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published online 1 May 2013Policy Politics Nursing PracticeBuckley

Alba DiCenso, Laura Housden, Roberta Heale, Nancy Carter, Brenda Canitz, Sandra MacDonald-Rencz and Christine RieckNursing Health Services Researchers

Incorporating a Health Policy Practicum in a Graduate Training Program to Prepare Advanced Practice  

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Article

Introduction

Health services research is intended to inform program plan-ners, administrators, and policy makers at the local, regional, provincial, federal, and international levels about issues such as resource allocation and the governance, organiza-tion, funding, and delivery of health services. Historically, however, there have been poor linkages between the worlds of health services researchers and policy makers, and as a result, the incorporation of evidence into policy making has been inconsistent (Lomas, 2000).

Landry, Amara, and Lamari (2001) describe an evolution in the nature of the relationship between researchers and policy makers from the knowledge-driven model in which information flows in a unidirectional manner from research-ers to policy makers, and the problem-solving model in which policy makers commission research, to an interactive model which actively engages researchers and policy mak-ers from generation through to application of research-based knowledge.

One strategy to help graduate health services research stu-dents learn how to participate in an interactive model with policy makers is the health policy practicum, a block of time during which the graduate student spends time in a policy setting. Our article focuses specifically on the integration of the policy practicum into graduate education for advanced practice nurses. We begin by providing definitions of the

484067 PPNXXX10.1177/1527154413484067<italic>Policy, Politics, & Nursing Practice</italic>DiCenso et al.research-article2013

1School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada2University of British Columbia, Vancouver, BC, Canada3Laurentian University, Sudbury, ON, Canada4School of Nursing, McMaster University, Hamilton, ON, Canada5University of Victoria, Victoria, BC, Canada6Strategic Policy Branch, Health Canada, Ottawa, ON, Canada7Canadian Nurses Foundation, Ottawa, ON, Canada

Corresponding Author:Alba DiCenso, PhD, RN, FCAHS, Professor, School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada. Email: dicensoa@mcmaster.ca

Incorporating a Health Policy Practicum in a Graduate Training Program to Prepare Advanced Practice Nursing Health Services Researchers

Alba DiCenso, PhD, RN, FCAHS1, Laura Housden, NP2, Roberta Heale, DNP, NP-PHC3, Nancy Carter, PhD, RN4, Brenda Canitz, MSc, RN5, Sandra MacDonald-Rencz, MA (Ed), CHE, RN6 and Christine Rieck Buckley, MSc, RN7

AbstractHealth services research benefits from the active engagement of researchers and policy makers from generation through to application of research-based knowledge. One approach to help graduate students learn about the policy world is through participation in a policy practicum. This is an opportunity to work for a defined period of time in a setting where policy decisions are made. This article focuses on the integration of the policy practicum into graduate nursing education for advanced practice nurses. Ten graduate students and two postdoctoral fellows who had recently completed their practicums and three policy makers who had recently supervised students in provincial, federal, and international practicum projects were invited to submit a narrative about the experience. Based on qualitative analysis of the narratives, this article outlines objectives of the practicum, the policy practicum journey, student learning, and finally, the benefits and challenges of the experience.

Keywordshealth policy, practicum, advanced practice nursing (APN), graduate education, experiential learning, qualitative study

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2 Policy, Politics, & Nursing Practice XX(X)

advanced practice nurse, the policy practicum, and policy makers. We then summarize the small body of literature that exists about policy practicums, describe our advanced prac-tice nursing (APN)-focused health policy practicum, and report on a study we conducted to learn the experience of learners and policy makers who participated in the practicum experience.

Advanced practice nurses are defined internationally as registered nurses who have acquired the expert knowledge base, complex decision-making skills, and clinical compe-tencies for expanded practice (International Council of Nurses, 2008). Their graduate education enables them to pro-vide an advanced level of clinical nursing practice and be involved in research, education, consultation, collaboration, and leadership activities. For the purposes of this article, we define the policy practicum as an opportunity for a learner to work for a defined period of time, as a formal part of their academic training program, in a nonacademic setting where policy decisions are made. The work that constitutes this experience usually includes a research component directed towards specific organizational objectives such as the gen-eration of data to inform a decision, the development of a policy report, or work towards a piece of legislation. Policy makers are those with power to influence or determine poli-cies and practices at an international, national, regional, or local level. They are also referred to as decision makers although this term is broader including those who may be making clinical and/or organizational decisions such as pro-gram planners, administrators, and managers.

Literature Review

Given the paucity of literature on the practicum, we begin by summarizing the only literature review we found on the use of practicums in higher education, followed by nursing-specific papers. Ryan, Toohey, and Hughes (1996) conducted a lit-erature review on the purpose, value, and structure of the practicum in higher education and concluded the following: (a) there is considerable agreement that its major purpose is to link theory with practice by providing the opportunity to apply and test knowledge, skills, and attitudes in the real world; (b) the value of the practicum includes gaining insight about the work world, developing interpersonal and social skills, improving integration into the work environment, and enabling more positive future contributions; (c) some of the drawbacks of the practicum include difficulty in organizing appropriate experiences, narrow focus on skill development rather than broader understanding of systems and organiza-tions, poor or uneven supervision and lack of preparation for supervisors, and exploitation of students as cheap labor; (d) three practicum structures are common in the literature: extended single placement toward the end of training;

multiple, shorter block placements distributed throughout the training program; and the concurrent model in which the student is in a part-time placement of 1 to 3 days per week over the duration of the semester or year.

A number of nursing graduate programs in the United States and Canada have integrated the policy practicum into their curriculum. Falk (2005) describes a 12-week policy internship completed as a nursing doctoral student in which she worked on veterans’ long-term care projects with the Health Care team at the Government Accountability Office in Washington D.C. The internship experience provided a hands-on opportunity to participate in the analysis and for-mulation of health policy and to understand the potential role of nurses in public and health policy development. Her responsibilities included identifying and critiquing relevant research, drafting reports, and briefing management and team members on the research.

Reutter and Duncan (2002) describe a graduate nursing course in a western Canadian university on promoting health-enhancing public policy in which students complete a 6-hr-per-week practicum over the 13-week course to gain experience in an aspect of the policy process at the organiza-tional, municipal, or provincial level. Examples of practicum experiences include working with a coalition advocating for a municipal bylaw for smoke-free public places accessible to children, developing health policies in the workplace, advo-cating for injury-prevention policies, and advocating for sup-portive environments for breast-feeding.

In the graduate education program in health policy for advanced practice nurses at the University of California, San Francisco, each master’s student completes a 240-hr health policy residency in settings such as large health orga-nizations with health policy and legislative units, advocacy organizations, governmental offices at the state or federal level, and professional organizations (Harrington, Crider, Benner, & Malone, 2005). Students are involved in activities such as collection and/or analysis of data, preparation of briefing documents or white papers, analyzing and advocat-ing for legislation, and assisting with designing and conduct-ing program evaluations.

Similarly, the nursing PhD program specialty in health policy at the University of Massachusetts, Boston requires students to complete a 6-credit, semester-long health policy internship that provides an intensive immersion experience designed to foster their development as analysts and leaders in health policy. The internship provides an opportunity to observe and participate in policy development and imple-mentation in settings such as federal or state government agencies, professional nursing organizations, private think tanks, and administrative and policy offices of large health care organizations and private nonprofit foundations (Ellenbecker, Fawcett, & Glazer, 2005).

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DiCenso et al. 3

As part of the Nursing Management and Policy specializa-tion in APN graduate program at Yale University and guided by a framework for political development of nurses, students spend a semester and a half in a community agency where they immerse themselves in the organization, learn about its culture, and complete meaningful work following which they participate in a semester-long group practicum on an agency-identified project (Cohen & Milone-Nuzzo, 2001).

Between 2001 and 2012, the Canadian Health Services Research Foundation (CHSRF) and the Canadian Institutes of Health Research (CIHR) funded 10-year awards for five regional training centers and 12 education and mentoring chairs across Canada to build capacity in health services and policy research. A compulsory practicum with a decision-maker organization was a core requirement of both the train-ing centers and the Chair programs (Conrad, 2008). The residency experiences offered by the regional training cen-ters have been described from both a faculty perspective (Sheps, Pong, Lavoie-Tremblay, & MacLellan, 2008) and a decision-maker perspective (Rathwell, Lee, & Sturtevant, 2008). Sheps et al. (2008) noted the importance of the faculty role in creating opportunities for substantive engagement between students and healthcare decision makers and ensur-ing a clear vision, shared learning, mutual understanding of context, and mutual respect. Rathwell et al. (2008) reported on a survey of decision makers that found that through the residency experience, students supported the organization’s efforts to become more evidence-informed through activities such as “introducing a research-focused and analytical mind to public policy initiatives” (p. 113) and in turn, students “benefited from their exposure to and knowledge gained about government and the application of research in a real-world context” (p. 116).

In this article, we will focus on student and policy maker perceptions of the health policy practicum completed by stu-dents and postdoctoral fellows accepted into one of the 12 Chair programs, that of the APN Chair. We begin with a brief description of the practicum requirements.

The APN Chair Health Policy Practicum

As part of the federally funded program described above, one of the authors (AD) was awarded a 10-year Chair in APN, the objective of which was to increase Canada’s capac-ity of nurse scientists who would conduct APN-related research that would meet the needs of clinicians, managers, and policy makers in the health sector. The Chair’s program blended several elements: the education of nursing doctoral students to conduct research to inform the utilization of advanced practice nurses across Canada; linkage and exchange with policy makers to ensure policy relevance and the dissemination and uptake of research results; and

mentoring of postdoctoral fellows and junior faculty. Details of the Chair program are published elsewhere (Bryant-Lukosius, Vohra, & DiCenso, 2009; DiCenso, 2013).

The objective of the 90- to 120-hr policy practicum was to provide students the opportunity to interact with policy makers to increase their understanding of the policy pro-cess, to identify factors that shape the policy-making envi-ronment, and to gain practical experience working with policy makers. The student was expected to contribute to an aspect of the policy process by analyzing, synthesizing, evaluating, and/or communicating policy-relevant informa-tion regarding a particular policy option under consider-ation through activities such as critical review of research evidence, grey literature synthesis, primary data collection, briefings, public policy forums, and stakeholder consulta-tions. In the case of the postdoctoral fellows affiliated with the Chair program, their external awards required the com-pletion of a 6 month policy practicum over the 2-year fel-lowship award.

The Chair worked with the student and her/his thesis supervisor, who was usually, but not always, a nursing fac-ulty member to identify a policy maker to serve as the pract-icum preceptor and brought the student and preceptor together to discuss the period and duration of the policy practicum and the number of hours per week the student could work (depending on their other education and employ-ment commitments), clarify the objectives of the practicum, and discuss the available learning opportunities. The student then completed a learning plan outlining learning objec-tives, resources to help meet the objectives, how achieve-ment of the objectives would be demonstrated, and a timeline for completing the objectives. Once agreed upon, both the student and preceptor signed the learning plan. It was the responsibility of the preceptor to evaluate the stu-dent during and on completion of the policy placement, pro-viding narrative feedback, and a pass/fail grade. If the student was not progressing as expected or unexpected issues arose in the policy setting that compromised the stu-dent’s ability to complete their assigned tasks, the preceptor and student were encouraged to contact the Chair who would then arrange a time to come together to renegotiate the learning plan.

The Chair program had some funds to pay for student travel to the policy setting if it was distant from their home. While Chair program funds were not available to cover stu-dent accommodation and while the policy settings did not offer student salaries or financial support, some did provide free accommodation for students.

We now outline the methods and findings of a study we conducted to learn about the experiences of students and policy makers involved in the APN Chair program practicums.

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4 Policy, Politics, & Nursing Practice XX(X)

Method

This project satisfied the ethics requirements of the Research Ethics Board of the Hamilton Health Sciences/McMaster University Faculty of Health Sciences. APN Chair program PhD and DNP students and postgraduate fellows who recently participated in a policy practicum (n = 11 graduate students and 2 postdoctoral fellows) were invited to submit a narrative responding to a number of questions about their practicum experience. As well, three policy makers, who had recently supervised students in provincial, federal, and inter-national practicum projects respectively, were asked similar questions. The students and policy makers were asked to describe the objectives of the practicum, their roles, student learning, and the associated benefits and challenges. Participants were given the option of returning the narratives directly to the Chair or to a contact person in the Chair pro-gram. After any identifying information was removed, the narratives were given to a qualitative researcher with no affiliation to the Chair program who coded the data and cre-ated related themes. The data were analyzed separately for students and for policy makers as opposed to matching student/policy maker responses as we did not have narratives for every policy maker who supervised the 13 participating students.

Results

Of the 13 students and three policy makers, all responded except one graduate student (94%). All the students were nurses, six of whom were nurse practitioners (NPs), one was a clinical nurse specialist (CNS), and five were neither. All three policy makers were nurses (although this was not a requirement of the preceptor). Nine of the 10 graduate stu-dents were in PhD programs in five universities across Canada and one student was enrolled in a DNP program at an American university. Five of the graduate students chose a policy practicum with a provincial focus (health ministries and a nursing regulatory body), two with a federal focus (Office of Nursing Policy, First Nations and Inuit Health Branch), two with a regional focus (regional health authori-ties), and one with an international focus (International Council of Nursing). One of the postdoctoral fellows com-pleted the practicum in a provincial setting and one in a fed-eral setting. The thesis supervisors were fully informed and supportive of the policy practicum and sometimes helped to match the student with an appropriate setting and policy maker.

The three policy makers representing provincial, federal, and international organizations, had extensive experience in their roles and in overseeing practicums. They served as pre-ceptors for four of the graduate students and one of the post-doctoral fellows participating in this study. The results are presented as follows: objectives of the practicum with exam-ples of projects; policy practicum journey; student learning; and finally, the benefits and challenges of the practicum.

Objectives of the Health Policy Practicum

The two policy makers working in government (provincial and federal) were remarkably consistent in what they felt students could derive from a practicum experience. Both identified the points included in one of the policy maker’s narrative:

1) seeing an overview of how government works; 2) understanding the process of policy development and implementation; 3) examining the importance of research, practice and education in the stewardship of health care; 4) networking within the public services; 5) participating in regular activities of the office.

There was also consistency between the two with respect to their reasons for participating in practicums as summarized by one of the policy makers:

1) keep abreast of the most recent research and information in particular areas of concentration; 2) push the thinking and the agenda to consider other perspectives; 3) provide a catalyst or ‘energy boost’ to the team with the addition of new information and insights, 4) build capacity; 5) increase community and academic contacts that could support and partner with the policy setting.

Upon learning more about the agency priorities, the students and preceptors identified a suitable “main” project for the student to undertake. These projects fell under a number of categories described below.

Study an Existing Policy/Activity. Two students in provincial ministries provided examples of projects in which a policy or activity was underway but was either problematic or required study to determine how it could be optimized. One student was charged with reviewing and analyzing an existing policy related to provincial data collection of NP clinical encoun-ters that had been identified as the source of frustration for almost all of the stakeholders involved in the process:

In discussion with my preceptor we determined a plan of action which included a review of the current state of policy implementation; consulting with stakeholders at the ministry, regional and clinical practice levels to obtain a complete picture of the situation; and analysing the findings of the review and consultation process to determine the most appropriate way forward.

The second student was asked to learn more about the NP community of practice in the province:

Within each health authority there are “communities of practice” of NPs that meet regularly. The Ministry was aware that these meetings were occurring but was unaware of how these groups influenced patient care or how they functioned to support NPs. My role was to attend the community of practice meetings and to interview NPs regarding their community of practice—its structure, format, challenges and triumphs.

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DiCenso et al. 5

Gather Policy-Informing Data. One student requested a policy practicum with an international focus. With the Chair of the International Council of Nurses (ICN) Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) Policy, Standards, and Regulation Subgroup as a preceptor, the student was asked to collect international data about APN regulation:

My initial discussions with the preceptor and APN Chair resulted in the decision to conduct a survey to determine the regulatory status of advanced practice nurses in countries around the world. My role in this practicum was to develop the survey, assist with distribution of the survey, analyze the data and report the findings at an INP/APNN conference.

Contribute Methodological Expertise. One of the postdoctoral fellows, with a research program focused on long-term care (LTC), worked extensively with the provincial ministry of health on related issues. One of the projects on which she collaborated was tool development:

My preceptor was in the midst of developing a tool to assess readiness for LTC homes to implement the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) system. I helped develop and evaluate this tool.

Develop Dissemination Plan for Completed Research. The sec-ond postdoctoral fellow had a strong interest in knowledge translation. Her policy practicum in a federal setting began soon after the APN Chair program completed an APN deci-sion support synthesis in collaboration with the Office of Nursing Policy in Health Canada (reported in a special issue of Canadian Journal of Nursing Leadership, Volume 23, December 2010, available at www.longwoods.com/product/download/code/22240). Consequently, one of the main proj-ects the fellow assumed in her policy practicum with the Office of Nursing Policy was the development of a dissemi-nation plan for the synthesis. Among a variety of activities, the fellow administered brief questionnaires to the provincial and territorial chief nursing officers to identify dissemination strategies that would suit busy nursing leaders in Canada.

Policy Practicum Journey

Initiation of the Practicum. Given the Chair program’s emphasis on linkage and exchange, many partnerships had been created with policy makers across Canada. Consequently, upon learn-ing a student’s interests, the APN Chair, along with the stu-dent’s supervisor, could often “make a match” with a policy maker who had similar interests and priorities. Once the “match” was made, the Chair met with the student, preceptor, and sometimes the supervisor, by teleconference to discuss the objectives and logistics of the practicum. The student and pre-ceptor discussed possible projects and when agreement was reached on the practicum objectives and activities, the student drafted a learning plan. Throughout the process, it was impor-tant to ensure that the mutually selected project was doable in

the time frame, contributed to the objectives of the policy set-ting, and matched the interests and skills of the student. The Chair’s involvement during the practicum varied but tended to be very little if all was going well and if the project did not require her expertise. However, she was more involved if the project was research focused and she could provide method-ological assistance (e.g., survey development).

All three preceptors emphasized the importance of a stu-dent orientation to the practicum that was similar to that of new employees and they ensured that the student met key policy leaders early in the practicum.

Enactment of the Practicum. The students and the preceptors outlined key features of the practicum designed to maximize the learning opportunities. The two preceptors in govern-ment identified very similar roles they played during the practicum as captured by one of them below:

1) ensure opportunities for exposure to a variety of program activities; 2) provide a supportive/learning environment (e.g., provide regular feedback on student’s work, be available to answer questions); 3) exchange information, share ideas and/or provide food for thought; 4) provide oversight, direction, constructive criticism, linking with appropriate nursing expertise; 5) provide different government learning experiences by working on a variety of files—some having lead, others contributing; 6) provide work based on the skill level and interests of the student.

Some students identified that having one “go-to” person in the department for the first part of the practicum was very helpful. Students appreciated being given a range of opportu-nities in which to participate in addition to their main project and looked to the preceptor and her team to be somewhat “directive” in identifying rich learning experiences. One stu-dent, who had two preceptors, one a chief nursing officer and one an executive director of primary care, described their roles in connecting the student to key decision makers, pro-viding mentorship and guidance, and facilitating opportuni-ties to discuss and disseminate the student’s work.

While many learning opportunities were made available to the students, they were also treated as mature independent learners. The students reported that their preceptors gave them a fair amount of autonomy and freedom to participate in various activities and did not micromanage the process. One student noted that “the importance of developing trust between the parties was very important in achieving the goal within a short timeline”.

Student Learning

Students outlined a number of learnings that occurred through the practicum including: learning how government and policy making work, broadening understanding of a policy issue, informing each other’s worlds, and communicating with policy makers.

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6 Policy, Politics, & Nursing Practice XX(X)

Learning How Government and Policy Making Work. Most stu-dents commented on the richness of their practicum experi-ence in helping them learn how governments, be they regional, provincial, or federal, operate and how policy mak-ing is enacted in these settings. Learning included under-standing nursing issues from a policy rather than clinical perspective; the complexities and influences of the policy environment that underlie health care delivery decisions; the context and culture of the policy world; policy perspectives on APN; and provincial, territorial, and federal APN issues. One postdoctoral fellow spoke about learning the process that occurs when a question is asked of a member of parlia-ment and it is then directed to the policy setting for response, how the government agenda translates into policy that influ-ences nursing in Canada, and how nursing leaders shape and influence policy. One student developed an appreciation of the change process at the government level and the signifi-cant effort required to shift priorities and make even small changes.

A preceptor acknowledged the myriad complex and inter-related factors that influence policy decisions and the impor-tance of students understanding this process:

Students have an opportunity to see the strategic negotiation and briefings and how we, as advisors to senior executives and elected officials, are able to support and inform key health care issues. Students start to understand the importance of strategic alignments in a very ‘grey’ landscape of decision making.

Broadening Understanding of a Policy Issue. At the time three of the students completed practicums with one provincial ministry, it was a challenging and discouraging time for NPs in the province because funding was not available to hire new NP graduates. Two of the students were NPs and went into their practicums with a sense of frustration regarding provincial support for their profession. However, all three emerged from the practicums with a broader understanding of this policy issue, an awareness of the challenges influenc-ing resolution of the issue, and the processes underway to seek solutions to the problem. One student summed it up in this way: “I went into the practicum feeling as though there was no hope for NPs in the province, but I left feeling that solutions were actively being sought.”

Informing Each Other’s Worlds. Policy makers and students described the practicum as informing and knowledge-producing. One preceptor shared the following ways stu-dents contributed to the policy setting, many of which were also mentioned by the other preceptors:

1) keep the organization in touch with the teaching approach used by educational institutions; 2) provide “fresh” eyes and a new perspective to an old file; 3) introduce the organization to new sources of information/research and expand the resource base; 4) are often better versed in areas around information

technology; 5) broaden perspectives by pushing the agenda; 6) have a fresher writing style (not ‘government speak’) which is fluid, crisp, and logical; 7) have young brains that can be very quick and in constant need of feeding, the drawback of which is sometimes missing the details.

Students had a sense that they learned about the policy process and at the same time, “gave back” by sharing and applying their research expertise. One postdoctoral fellow noted:

I was a learner, attending meetings, reading and being an observer of the policy “context”. I was a “research advisor” using my research experience and expertise to advise on projects. I was also a researcher embedding a small Delphi study into one of the policy setting’s processes.

Another postdoctoral fellow noted that she was able to “frame their work within a research perspective that I don’t think would have happened otherwise” and described the dissemination of the work through copresentation at a con-ference and coauthoring a paper with her preceptor.

Communicating With Policy Makers. Effective communication with policy makers, in writing and orally, must be concise to capture and maintain the attention of these busy officials. Many of the students commented on their learning of this skill during their practicum. As one student stated:

Reading briefs and partnering with an advisor with many years experience writing for government helped me transform the expansive and detail-rich academic writing into a brief, practical and useable document that provided specific directives to initiate and implement changes in practice. Likewise, as my mentor set her key priorities to address with the Minister of Health, she developed a consistent “sound bite” about the importance of expanding the implementation of NPs in primary health care.

Benefits of the Policy Practicum

In addition to mutual learning, preceptors described the “win-win” opportunity to move an agenda forward while at the same time enabling new student learning. They com-mented about the shared benefits with one noting that “the learnings and ‘flow of information’ are two way” and the other noting that “benefits accrue to both the student (in terms of knowledge and skills development) and program (in terms of contribution to program activities)”. Students com-mented about the policy practicum solidifying their interest in policy research and analysis and providing a unique opportunity to build knowledge, perspective, networks, skill sets, and capacity “way beyond what can be achieved in a lecture hall”. One student noted that the “experience ignited my passion for health policy and gave crucial insight into the policy world and how to best effect change”. Two additional benefits will be described in more detail: role modeling

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provided by preceptors both in leadership and mentorship roles and the lasting connections created between the student and the policy setting.

Role Modeling. Students were supervised by senior, highly experienced, and expert leaders. In addition to guiding the student learning in the policy setting, these preceptors offered rich role modeling for the students in areas such as leader-ship and mentoring. As one student noted, “the most signifi-cant learning was observing my preceptor as she became newly established in her role as the provincial chief nursing officer . . . demonstrating how true leadership is earned and enacted”.

One preceptor described the commitment to an active mentoring role to students:

I believe policy makers provide an opportunity for students to link with key partners both in and outside of government, expose them to the realities of providing strategic advice in a very politicized environment, partner with them to develop policy and introduce them to the complexities of making decisions at the ‘health care system’ rather than unit or institution levels.

Lasting Connections. It is expected that graduates of the Chair program will partner with policy makers when conducting future health services research in order to ensure application of the findings. Therefore, an important benefit from the policy practicum was the lasting connections that occurred between the student and the policy setting and policy mak-ers. Students commented about this:

My mentor continues to include me in her teleconferencing with key stakeholders, is supportive of my research, and thoughtful about her contacts who would be interested in my research and influential in the dissemination of the findings.

I’ve been able to develop linkages with others (at the Ministry) with similar interests. I find myself now emailing new research publications to my policy maker partners if I think they might be of interest to them and they do the same for me with government documents.

Challenges of the Policy Practicum

Students and preceptors outlined a number of challenges related to the practicum including: placement identification, placement readiness, addressing problems during the practi-cum, engaging stakeholders, confidentiality and ethical approval issues, and insufficient time.

Placement Identification. While the Chair had developed many contacts with policy makers at the provincial and fed-eral levels, she had fewer such contacts at regional levels leaving the student to play a larger role in placement identi-fication. One student used his own contacts to arrange a pol-icy practicum tailored specifically to his area of interest and

noted that while it allowed him to take responsibility for his own learning, conceptualize the experience, and recruit the necessary people and resources to make it happen, he would have benefitted from hearing about other student’s experi-ences in arranging their practicum.

Placement Readiness. At other times, the setting was easily identified but the practicum was a challenge to arrange because of unavailability of the preceptor or changes occur-ring in the setting. With fairly high turnover of policy mak-ers, departmental reorganizations, and roll out of new programs, students were sometimes asked to wait until “the dust settled” before starting the practicum which in some cases resulted in significant delays.

Addressing Problems During Practicum. Once the learning plan was developed and the practicum was underway, the Chair often had no contact with the student and preceptor and assumed that all was going well. However, in a few cases, students were struggling to address problems on their own. One student found herself in a situation where expectations were unrealistically high and acknowledged only at the end of this stressful experience that regular contact with the APN Chair and preceptor throughout the process would have been helpful.

Engaging Stakeholders. Some students encountered chal-lenges in collecting the information they were charged with obtaining. This took the form of stakeholder reluctance to take the time to share their views or language barriers when designing and administering an international survey.

Confidentiality and Ethical Approval Issues. Two preceptors identified the need to ensure confidentiality in the policy set-ting. Students sometimes were given access to confidential government policy or political directions in developmental stages and while the preceptor reported always having dis-cussions with learners about the importance of confidential-ity, she wondered whether it might also be helpful to have a formal document to that effect.

One student encountered an unexpected issue related to ethical approval of a study:

It was recommended that the evaluation being conducted by a contractor did not need ethics approval. I was concerned with this recommendation and after consultation with my PhD supervisor, I decided to remove myself from continued involvement.

Insufficient Time. Insufficient time was frequently identified as a challenge. Time issues arose with respect to the need for flexibility with timelines, preceptor, and student time con-straints, the short duration of the practicum, and taking time away from work and the campus to attend the practicum, and in some cases to travel to the practicum. Time delays for eth-ics approval were also mentioned. In one project, both the

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8 Policy, Politics, & Nursing Practice XX(X)

preceptor and the student identified the need for flexibility. As noted by the preceptor:

The student learned that timelines need to be flexible when working with an international group. Given that there were many players involved, it was often difficult to obtain information quickly; there were also challenges with everyone’s busy schedule and vacations.

A preceptor noted the difficulty she experienced in mak-ing sufficient time to plan for students, explain government processes, and provide adequate direction and feedback. She also noted that the part-time nature of some students’ avail-ability wasn’t always congruent with the requirements of the placement setting and the student distance from the policy office resulted in missed learning opportunities. One student describes the time and distance challenge:

The significant challenge for me in this learning experience was the travel time and distance required to participate in the practicum. While I was on site in my practicum, my mentor filled my time with opportunities to meet stakeholders and policy makers and attend meetings. I was able to do much of the research and writing from home and use the time on site to participate in face-to-face meetings, teleconferences and networking with key policy makers. However, as I came and went from the practicum site with a few weeks between visits, continuity in projects and establishing relationships were difficult to achieve.

Both preceptors and students identified the short duration of the practicum (90-120 hr) as a challenge as described below by first, a preceptor and then a student:

I sometimes felt the practicum was too short for them to take on major projects. A full term (i.e., 4 months) similar to a co-op student would allow them to sink their teeth into more complex issues and see them through.

Understanding and really grasping the complexity of the environment and players is difficult to do in a short time frame; one just starts getting comfortable in the environment and it is over; if the practicum entails living away from home, this means taking time away from work and family; preceptors may underestimate the amount of time the practicum deliverables may take.

Discussion

Experiential education is defined as “a philosophy and meth-odology in which educators purposefully engage with learn-ers in direct experience and focused reflection to increase knowledge, develop skills and clarify values. It is a system-atic approach to applied learning whereby a student is directly engaged in professional and productive learning activities” (Association of Schools of Public Health Council of Public Health Practice Coordinators, 2004). Policy

practicums are a type of experiential learning, a concept which is becoming more popular in university education. The 2011 National Survey of Student Engagement, adminis-tered to nearly 1,500 colleges and universities in the United States and Canada, asked undergraduate students if they par-ticipated in a “practicum, internship, field experience, co-op experience, or clinical assignment”. Participation rates ranged from 43% for business majors to 71% for education majors (e.g., student teaching). Senior students identified the following benefits of the experience: developing career-related skills, working with others in meaningful activities, connecting academic and experiential learning, developing new ways of thinking, and having serious conversations with diverse people (National Survey of Student Engagement, 2011). In response to these data, Dr. Patrick Deane, President of McMaster University, noted:

experiential components deliver obvious benefits in terms of the quality of the learning experience and the level of engagement felt by students. If well-conceived and effectively, ethically managed, they also bring tangible social and economic benefit to the community outside of the campus. Experiential learning will thus be key both to the future quality and to the sustainability of university programs (From the President Newsletter, p. 7, Sept 2011).

In this article, we described an experiential learning oppor-tunity at the doctoral and postdoctoral levels. Similar experi-ences have been offered at the master’s level (Harrington, Crider, Benner, & Malone, 2005; Sheps et al., 2008). Consistent with the health policy practicums described in the literature (Cohen & Milone-Nuzzo, 2001; Ellenbecker et al., 2005; Falk, 2005; Harrington et al., 2005; Reutter & Duncan, 2002; Sheps et al., 2008), our policy practicum was designed to provide a hands-on opportunity to contribute to an aspect of the health policy process through participation in activities such as identifying and critiquing relevant research, collect-ing and/or analyzing data, and preparing briefing documents.

With the growing demands on health care resources and a general culture of accountability, there is a greater emphasis on generating knowledge that can have a practical impact on the health system (Lomas, 1997). By spending time in the policy world, students develop an appreciation of the dynam-ics involved in using evidence to inform health service deci-sions. They also learn the importance of actively engaging with policy makers from the identification of a policy-relevant research question through to its application in evidence-informed policy making. Active engagement facilitates the development of a trusting relationship which has been shown to improve information exchange that results in change (Mitton, Adair, McKenzie, Patten, & Perry, 2007). Given the research and leadership dimensions of the APN role, learning to interact with policy makers is essential to their conduct of policy-relevant APN-related health services research and to considering health policy leadership roles.

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DiCenso et al. 9

The narratives gathered in this study provided a rich description of the successes and challenges of the policy practicum as well as recommendations for future policy practicums. Many of the challenges could have been addressed through better communication in the form of: more “checking in” by the Chair with the student and pre-ceptor to ensure all was going as planned, regular meetings between the student and preceptor to review how the expe-rience was progressing vis-a-vis the objectives of the pract-icum, and arranging opportunities for students to share their practicum experiences with each other. Students need to be prepared for some uncertainty within the policy pract-icum given that key players, policy priorities, and timelines can change quickly. Other recommendations include: care-fully considering whether the advantages outweigh the dis-advantages of choosing a practicum setting a distance from home, providing a formal orientation for the learner, addressing confidentiality and ethical approval issues early on, and providing a variety of learning experiences in addi-tion to the main project assigned to the student. Finally, the length of the practicum requires careful consideration within the context and goals of the training program in which it is situated. In many cases, 90 hr to 120 hr was too short.

Strengths of this study included the following: inclu-sion of both students and policy makers in the sample; excellent response rate; participation of students/postdoctoral fellows and policy makers engaged in various levels of policy work including regional, provincial, federal and international levels; opportunity to return the narratives to a contact person within the Chair program rather than the Chair herself to encourage sharing of negative perspec-tives; and coding of data by a qualitative researcher with no affiliation to the Chair program. The study also had limitations. It was a small sample. The invitation to par-ticipate came directly from the Chair with the initial instructions to send responses to the Chair which may have made respondents uncomfortable sharing negative experiences; however, after recognizing this possibility, participants were encouraged to send their responses to a contact person in the Chair program who then sent them directly to the analyst.

There is very little research on health policy practicums in graduate education. Future research could examine char-acteristics of policy settings likely to produce a positive learning experience, strategies for preparing policy makers to be effective mentors, types of mentoring experiences that ensure effective engagement, strategies for preparing stu-dents and mentors for the experience, how the experience develops the student in ways that would otherwise not hap-pen, how these students differ from those who have not had the experience, what they take into their postgraduate careers that they wouldn’t have, and finally, how effectively they engage with policy makers in their future research programs.

Acknowledgments

The authors would like to acknowledge the graduate students, post-doctoral fellows, and policy makers who took the time to reflect on the health policy practicum experience and to respond to the ques-tions asked of them.

Declaration of Conflicting Interests

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

There was no external financial support for the research, authorship and/or publication of this article. Internal funds were paid to a qual-itative data analyst to code the narratives.

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Author Biographies

Alba DiCenso, PhD, RN, FCAHS, is a professor in the School of Nursing and the Department of Clinical Epidemiology and Biostatistics at McMaster University in Hamilton, Ontario, Canada. From 2001 to 2011, she held the CHSRF/CIHR Chair in Advanced Practice Nursing (APN), the mandate of which was to increase Canada’s capacity of nurse researchers conducting APN-related health services research informed by the needs of health managers and policy makers.

Laura Housden, NP, is a doctoral student in the School of Nursing at the University of British Columbia in Vancouver, Canada, a CHSRF/CIHR APN Chair Program graduate, a Michael Smith Foundation for Health Research (MSFHR) junior graduate trainee and a Transdisciplinary Understanding and Training on Research - Primary Health Care (TUTOR-PHC) trainee.

Roberta Heale, DNP, NP-PHC, teaches in the bachelor’s, mas-ter’s, and nurse practitioner programs at Laurentian University in Sudbury, Ontario, Canada and continues to practice as a nurse practitioner.

Nancy Carter, PhD, RN, is an assistant professor in the School of Nursing at McMaster University in Hamilton, Ontario, Canada and teaches in the undergraduate, graduate and nurse practitioner pro-grams. She is acting director of the Canadian Centre for Advanced Practice Nursing Research (CCAPNR).

Brenda Canitz, MSc, RN, is on secondment as the executive direc-tor, Partnerships for Health in Human and Social Development at the University of Victoria teaching at the baccalaureate and gradu-ate levels. She previously served as chief nursing executive and executive director Clinical Care and Patient Safety in the Ministry of Health in Victoria, British Columbia.

Sandra MacDonald-Rencz, MA (Ed), CHE, RN, was the execu-tive director of the Office of Nursing Policy, Health Policy branch at Health Canada from 2004 to 2012. Currently, she has assumed a special assignment within the Strategic Policy branch, Health Canada where she continues to provide policy advice on health sys-tems and nursing policy issues across directorates and the branch.

Christine Rieck Buckley, MSc, RN, is executive director of the Canadian Nurses Foundation. Previously, she was Manager of Regulatory Affairs at the Canadian Nurses Association (CNA), where she managed the operations of the Canadian Registered Nurse Examination (CRNE) and the exams within CNA’s Nurse Practitioner Examination program. She currently chairs the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) Health Policy Subgroup.

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