The Creation of a Novel Undergraduate Nursing Employee/Student Hybrid Role in the COVID-19 Response

Abstract

The COVID-19 pandemic impacted nursing education and health care systems alike. Increases in staff absenteeism along with increased hospitalizations have strained health systems across the globe. Postsecondary institutions (PSIs) were required to remove students from clinical placements, thus delaying nursing students' ability to complete their programs, and in turn, contributing to the nursing workforce challenges. Health care organizations and PSIs had to collaborate innovatively to support the health care response to the pandemic while continuing to educate and graduate students to expand the nursing workforce. In Alberta, the collaboration between the health system and PSIs led to the creation of an undergraduate nursing employee/student hybrid (UNE/Hybrid) role. This role was not only a response to the nursing workforce challenges created by the pandemic, but it provided nursing students with positive learning clinical placements ensuring that they completed their program in a timely manner. This role was designed to assist with the fourth wave of the pandemic (omicron variant), which was expected to be the most severe wave in terms of hospitalizations and increased staff absences. The UNE/Hybrid role allowed nursing students to complete the required learning for their final preceptorships and/or complete leadership placements in a paid role while being integrated into the unit culture and becoming part of the team. The initiative's results, including its successes, challenges, and lessons, are discussed.

THE CORONAVIRUS DISEASE-2019 (COVID-19) pandemic caused unprecedented strain in all industries on a global scale, and this has been more evident in health care.1 As the pandemic persisted and hospitalizations increased, nurses bore the brunt of this strain. Very quickly, it became clear to health leaders that a severe nursing shortage loomed, and a drastic response was warranted. Concurrently for postsecondary institutions (PSIs), the ability to graduate nursing students was jeopardized as many of them either missed clinical hours or clinical placements were cancelled. Nurse absenteeism, burnout, and attrition, coupled with a disruption to the regular number of graduating nurses ready to enter the workforce, became the foremost problem for health care systems.2–4

Nursing workforce gaps were not introduced by the pandemic, but rather were exacerbated by it. Historically, a key problem in the nursing workforce is forecasting demand and the lack of shared accountability to address the workforce challenges among many stakeholders involved.4 The lack of shared accountability for forecasting of the needs of the nursing workforce and planning to address workforce challenges is a Canada-wide gap.4 Bourgeault4^(p13) noted a lack of coordinating superstructure over the entire Canadian health care system and its stakeholders, which creates challenges in having basic information on trends in the nursing workforce over time (ie, “the who, what, and where of the nursing workforce”). In addition to the local and national absence of predictive workforce plans that could remedy the increased workload, the pandemic added complexity of nursing workforce challenges as a result of forecasting limitations and the unique physical and mental occupational hazards of the profession, causing a great increase in absenteeism and thus increased workloads.

Strategies to increase workforce capacity such as international recruitment, educational seat expansions, financial incentives, and relocation bonuses have been utilized; however, these traditional approaches have had mixed effectiveness.3 Stevenson et al3 argued for new approaches such as establishing supportive new graduate initiatives and collaboration among stakeholders accountable for the overall nursing workforce (ie, PSIs, government, employers, and regulators) as the key to addressing the nursing shortage in the postpandemic era.

ADDRESSING NURSING WORKFORCE CHALLENGES IN ALBERTA

In Alberta, the collaboration between 2 provincial health care organizations (Alberta Health Services and Covenant Health) and 8 PSIs in Alberta led to the creation of an undergraduate nursing employee/student hybrid (UNE/Hybrid) role as a response to the nursing workforce challenges created by the pandemic. The undergraduate nurse employee (UNE)/Hybrid initiative was one of the key strategies used in Alberta to respond to the omicron wave of the pandemic. Conducted from January to April 2022,5,6 this initiative was designed to increase the health care workforce while ensuring process change focused on positive clinical placements and an opportunity to remain in clinical practice in order for nursing students to complete their program requirements and graduate on schedule.

The purpose of this article is to illustrate the collaboration between a major health care organization in western Canada and 8 PSIs in developing a UNE/Hybrid initiative and how this was evaluated by the students who took the UNE/Hybrid role in response to the nursing workforce challenges caused by the COVID-19 pandemic.

THE STUDENT AS AN EMPLOYEE

Students have traditionally wished for a “great placement” for their final focus that will allow them to consolidate the learning received as an undergraduate nursing student while, hopefully, will provide a place of employment once the final practicum is completed. As future employees, students learn unit culture, patient populations, and the daily business of their placement site. PSI placement teams and clinical coordinators are mindful to remind students that their final focus placements are not job interviews, but rather an introduction to working as a registered nurse, with the same schedules and shifts of their preceptors. This traditional cognitive apprenticeship role has best been described as focusing on “learning through guided experience on cognitive and metacognitive skills and processes.”7 The independence from faculty, and growing relationship with the “expert” practitioner, allows the student to gain additional confidence and skills prior to graduation and entry into a workforce that may, or may not, be able to hire them. Partnering with the major health care organizations within the province is this unique staffing role benefits not only the student, who will be able to move into a staff role with greater ease, but the health care organizations as well. The organizations gain unit-trained and freshly mentored staff while the students gain an employer upon graduation.

A UNE/HYBRID ROLE

The UNE role is an unregulated role that provides direct patient care under the supervision of a registered nurse or a registered psychiatric nurse. The existing UNE role requires prior competency to perform nursing activities with patients. A key difference in the UNE/Hybrid role is the RN preceptor coaches and mentors in addition to providing overall supervision of the student. This allows the student to perform clinical skills if they have previously received theoretical/laboratory instruction. For example, a student who has completed theory and laboratory practice to initiate a vascular access device can gain skill competency in the UNE/Hybrid role. The participating students were those who were required to complete 300 to 388 hours of their final consolidated preceptorship (from 8 PSIs). The students were given a choice to move their clinical placement to care areas in most need due to the pandemic (eg, medical, surgical, or emergency departments) if they were not already placed in those areas with their original practicum placement. Students were paired with at least one preceptor (or mentor) who provided direct supervision and opportunities to consolidate their learning in theory, laboratory, and clinical. The relationship between the preceptor and the student is a key component in the process of socializing nursing students into the profession.8

Assignment of care was determined by the nature and level of risk of the nursing activity, the established competency of the UNE/Hybrid student, the employer policy, and the practice setting. UNE/Hybrid students only performed skills for which the theoretical knowledge was covered in the nursing program, although the unit may have additional learning materials for students to complete activities. UNE/Hybrid students were provided with opportunities to perform skills in clinical settings with direct or indirect supervision and coaching by a registered nurse who is authorized and competent to perform and consents to supervise. The student could process orders if this was included in the nursing program; however, they were prohibited from taking verbal or telephone medication orders and providing supervision to other employees (such as health care aides or other students).

INITIATIVE ROLLOUT AND SUPPORT THE UNE/HYBRID ROLE

Two fundamental principles guided this unique collaboration between the health care organization and 8 PSIs: triad wrap-around support and student employment status. The triad support consisted of the preceptor (or leadership mentor for the leadership student), unit manager/clinical nurse educator (CNE), and the faculty advisor from the PSI assigned to the student. Nursing managers, educators, and faculty representatives (course leads) received information and resources to understand the unique needs of these students and the importance of regular touch points, appropriate assignments, and communication for addressing concerns and challenges. Preceptors had access to all support resources developed including a role description, frequently asked questions, role comparisons (UNE-UNE/Hybrid student), and email access to the provincial team supporting this initiative for specific questions. Significant effort was made to ensure student learning needs were not jeopardized in this unique arrangement, which was taking place in a stressed system. With respect to employment status, 487 nursing students were hired into the 2 participating health care organizations. Employing the students, even though they were spending most (if not all) of their paid hours learning, was important for two reasons: first, it was necessary to have the students stay on to support patient care if the pandemic worsened and resulted in the discontinuation of clinical placements, as was the case in earlier waves of the pandemic; second, employing the students into a central staffing pool but placing them into specific units created an opportunity to integrate them into the team, thus paving the way for postgraduation recruitment. These potential recruitment and retention strategies would only be effective on the premise of students being placed in welcoming and supportive environments so that they could be easily integrated into the team, which would increase the chances of students remaining with their home units and applying to graduate and registered nurse positions.

The UNE/Hybrid initiative was evaluated using a process improvement lens with the aim of examining whether the initiative met the goal of ensuring students completed their clinical placements successfully and had positive experiences in the UNE/Hybrid role. It is also hoped that the findings from this evaluation will inform the delivery of similar initiatives as viable recruitment and retention strategies to address future nursing workforce challenges while protecting the learning process of nursing students.

METHODS

Student survey

Two online surveys were developed and distributed to all 487 students from 8 participating PSIs to evaluate the initiative. The surveys were completed at the midpoint (end of February and early March 2022) and the end of the initiative (end of April). The midpoint survey included questions related to students' experiences with their preceptor(s), unit managers, CNEs, and unit staff, as well as students' perceived confidence and competence in providing care for patients, and satisfaction with the UNE/Hybrid role. The endpoint survey evaluated topics similar to the midpoint survey, with additional questions to assess individuals' perceived confidence and preparedness in their ability to provide safe patient care as graduate nurses. Responses to questions were on a 4-point Likert scale ranging from strongly disagree (1) to strongly agree (4). Both the mid- and endpoint surveys included open-ended questions for students to provide additional information about their experiences, what they liked about the UNE/Hybrid role, and suggestions for improvement.

RESULTS

Of 487 UNE/Hybrid students invited to participate in the midpoint survey, 225 responded, with 186 surveys fully completed and 39 surveys partially completed. For the endpoint survey, of 108 responses, 106 were completed and 2 were partially completed. Results from both surveys are shown in Tables 1 to 4.

Table 1. Frequencies and Percentages of Responses From Midpoint Student Survey (n = 201).

	n (%)
I meet regularly with my preceptor
Strongly disagree	5 (2.5)
Disagree	7 (3.5)
Agree	41 (20.4)
Strongly agree	148 (73.6)
My preceptor provides supervision when needed
Strongly disagree	2 (1.0)
Disagree	4 (2.0)
Agree	43 (21.4)
Strongly agree	152 (75.6)
My preceptor encourages me to ask questions and engage in self-reflection
Strongly disagree	6 (3.0)
Disagree	9 (4.5)
Agree	46 (22.9)
Strongly agree	140 (69.7)
My preceptor appears to understand the final preceptor stage of nursing education and tailors expectations accordingly
Strongly disagree	8 (4.0)
Disagree	8 (4.0)
Agree	50 (24.9)
Strongly agree	135 (69.7)
My preceptor and I are given adequate opportunity to focus on my specific learning needs
Strongly disagree	9 (4.5)
Disagree	22 (10.9)
Agree	52 (25.9)
Strongly agree	118 (58.7)
My preceptor provides ongoing constructive feedback on my performance
Strongly disagree	7 (3.5)
Disagree	13 (6.5)
Agree	63 (31.3)
Strongly agree	118 (58.7)
I have developed a trusting relationship with my preceptor
Strongly disagree	6 (3.0)
Disagree	10 (5.0)
Agree	43 (21.4)
Strongly agree	142 (70.6)
I have regular check-ins with my manager/CNE
Strongly disagree	22 (10.9)
Disagree	68 (33.8)
Agree	78 (38.8)
Strongly agree	32 (15.9)
Missing	1 (0.5)
My manager/CNE encourages me to ask questions to support my role
Strongly disagree	12 (6.0)
Disagree	44 (21.9)
Agree	91 (45.3)
Strongly agree	53 (26.4)
Missing	1 (0.5)
My manager/CNE creates an environment where I could be easily immersed in the unit
Strongly disagree	6 (3.0)
Disagree	19 (9.5)
Agree	111 (55.2)
Strongly agree	64 (31.8)
Missing	1 (0.5)
The team on my unit was aware of my unique UNE/Hybrid role
Strongly disagree	16 (8.0)
Disagree	44 (21.9)
Agree	87 (43.3)
Strongly agree	53 (26.4)
Missing	1 (0.5)
I felt very welcome as a new staff member
Strongly disagree	4 (2.0)
Disagree	17 (8.5)
Agree	101 (50.2)
Strongly agree	78 (38.8)
Missing	1 (0.5)
There was no horizontal violence (eg, bullying and conflict between groups) on my unit
Strongly disagree	10 (5.0)
Disagree	19 (9.5)
Agree	81 (40.3)
Strongly agree	90 (44.8)
Missing	1 (0.5)
I am becoming confident in my ability to provide safe patient care on this unit
Strongly disagree	1 (0.5)
Disagree	4 (2.0)
Agree	90 (44.8)
Strongly agree	102 (50.7)
Missing	4 (2.0)
I am clear about my role as a UNE/Hybrid and the roles of those in other professions
Strongly disagree	9 (4.5)
Disagree	23 (11.4)
Agree	95 (47.3)
Strongly agree	70 (34.8)
Missing	4 (2.0)
I feel control over decisions related to my patient's care
Strongly disagree	2 (1.0)
Disagree	12 (6.0)
Agree	122 (60.7)
Strongly agree	61 (30.3)
Missing	4 (2.0)
My experience as a UNE/Hybrid role is based on my learning needs
Strongly disagree	6 (3.0)
Disagree	25 (12.4)
Agree	92 (45.8)
Strongly agree	74 (36.8)
Missing	4 (2.0)
I have an overall positive experience working as a UNE/Hybrid role on the current unit
Strongly disagree	3 (1.5)
Disagree	10 (5.0)
Agree	86 (42.8)
Strongly agree	98 (48.8)
Missing	4 (2.0)
If a friend asked for your recommendation on whether or not to apply for a similar UNE/Hybrid role, would you recommend they apply?
Definitely not recommend	2 (1.0)
Probably not recommend	12 (6.0)
Probably recommend	61 (30.3)
Definitely recommend	111 (55.2)
Missing	15 (7.5)
If there is an opportunity to work in a graduate nurse position at the completion of your practicum/coursework at the same place of a UNE/Hybrid role, would you take the job?
Definitely not take the job	7 (3.5)
Probably not take the job	14 (7.0)
Probably take the job	50 (24.9)
Definitely take the job	115 (57.2)
Missing	15 (7.5)

Abbreviations: CNE, clinical nurse educator; UNE/Hybrid, undergraduate nursing employee/student hybrid.

Table 4. Descriptive Statistic (Means and Standard Deviations) Results From Endpoint Student Survey.

	Mean	SD	Range (Min-Max)
Students' experience with preceptor/unit manager/CNE/unit staff
My preceptor(s)/mentor(s) supported me in my learning and growth	3.55	0.78	3 (1-4)
The unit manager on my unit supported me in my learning and growth	3.30	0.85	3 (1-4)
The CNE(s) on my unit supported me in my learning and growth	3.34	0.78	3 (1-4)
The staff on my unit were welcoming and supportive in my learning and growth	3.48	0.80	3 (1-4)
Students' perceived confidence, preparedness, and overall satisfaction
I feel confident in my ability to provide safe patient care as a graduate nurse	3.39	0.71	3 (1-4)
My experience as a UNE/Hybrid prepared me for my role as a graduate nurse	3.37	0.75	3 (1-4)
I had an overall positive experience working as a UNE/Hybrid role on the current unit	3.48	0.80	3 (1-4)
If a friend asked for your recommendation on whether or not to apply for a similar UNE/Hybrid role, would you recommend they apply?	2.64	0.54	3 (1-4)

Abbreviations: CNE, clinical nurse educator; UNE/Hybrid, undergraduate nursing employee/student hybrid.

Midpoint survey

Student responses from the survey indicated that overall they received great support from, and had positive relationships with their preceptors. Most students responded that their preceptors provided supervision when needed (97%) and gave ongoing constructive feedback on their performance (90%). Students' experience of working with their unit managers, CNEs, and the unit staff was also mostly positive such that the manager and CNE encouraged them to ask questions (72%) and created an environment where students could be easily immersed in the unit (82%). Most students felt welcomed as new staff members (89%) and became confident in their ability to provide safe patient care on the unit (95%). Almost 92% reported they had an overall positive experience working in the UNE/Hybrid role on their current unit. Open-ended comments by students indicated that taking a UNE/Hybrid role provided them with an opportunity for professional growth and confidence while fostering new relationships with the staff as employee/team members. They were able to gain an understanding of unit culture and routines and had opportunities to practice independently and autonomously. Suggestions for improvement included: a more clearly defined scope of the UNE/Hybrid role; clarification of workload expectations; and education for staff members about the UNE/Hybrid role (eg, paid preceptorship). Tables 1 and 2 outline the results from the midpoint survey.

Table 2. Descriptive Statistic (Means and Standard Deviations) Results From Midpoint Student Survey.

	Mean	SD	Range (Min-Max)
Students' experience with preceptor(s)
I meet regularly with my preceptor	3.65	0.67	3 (1-4)
My preceptor provides supervision when needed	3.72	0.55	3 (1-4)
My preceptor encourages me to ask questions and engage in self-reflection	3.59	0.72	3 (1-4)
My preceptor appears to understand the final preceptor stage of nursing education and tailors expectations accordingly	3.55	0.75	3 (1-4)
My preceptor and I are given adequate opportunity to focus on my specific learning needs	3.39	0.85	3 (1-4)
My preceptor provides ongoing constructive feedback on my performance	3.45	0.77	3 (1-4)
Students' experience with unit manager/CNE/unit staff
I have developed a trusting relationship with my preceptor	3.60	0.72	3 (1-4)
I have regular check-ins with my manager/CNE	2.60	0.89	3 (1-4)
My manager/CNE encourages me to ask questions to support my role	2.93	0.85	3 (1-4)
My manager/CNE creates an environment where I could be easily immersed in the unit	3.17	0.71	3 (1-4)
The team on my unit was aware of my unique UNE/Hybrid role	2.89	0.89	3 (1-4)
I felt very welcome as a new staff member	3.27	0.70	3 (1-4)
There was no horizontal violence (eg, bullying and conflict between groups) on my unit	3.26	0.83	3 (1-4)
Students' perceived confidence, competence, and overall satisfaction
I am becoming confident in my ability to provide safe patient care on this unit	3.49	0.57	3 (1-4)
I am clear about my role as a UNE/Hybrid and the roles of those in other professions	3.15	0.80	3 (1-4)
I feel control over decisions related to my patient's care	3.23	0.60	3 (1-4)
My experience as a UNE/Hybrid role is based on my learning needs	3.19	0.77	3 (1-4)
I have an overall positive experience working as a UNE/Hybrid role on the current unit	3.42	0.66	3 (1-4)
If a friend asked for your recommendation on whether or not to apply for a similar UNE/Hybrid role, would you recommend they apply?	3.33	0.67	3 (1-4)
If there is an opportunity to work in a graduate nurse position at the completion of your practicum/coursework at the same place of a UNE/Hybrid role, would you take the job?	3.29	0.79	3 (1-4)

Abbreviations: CNE, clinical nurse educator; UNE/Hybrid, undergraduate nursing employee/student hybrid.

Endpoint survey

Most of the students who completed the endpoint survey indicated that they had support in their learning and growth from their preceptors (91%), unit managers (87%), CNEs (87%), and unit staff (90%). Students agreed that they felt confident in their ability to provide safe patient care as (soon-to-be) graduate nurses (94%), and their experience in the UNE/Hybrid role prepared them for the graduate nurse role (91%). Students reported that they had an overall positive experience working as a UNE/Hybrid on their current unit (90%) and would recommend applying for a similar UNE/Hybrid role to a friend (95%). Comments from students in terms of their experiences indicated that those who reported a “great experience” with their preceptors received constructive criticism and feedback, and challenges for professional growth and confidence. Negative comments pertained to less experienced preceptors who did not provide a robust learning environment, and preceptors with unrealistically high expectations, both of which contributed to student anxiety, and are not unique to the UNE/Hybrid role. Several positive comments from students included their unit managers and CNEs as great resources for their learning, and extra support provided to them in terms of the scope of practice as a student within the unit. A few students were not able to interact much with their managers and/or CNEs as they were not readily available on the unit (eg, small rural sites). Most UNE/Hybrid individuals stated that unit staff members were mostly kind and approachable and provided a sense of belonging to students as team members. Students also reported witnessing significant staff burnout and fatigue on their units due to the demands of the pandemic and staffing shortages. Tables 3 and 4 outline the results from the endpoint survey.

Table 3. Frequencies and Percentages of Responses From Endpoint Student Survey (n = 107).

	n (%)
My preceptor(s)/mentor(s) supported me in my learning and growth
Strongly disagree	5 (4.7)
Disagree	4 (3.7)
Agree	25 (23.4)
Strongly agree	72 (67.3)
Missing	1 (0.9)
The unit manager on my unit supported me in my learning and growth
Strongly disagree	7 (6.5)
Disagree	6 (5.6)
Agree	41 (38.3)
Strongly agree	52 (48.6)
Missing	1 (0.9)
The CNE(s) on my unit supported me in my learning and growth
Strongly disagree	4 (3.7)
Disagree	8 (7.5)
Agree	41 (38.3)
Strongly agree	52 (48.6)
Missing	2 (1.9)
The staff on my unit were welcoming and supportive in my learning and growth
Strongly disagree	5 (4.7)
Disagree	5 (4.7)
Agree	30 (28.0)
Strongly agree	66 (61.7)
Missing	1 (0.9)
I feel confident in my ability to provide safe patient care as a graduate nurse
Strongly disagree	4 (3.7)
Disagree	2 (1.9)
Agree	49 (45.8)
Strongly agree	52 (48.6)
My experience as a UNE/Hybrid prepared me for my role as a graduate nurse
Strongly disagree	4 (3.7)
Disagree	5 (4.7)
Agree	45 (42.1)
Strongly agree	52 (48.6)
Missing	1 (0.9)
I had an overall positive experience working as a UNE/Hybrid role on the current unit
Strongly disagree	5 (4.7)
Disagree	5 (4.7)
Agree	30 (28.0)
Strongly agree	66 (61.7)
Missing	1 (0.9)
If a friend asked for your recommendation on whether or not to apply for a similar UNE/Hybrid role, would you recommend they apply?
Definitely not recommend	2 (1.9)
Probably not recommend	3 (2.8)
Probably recommend	34 (31.8)
Definitely recommend	68 (63.6)

Abbreviations: CNE, clinical nurse educator; UNE/Hybrid, undergraduate nursing employee/student hybrid.

PRACTICE IMPLICATIONS

The aim of this initiative was to think “outside the box” with a collaborative initiative between the health system and PSIs to support the nursing workforce during the surge of the COVID-19 pandemic. This initiative created a work-integrated experience for undergraduate nursing students to be employed in the newly created UNE/Hybrid role. Crisis-driven innovations are reported in the literature1,9 and highlight the importance of innovativeness in health care and nursing education—areas not typically associated with innovation. This initiative was ambitious and required shared responsibility from both the health system and PSIs. It required ongoing communication to work together to support student learning and acclimatize them into a complex and challenging nursing workforce environment.

The UNE/Hybrid role may be thought of as a disruptive innovation in health care, defined as an innovation causing radical change, often resulting in a new way of doing things, and having rippling effects throughout the system.11 The UNE/Hybrid initiative not only helped stabilize the nursing workforce, but also allowed nursing students to be part of the solution in responding to the COVID-19 pandemic: senior nursing students stepped in and were accountable for their nursing practice in a safe environment, with support from their preceptors, CNEs, unit managers, and faculty advisors. From an academic institutional perspective, it enabled students to transition from undergraduate to graduate nurses without delay and ensured students had a positive clinical placement where both institutions have shared responsibilities for positive student learning environment. The collaboration between the health care organization and the PSIs enabled students to utilize their clinical placement/employment setting as a platform for skill development, confidence, and positive nursing experiences.

This initiative has emphasized the importance of considering how work-integrated experiences can be leveraged to support the development of nursing students as well as health care systems during challenging times. The scale of the initiative, and the overall positive experience for participants, was only possible due to intentional relationship building, shared responsibility, open communication, and commitment to the collaboration process.

The COVID-19 pandemic brought challenges for both health systems and PSIs. It took a crisis to bring together stakeholders and shift mindsets from traditional approaches to more flexible and innovative ways of thinking with respect to nursing education and workforce planning/stabilization. In this case, undergraduate nursing students needed to be in a practicum that developed their nursing skills and allowed them to meet the entry-to-practice requirements of the nursing profession as they transitioned to newly graduated nurses. The collaboration between the health system and PSIs was an innovative way to address the nursing shortage, stabilize the workforce, and allow senior nursing students the opportunity to both finish their undergraduate education and contribute to the COVID-19 pandemic response. Student feedback via mid- and endpoint surveys confirmed that their development, knowledge, autonomy, and confidence were fostered and supported, and led to a successful transition into the nursing profession.

This role impacted student learning, and it provided an opportunity for leadership experience to develop students' confidence and competence as they prepare to transition into their role as the registered nurse. The clinical placement provided positive learning interactions that collaborated working with registered nurses, and other allied health professionals to develop their own relational capacity, decision-making abilities, and thinking about becoming leaders and innovators in their own practice. For instance, in the placement where they needed to work in interprofessional teams, they were able to consolidate their learning and put it into practice. This experience allowed students to understand their role within the health care systems and change some of the current practices and demonstrate thinking outside of norms.

When health care systems and PSIs collaborate on innovative solutions to crises such as the recent pandemic, everyone benefits. With this kind of collaboration, there is an increased likelihood for learning opportunities, the development of innovative solutions to complex problems, and approaches to both education and health care delivery in mutually beneficial and sustainable ways. With ongoing budget cuts, nursing workforce shortages, and overall strain on the health care system, a coordinated effort from all stakeholders is not only needed: it is critical.

LESSONS LEARNED: A PATH FORWARD

For both the health care system and nursing education, the pandemic proved a unique opportunity for systemic creativity. The UNE/Hybrid role was a successful and innovative project that, like all disruptive innovations, came with several lessons learned:

1. Future initiatives must consider the role and the engagement of unit staff and preceptors early in the process. Preceptor buy-in is especially important in evolving the preceptor model of learning.

2. The role and the expectation of the clinical managers also require particular attention. The combination of increased workload for clinical managers and lack of understanding of the UNE/Hybrid role may have negatively impacted students, particularly during the early phases of this initiative. While these issues were resolved over the course of the project, some were left with negative feelings about the UNE/Hybrid role, thus demonstrating the need for increased communication and education.

3. Some attention must be given to the long-term effects of this initiative; for example, whether these students were hired into RN roles in the area and how they were supported and retained.

Limitations:

1. There was lack of previous data to compare with, due to the shared patient assignment, whereas the traditional UNE role was different.

2. The implementation had urgency and time limitations.

3. There is limited research on student employment within the nursing work-force.

There is currently a gap in the literature on early student integration into the nursing workforce, and also on strategies and options for continuing with nursing clinical placements during times of health care system crisis. Supervised internship, dedicated educational units, and incentives to precept are potential areas to explore. Both practice and theoretical discussion are needed within the nursing profession regarding postpandemic clinical education. An evidence-based risk-benefit analysis from both student experience and system needs perspectives is also needed. Limitations and barriers to students integrated into clinical settings in times of health care system crisis also indicate the need for the development of an educational conceptual framework. These limitations could have a profound impact on nursing clinical education and equally on the nursing workforce. Therefore, it is critical to evaluate and projects such as this and to provide evidence of their effectiveness as we continue to face the challenges of workforce shortages within the health care system.

FUTURE RESEARCH

There are limited studies related to initiatives such as the UNE/Hybrid role in Canada. It will be critical for future research to focus not only on the long-term efficacy of this role and the impact on the health system/nursing workforce, but also on whether the continued use of the UNE/Hybrid role in nonpandemic times is a useful workforce strategy. In addition, a better understating of the role nursing leaders play, the tools and the skills they need to create clinical positive learning environments, and a culture that promotes coaching and mentorship as an essential nursing skill will be needed. With an aging population, the retirement of baby boomers, and burnout from the pandemic, the nursing profession will continue to be challenged in significant ways. Without investment in this area (both capital and social), PSIs will face issues recruiting enough preceptors10; having clinical placements to continue, especially senior placements; and health care systems will continue to be challenged with a potentially catastrophic nursing shortage.

CONCLUSION

The COVID-19 pandemic created a perfect storm for the nursing profession. The workforce will need a multilevel transformation to evolve and become prepared for the next global pandemic. Nurses are the bedrock of the health care system, and their experience is a warning about the vulnerability of the system. With a depleted health care workforce, an aging population, and an increased demand for health care services, Canada will need a transformative solution to maintain its public health care system. Innovative solutions such as the UNE/Hybrid role are important to consider as responses to this problem. Communication, collaboration, and creativity were key to the success of this UNE/Hybrid role as an innovative response to the unprecedented demands of the pandemic.