Taking a fresh look at the pediatric clinical experience.

The National League for Nursing’s (NLN) fi nal report from the Think Tank on Transforming Clinical Nursing Education (2008) challenges the paradigm of the traditional “clinical rotation” and questions the practice of placing students exclusively in an inpatient unit to complete a set of tasks. This report prompted me, a veteran clinical instructor, to take a fresh look at how we structure the pediatric clinical rotation in our undergraduate program and to ask whether assigning the majority of pediatric clinical hours on an inpatient unit is addressing student learning needs in light of changing patterns of care delivery. The traditional pediatric clinical rotation in an inpatient unit exposes students to a small subset of acutely ill children and adolescents. The National Association of Children’s Hospitals and Related Institutions (2010) reported that in the past few years pediatric inpatient units nationally have been running at only 73% of capacity, whereas the incidence of outpatient surgery has increased by 8.3% and outpatient visits have grown by 18.2%. Today, fewer children are admitted to the inpatient unit; however, they are sicker and have more complex illnesses. A large majority of pediatric patients who were once cared for in the hospital setting now receive much, and in many cases, all of their health care in ambulatory care, community, and home settings. Primary care offi ces and schools are prime examples of settings that have assumed an expanded role in this shift of care. The primary care offi ce provides health supervision, acute and chronic illness management, and the bulk of mental health care for the pediatric population (Kelleher, 2009). The primary care health home, built around a trusting relationship with a primary care provider and a care team, is the starting point for most children’s health care (Marble, 2007). With the average school-age child spending at least 6 hours per day in school, school nurses also play a major role in providing care throughout the school year for children, including those with acute and chronic illnesses. The National Association of School Nurses (2010) noted that 18% of the 52 million students enrolled in school in the United States have chronic health issues, and approximately 75% of schools employ a nurse in at least a part-time position. School-based nursing care encompasses everything from administering acetaminophen for a headache to the suctioning of a tracheostomy, as well as counseling for mental health concerns and providing health education. As nursing schools prepare students with the knowledge and skills needed to provide safe, competent, and appropriate care for children, clinical experiences in the undergraduate baccalaureate program should refl ect the changing roles and landscape of where and how pediatric health care is delivered. Increasing inpatient acuity and complexity and the declining inpatient census refl ect a fundamental shift in pediatric health care and reduces or complicates the availability of productive clinical learning experiences with pediatric patients in hospital settings. Further, the types of pediatric health problems that necessitate inpatient care are rare and infrequent and do not represent the broader spectrum of health problems, including the developmental and chronic health problems that are more prevalent in children. Another compelling reason for making a shift from inpatient to outpatient and community care settings for clinical learning experiences is the rise in nursing school enrollments, which additionally burden inpatient pediatric clinical rotations. According to the American Association of Colleges of Nursing (2012), enrollment in entry-level baccalaureate nursing programs increased by 5.1% in 2011, thus challenging the pediatric instructor to provide enriching clinical assignments to more students at a time when acute care pediatric settings are experiencing signifi cant declines in census. In addition to providing quality clinical placements, faculty teaching in undergraduate nursing programs must be aware of how assignments impact students’ ability to learn. The pediatric inpatient clinical rotation has been identifi ed as being quite stressful, and medication administration to children causes considerable worry for students (Oermann & Lukomski, 2001). Therefore, the creation of meaningful pediatric clinical experiences requires thoughtful consideration of the setting and the support needed to effectively engage students in the learning process. The time has come to take a fresh look at pediatric clinical education. A fi rst step is to reinvent the clinical rotation as a broad-based pediatric clinical experience and not as an acute care clinical placement. Course objectives should be written so they are not tied to a specifi c place, such as an inpatient unit, but instead, to encompass the broader scope