuring all staff members were informed of the new program and practice scope of the nurse intern. In cohort two, the internship manager made a concerted effort to personally connect with human resources and staff educators and provide guidance, rather than leaving this up to DONs or administrators.

Acquiring resources for implementing and sustaining the LTC-CSP has also been a challenge. First, the required personnel time was significant during the startup period to recruit nursing homes and develop the curriculum, but as systems were developed and nursing homes returned to the program the following year, this time decreased. Each spring semester, the program requires approximately 40 hours of combined faculty and administrative staff time for recruitment, management and preceptor preparation. During the summer, a faculty person is required to manage and teach the workshops, similar to a two-credit course. The faculty to intern ratio for these workshops was high at 1:5-6 initially, but is being expanded with the goal of 1:10 for future cohorts. However, unlike traditional clinical rotations, faculty resources are not required for intern clinical experiences in the LTC-CSP. Faculty are not responsible for direct clinical supervision in the nursing home because the interns are employees of the nursing homes and supervised by a Registered Nurse within the facility. As of 2014, the LTC-CSP continues to operate successfully. The LTC-CSP has used creative solutions to maintain the program with limited resources. Partnerships between two schools of nursing are leveraged to divide the work and resources required to administer the program. Each participating school of nursing enlisted a faculty person with 12-month appointments to split management and teaching duties during the spring and summer. Enlisting the support of volunteer experts to teach summer workshops also decreases cost and maintains the program quality. We have explored a one- or two-credit course structure, but interns have indicated that they would be less likely to enroll in the program if tuition was charged.

There are several limitations in interpreting program outcomes. First, the survey used to understand intern satisfaction with the program and likelihood of working in nursing homes was developed by the program team and not validated. Furthermore, selection bias may have influenced results. Finally, the LTC-CSP was a multicomponent program that included workshops, clinical employment, and preceptor training. While interns suggested each component was important for a positive experience, it was outside the scope of the evaluation to test whether all of these components were necessary for improving outcomes. Further research is needed to determine the relative value of each component for intern outcomes. Finally, while the impact of the program on intern confidence and intention to work with older adults is promising, the small number of participants limits our ability to generalize findings.

Lessons learned from the LTC-CSP suggest educators can help meet the need for well-qualified long term care nurses by providing opportunities for students to practice in nursing homes at an expanded level beyond traditional clinical rotations as well as proving education on the unique environment of long term care. The LTC-CSP model could be tested with other health disciplines such as pharmacy, social work, therapies, and medicine. With adequate preparation, these nursing homes can serve as rich educational sites providing experiences that allow students to practice complex critical thinking and other health care skills with a growing population that requires extensive geriatric expertise. Educators can cultivate partnerships with long term care sites by co-designing student experiences with local partners that are mutually beneficial, educating nursing home leadership and staff on the importance and benefits of facilitating student experiences and exploring the support they may need to build into their workplace to precept students (e.g., paid time to participate in preceptor education, extra backup while precepting). Finally, educators and practitioners should partner to expand the pool of well-prepared preceptors. Practitioners can assist by identifying and supporting positive role models in nursing home settings and educators can contribute through provision of coaching and mentoring education.

Conclusions

The LTC-CSP provides one unique example of how to prepare and recruit students to work with older adults, particularly in nursing homes. Results from the evaluation show the program improved student feelings of preparedness to work with older adults, clarified the role of nurses in nursing homes, and enticed students to seek employment in nursing homes. Educators in health disciplines should consider how to incentivize students to explore caring for older adults in nursing homes through expanded practice opportunities with no financial burden. Developing partnerships with local practice sites to co-develop student opportunities and increase precepting capacity is an important first step to creating positive nursing home experiences.