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IMPROVING NURSING EDUCATION AT THE PROGRAM LEVEL
THIS CHAPTER PRESENTS an agenda of recommendations to transform nursing education to meet today’s needs. The recommendations presented are based on our findings and have been discussed in forums of nursing leaders in education, policy, research, and practice. Some of the recommendations are more controversial than others. Although not all in the nursing forums agreed with each one, we found strong support and interest for these recommendations and strong agreement on the problems identified.
The following recommendations fall into six general categories that speak to the need for change in nursing education: in nursing schools or programs, for student populations, in the ways student experience their education, in teaching the practice, in ways to enter practice, and for more coordinated national oversight. Several recommendations concern faculty development, which are best undertaken with a two-step approach. First, regional and national nursing organizations, graduate schools, and schools of nursing need to pool their resources to offer regional courses and workshops for educators to develop their teaching. At these meetings, nursing faculty can learn about new research findings. Second, faculty can then return to their individual institutions with knowledge about new pedagogies and new approaches to share with others.
To fulfill the professional promise nursing offers society nursing organizations and the service sector need to join nurse educators and students to improve nursing education before graduation and over the course of a nurse’s career.
Entry and Pathways
1. Come to agreement about a set of clinically relevant prerequisites. There is a pressing need to reevaluate the prerequisites for nursing education and address variation in quality and content. There is also a need in many states to expand the number of available courses. We recommend a national advisory group consisting of nursing faculty, clinicians, physicians, pharmacists, and expert science teachers agree on what prospective students must know in the humanities, natural sciences, and social sciences and how they are relevant to clinical practice before they begin their nursing programs. We expect that these prerequisites would be examined and updated regularly—and that programs would honor them consistently.
We also recommend an agreement on relevant prerequisites for the many students who are coming to nursing school with a baccalaureate or advanced degree, many of whom have completed extensive coursework in natural sciences, social sciences, and humanities. Although an increasing number of second-degree students are enrolled in all types of nursing schools, nursing curricula have not changed to accommodate them. Accelerated second-degree baccalaureate programs are growing quickly, but for reasons of affordability many second-degree students enroll in community colleges—yet they have to spend three years completing the program. An evaluation is needed to compare the learning needs of this new population of nursing students with students in generic baccalaureate programs. The Fuld Foundation grant to the Duke University School of Nursing is one example of such an evaluation that is still in its data collection phase.
Given our findings on teaching and learning nursing knowledge and science, we call into question the wisdom of not requiring more prerequisites or more coursework in science for RN-to-baccalaureate transition programs. We recommend that the programs continue to be designed for completion within two years. However, we recommend that these programs develop and require relevant science courses tailored for the individual RN-to-baccalaureate-degree student. Students who do not place out of science entry examinations should be required to take these courses.
2. Require the BSN for entry to practice. Unlike their colleague educators preparing lawyers, clergy, physicians, and engineers, nursing faculty and preceptors have relatively little time to build a broad and deep knowledge base and guide students in professional formation. Yet nursing requires a high degree of responsibility and judgment in high-risk, underdetermined situations. Thus the baccalaureate degree in nursing should be the minimal educational level for entry into practice. We agree with the Association of American Colleges of Nursing, the American Nursing Association, and other leading nursing organizations that all nursing programs immediately move to baccalaureate degree or master’s-level entry for nurses. We challenge the profession to come to swift agreement about the most effective way to transform the current diverse pathways into a unified whole.
3. Develop local articulation programs to ensure a smooth, timely transition from the ADN to the BSN. We recommend a redesign and reconfiguration of the roles of diploma and community colleges in nursing education. Currently, many ADN programs offer the baccalaureate degree in nursing, and more programs are in the planning stages. In general, we do not see the merit of this; it stretches the already overburdened community college mission and diminishes its capacity and role in opening access to educational paths. What was meant to constitute a swift entry to practice has resulted in a logjam, and students are not moving on to the BSN in appreciable numbers. We urge local and regional consortiums, on the order of the Oregon Consortium for Nursing Education, to create a seamless transition from the ADN program to the BSN—and beyond.
4. Develop more ADN-to-MSN programs. We recommend increasing the number of ADN-to-MSN programs. Orsolini-Hain (2008) found that few ADN students felt motivated to return to school for a baccalaureate degree because the degree would not significantly influence their job capacities and functions. We believe that ADN-to-MSN programs would appeal to practicing ADNs and give them a realistic incentive to return to school for better job opportunities and salaries. Another benefit of this action would be growth of the applicant pool for doctoral study and enlargement of the faculty pipeline.
Student Population
5. Recruit a more diverse faculty and student body. We note that African Americans, Hispanic Americans, Asian Americans, and American Indians are underrepresented in nursing. As a profession nursing remains far from being as diverse as the populations it serves. Yet to practice, nurses must be attuned to the diversity of concerns, attitudes, and values that patients and their families bring to bear on their health. This attunement comes in part from a diverse profession. Underrepresented minorities are also are more likely than others to pursue the baccalaureate or a higher degree in nursing (AACN, 2008) and thus be ready for graduate school, which could lead to a more diverse nursing faculty. Local, regional, and national efforts to recruit more diverse students and faculty are needed. We note that schools and health care organizations offer outreach and pipeline programs for high school students, and we commend these programs and recommend that they be strengthened through continued financial support and recruitment and retention infrastructures. It is essential that health care institutions increase their commitment to supporting education as well as their diversity. Such commitment could be shown through growth in incentives for minority nurses to become nurse educators, including more scholarships for minority nurses and active recruitment for minority nurses to pursue graduate education.
6. Provide more financial aid, whether from public or private sources, for all students, at all levels. Many health care organizations have created programs to make loans that are reduced or forgiven if the graduate works for the organization. We commend these efforts and recommend more focused attention by federal, state, and local authorities to support the education of nurses. In addition, every health science education center could add fellowships to the annual campaign in order to immediately address the shortfall in funding for nursing and medical education. In the context of the acute nursing shortage, new opportunities exist to encourage state governments to offer more entitlements for nursing scholarships through education taxes imposed on new health care facility extensions.
The Student Experience
7. Introduce prenursing students to nursing early in their education. Nursing programs are short, yet the formation of nurses is complex. Programs should take the earliest opportunity to introduce students to the profession. We note that BSN programs could bring students into the nursing curriculum earlier, before the junior year. For example, first-year (that is, freshman) students who intend to be nurses might take a seminar on nursing. We also recommend that they begin taking prerequisites for clinical courses during the first two years of college. The school would also need to offer summer courses to accommodate students who transfer or do not decide on their nursing major until the sophomore year. However, the advantage of beginning to use and integrate knowledge early from prerequisite science and humanities and the additional time for formation produce a strong rationale for an earlier start to nursing courses.
8. Broaden the clinical experience. Although the amounts vary by type of program, much of a nursing student’s clinical time in school is focused on acute-care hospital practice. However, more than 50 percent of nurses now work outside the hospital setting. With an aging population, more nurses will be needed for staffing and upgrading the quality of long-term institutional and home care. Likewise, community health care and school nursing have become more important as more of the population is underinsured or uninsured. Placements in such settings can have the added benefit of making the profession visible to a broader population of prospective students. Increasing the variety of clinical settings would also address a common student complaint: that clinical schedules are not announced well in advance and often involve long student commute times to clinical placements and variable and unpredictable hours that make it difficult to coordinate school, work, and family responsibilities. Although it is difficult for school administrators to predict clinical site availability, every effort must be made to set student schedules as far in advance as possible. We recommend flexibility wherever possible in helping students find clinical sites and schedules that accommodate their home and work life.
9. Preserve postclinical conferences and small patient-care assignments. When students have the opportunity to reflect on their clinical experiences, the power of experiential learning increases. Students need time to reflect on their care of patients, and the postclinical conference is an ideal time for that reflection. We observed many conferences focused on continuous improvement of care provided. As they continued the situated coaching that they had used while the students were with their patients, the teachers guided the students in developing a sense of salience, using knowledge in clinical situations and taking action steps related to knowledge and skills.
We noted, also, that students are better able to reflect on their practice if they care for only one or two patients at a time. We found that the patient assignments given to students strongly influenced their ability to reason on behalf of and solve problems with their patients. Students also highly valued their smaller patient-care assignments of one or two patients. They explained that they could get to know their patients, develop their relational and communication skills, and increase their understanding of the patient’s experience.
Even so, pressure from employers mounts, and many programs operate on an untested assumption that handling larger patient care loads will make the students more efficient on graduation. We believe that larger patient-care assignments, and the attendant cut in time for learning and reflection, will contribute to gaps in the student’s understanding of the nurse-patient relationship and communication. Moreover, few schools have clinical curricula that allow students to follow patients and families across time and institutional settings. Students thus focus on acute and episodic assignments in hospital settings, caring for patients over one or two days.
We recommend small patient-care assignments of one to two patients at the start of each new clinical rotation. In addition to the experience of providing total patient care, we recommend that students have the opportunity in each specialty to work with nurses with such clinical specialties as infection control, quality and safety improvement, and discharge planning.
10. Develop pedagogies that keep students focused on the patient’s experience. We recommend teaching medical pathology and disease mechanisms in direct association with patients’ illness experiences, psychosocial aspects of illness, patient and family coping, and teaching of self-care.
Attendant to this approach would be support for teachers to learn to scaffold their course around patient care. Examples of pedagogies are simulation exercises, the unfolding cases that Lisa Day uses in her class, narrative structures for making a case, and interviews of patients in class. Whether during a simulation nurse educators use expensive mannequins, or simply a few props to mimic a clinical situation, they have the luxury of being able to start and stop it. They can then pose questions to students, ask them to think about clinical puzzles, or discuss rationales for treatment in more detail than is appropriate while caring for patients. By coaching students to focus on actual patients in specific situations, teachers give students the opportunity to rehearse aloud or in writing the appropriate care of communities and patients and their families. It is important to keep in mind though that the ability to stop and start the exercise is at odds with actual clinical situations. In short, it can be difficult for students to be fully engaged when a simulation stops and starts. It can also be difficult for many to engage in solving clinical puzzles with a mannequin. We recommend that during simulation exercises, as Lisa Day does, the nurse educator return often to the experience of the patient and the patient’s responses to therapies.
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