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A NEW APPROACH TO NURSING EDUCATION
BECAUSE NURSING PRACTICE demands both depth and breadth of knowledge in many areas, the problem of asking students to learn a great deal in a brief period cannot easily be resolved.
It is tempting to allow the current crises of the nursing shortage to distract from the need to make important changes in nursing education to increase the quality of prelicensure education. Yet the practice-education gap, the undereducation of nurses in prelicensure programs, and insufficient continuing nursing education for those in practice are, we believe, at least as serious a set of problems as the shortage of nurses and nurse educators. The nursing shortage must be addressed through changes in both structure and approach to teaching and learning.
As we mentioned in the previous chapters, we believe that nursing education must commit to important structural changes. These include requiring the baccalaureate as the entrance to practice, introducing nursing courses in the first year of the baccalaureate program, increasing second-degree baccalaureate and master’s programs, improving students’ efficient progress from ADN programs to baccalaureate and master’s programs, requiring a postgraduate year of internship in a clinical setting, and more.
We know that making such structural changes will require considerable time and funding. Moreover, these needed structural reforms—extensions of the period of formal education for nurses—are only part of the answer. The time in nursing school must be used more effectively. As the previous chapters describing teaching in the clinical setting and the classroom suggest, nursing education has considerable strengths, especially experiential learning, along with effective pedagogies such as coaching. Nursing education must bring these effective teaching strategies into the classroom. Moreover, the educational experience must model and promote integration across the professional apprenticeships: knowledge, skilled know-how, and ethical comportment. Toward these ends, we offer a new way of thinking about nursing education.
Many nurse educators tend to valorize a narrow form of reasoning, trying to teach students to stand outside a given situation to take a snapshot view of it and make a rational choice about an action. Perhaps in an effort to follow an “academic” approach, some nurse educators try to teach students to interpret a situation with formal, unchanging, or standardized criteria based on abstract properties and directives that come from outside the situation. In effect, this suggests to the student that any situation can be made completely explicit and that different situations can be made comparable by using generalized assumptions and formal criteria for making judgments. This approach works only up to a point, where the decision maker can verify that all the assumptions made about the situation are precisely the same and that the criteria are appropriate (Taylor, 1993). However, in evolving situations that are underdetermined, that cannot be made completely explicit, which is the norm in today’s nursing practice, the nurse must take into account patient trends over time. The critical pathways guidelines or formal decision-making strategies do not fit every situation, and it is misleading to suggest that these are anything but guides. Again, approaching nursing education through domain-specific teaching brings a more effective focus to teaching clinical reasoning across patient transitions (a form of practical reasoning).
Four Essential Shifts for Integration
Nursing educators must strive for deeper, more effective integration of the three professional apprenticeships. To that end, we suggest that teachers change their assumptions about teaching and their approach to fostering student learning in four ways, two of which we review briefly here because we have already discussed them in Chapters Two and Three. We describe the second two shifts more extensively because they are being introduced in this chapter.
We suggest that nurse educators:
1. Shift from a focus on covering decontextualized knowledge to an emphasis on teaching for a sense of salience, situated cognition, and action in particular situations.
As we noted in Chapter Three, many teachers organize their classes around lists of abstract taxonomies, or other abstract theory and knowledge, which gives their students little or no indication about how to integrate the knowledge they present in a practice context. We found most troubling the ubiquity of the strategy of presenting theories and clinical knowledge as taxonomic naming systems. Few students can imagine how the classification systems can be used in their actual direct patient care. Although learning classification systems is integral to mastering and retrieving information systems (Bowker & Star, 1999), these systems are not sufficient. Instead of presenting flat representations of multiple taxonomic structures, or “cataloguing,” nursing educators need to help students learn to use nursing knowledge and science. For example, teachers might develop computer-based exercises as part of learning various nursing documentation and care-planning strategies. Students can also learn taxonomies in the context of critiquing, updating, and improving practice in a particular situation.
Precious classroom time could then be used instead for developing a sense of salience about what is important and unimportant about a clinical situation. As Bourdieu (1990) points out, the heart of practical reasoning requires understanding the nature of the situation. Nurses work in complex, relatively unstructured clinical situations where they must learn to quickly recognize and assess what is most and least important. Because practice situations are underdetermined, are open-ended, and change over time, practitioners must first grasp the nature of the situation before they can act intelligently and prudently. It is not possible for the student to build up a holistic grasp of the situation element by element in an actual complex practice situation. The most that can be arranged or controlled is for the instructor to assign the student patients who are not in crisis and who require relatively simple, straightforward interventions. Continued situated coaching is required for the student to grasp the changing relevance, and demands, resources, and constraints in a particular situation, and therefore it entails developing a sense of salience, what Eraut (1994) calls a productive form of knowledge use and Lave and Wenger (1991) call situated cognition. Over time, students effectively shift to what they can notice (drawing on their background understanding) in the situation without deliberate prompting and place their focused attention (put in the foreground) on more novel aspects of the situation. Developing a sense of salience requires linking perception and discernment with the ability to use knowledge from a rich knowledge base.
2. Shift from a sharp separation of clinical and classroom teaching to integration of classroom and clinical teaching.
As we discuss in Chapters Two and Three, we observed in all schools of nursing a sharp divide between classroom and clinical teaching, and the students notice the significant difference between their experiences in both. A formal separation of clinical and classroom teaching does not support a complex, integrated use of knowledge and skills that nursing practice demands.
Unfortunately, we observed many situations where teachers expect students to perform, demonstrate, or present a given skill out of clinical context, usually in a skills laboratory. It can be helpful to use a nonclinical setting to teach first-year nursing students how to take vital signs or other elemental competencies. If teachers present only simple, stripped-down examples or test students on elemental competencies, they may not help students prepare for many clinical situations. To take a common example, when students learn to measure blood pressure, they often learn in simplified and decontextualized situations where they are taking blood pressure measurements on healthy individuals. These tasks are fine as a starting point. But they do not prepare a student to make a clinical assessment about, for example, a hypertensive patient in labor and delivery, where the student must move quickly in interpreting information from the patient’s vital signs and taking account of the particulars in the situation. Lists of broad areas of competent performance, such as those enumerated by the Institute of Medicine and used in the Quality and Safety in Nursing Education project (Cronenwett et al., 2007), demonstrate an integrative view of clinical performance rather than emphasize narrowly prescribed lists of elemental competencies. By integrating clinical and classroom learning into a seamless whole, nurse educators could address the fragmentation students currently experience and take some of the burden of overload off themselves, their colleagues, and the students.
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