Rising to the Challenge of Nursing Education
Submitted by Beth Kalkman, MSN RN, RNC-OB
In 2010, the Institute of Medicine (IOM) published its report, The future of nursing: Leading change, advancing health. In it, the IOM praised the important role nurses play in providing care in both the acute and community setting (Institute of Medicine [IOM], 2010).Nurses have been instrumental in a number of improvements evident in healthcare such as shorter lengths of hospital stays, access to healthcare for underserved communities, and improved safety initiatives within healthcare settings (IOM, 2010). Furthermore, nurses provide knowledgeable and appropriate care across the life span, and they do so in a way that addresses the unique need for connectedness that is inherent to all members of the human race (Touhy, 2008). One reason nurses are so valued is because they care (Cappabianca, Julliard, Raso, & Ruggiero, 2009).
Now, as healthcare continues to advance in its complexity, nursing educationis faced with preparing competent novice nurses who, in response to rapid change and increasing technology, are ready to function andprovide exceptional care within a challenging healthcare system. To meet this expectation, nurse educators need to look for innovative strategies to address existing and potential issues in nursing and nursing education. This paper will discuss the changing nature of nursing education and make two recommendations for how the role ofnurse educator can evolve to effectively prepare students for their future inhealthcare. Information from relevant theory, research, and literature will be presented to support these recommendations.
A Shortage of Faculty, Space, and Money
As documented by Benner, Sutphen, Leonard, & Day (2010), there has been an ongoing nursing shortage since the late 1990's. Concomitant with this has been a national shortage of nursing faculty, clinical sites, andfinancial resourcesneeded to address the call for more nurses(Benner, Sutphen, Leonard, & Day, 2010).Despite the IOMs (2010)proclaimed desiretoincreasethe number of nurses entering the workforceand to alsoattain highereducationfor existing nurses, little has been done to effectively address the deficits in keyresourcesneeded for nursing education. These issues haveremained essentially uncorrected for over twenty years. At the same time, throwing money into a broken system does not change the fact that the system is, in fact, broken. As Oermann, Yarbrough, Saewert, Ard, and Charasika (2009) state, "The obligation to move more students into and through nursing programs must be balanced against the obligation to assure the public that nursing graduates are safe and competent to enter practice" (p.352). A sudden influx of money alone, will not guarantee that this obligation is met. Withoutsignificantly increasingthe number of available nursing faculty, increasing the number of qualified nursing graduates is almost impossible(Kowalski & Kelley, 2013). Likewise, without classroom space to accommodate students, more students cannot be educated. In other words, there can't be an increase in the production of nurses without a more formidable production plan.
Creating a More Formidable Production Plan-The Faculty
According to the National League for Nursing's Top 10 List of reasons for becoming a nurse educator, the number one reason to pursue a career in nursing education is to "teach what you love" (National League for Nursing, 2011, p. 1). However, despite many graduate schools offering Master of Science in Nursing (MSN) degrees with an emphasisin nursing education for those who desire to teach, the debate related to who should teach in academia seems to revolve around the Doctorate of Nursing Practice (DNP) or the Doctorate of Philosophy (PhD) in Nursing. Neither of these degrees professes teaching as their primary motivation for higher education; the PhD traditionally focuses on research, while the DNP focuses on clinical practice. In fact, Benner et al. (2010) question whether either terminal degree demonstrates that an individual is adequately prepared to teach. Furthermore, according to Finke (2012), the AACN verbalizes the need for more nurses trained at the doctoral level not to teach as one might suspect, but in orderto perform more research and to analyze current issues and trends in healthcare. This request, then, does not address the need to produce more entry-level nurses. The MSN who, on the other hand, has declared a desire to teach is often left out of the conversation (Brar, Boschma, &McCuaig, 2010). As the nursing faculty shortage indefinitely continues, all three degrees should not only be welcomed, but desired in academia.
Boyer's Definition of Scholarship
When considering nursing education and the appropriateness of the MSN or doctoral degrees for academic faculty as described above, one is quickly reminded of Boyer's (1990) proposed definition of scholarship (Finke, 2012). His definition promotes discovery, integration, and teaching as all viable expressions of scholarship; not one more significant than the other.Each of thethree attributes described by Boyer poignantly points to one of the three higherdegrees in nursing: Discovery connotes the PhD's focus on research; integration suggests the DNP's emphasis on clinical practice; and, teaching (for some) implies the MSN. Perhaps, these degrees should be thought of as complementary, not competitive. Working collectively,nursing faculty with expertise in the various forms of scholarship can comprehensively address the broad knowledge base needed by future nursing students.
Taking a Cue from Other Areas of Education
One of the reasons often cited for needing preparation beyond the MSN for teaching in nursing is that without a doctorate, the educator is essentially teaching future nurses from his or her experience (Bartels, 2007). Without offending my colleagues who have attained their terminal degree in nursing, it is important to note that in the elementary, secondary, and collegiate setting of the United States educational system, there are varying levels of preparation for the teaching role. To teach kindergarten through 8th grade, a generic 4-year education degree suffices; to teach at the secondary level, teachers are required to claim a major(s) for additional focus and complete a 4-year education degree or possibly a master's degree; and, at the collegiate level, teachers are required to have a master's or doctoral degree in order to teach (Calvin College Education Department [Calvin], 2013).
While this comparison may be seen as an over-simplification of the preparation required to educate future nurses; at the same time, graduates of baccalaureate nursing programs only demonstrate a "minimal level of competency" by passing the NCLEX exam (Long, 2004, p. 48). They don't demonstrate an ability to perform quality research and they don't exhibit, for example, the ability to run a full code on a patient suffering from Malignant Hyperthermia or thoroughly explain what the syndrome entails. Their acquired learning is only the foundation for the knowledge they will need to pursue throughout their nursing career.
In some ways, preparing baccalaureate nursing students for entrance into practice is akin to preparing secondary education students to pass college entrance examssuch as the ACT or SAT in preparation for college. These tests measure a student's readiness for college. The NCLEX measures a graduate nurse's readiness to perform basic nursing. It is conceivable thattheeducational preparation necessary for nursing faculty can be based upon the educational pursuits of nursing students.Certainly, nurses seeking to perform research or to practice at an advanced level should be taught by faculty whose focus is on research or advanced level practice. To meet the IOMs (2010) plea for more nurses at all levels of practice, however, we need to show innovation in our approach to nursing preparation.
To emphasize the point of creating a good skill mix in academia, let me share from my personal experience. As I prepared for the 300 hour practicum required for the MSN degree through Ferris State University (Ferris State University School of Nursing [FSU SON], n.d.), I met with my selected preceptor at Grand Valley State University. She holds her PhD in Nursing and wrote a dissertation entitled "Cortisol and Estradiol Circadian Rhythms in Healthy Women"(Kalkman, 2013, p. 11). She is without a doubt, a brilliant individual. When I discussed with her my educational goals related to the National League for Nursing's (NLN) (2005) core competencies for nurse educators, however, her response was, "Well, OK. But you know, my focus is on research. I was hoping you could help me with some of that" (K. Butler, personal communication, July 10, 2013).
The ability to teach should not be presumed by one's intelligence, just as bearing a title of leadershipdoes not guarantee one's ability to lead. As stated by Siela, Twibell, and Keller (2009), "Clinical expertise is a necessary, but not sufficient, criterion for teaching nursing students. . .Just as there is evidence required for clinical nursing practice, evidence also guides the teaching practices of faculty members" (p.20). My preceptor and I both recognize the reciprocity in our relationship. Each of us has something to learn from--and provide to--the other.Given the opportunity, this may be found true in the larger scope of academia. Not only can we benefit from each other, but we can enrich the academic environment in which we are teaching.
While securing funding for nursing education may be a difficult endeavor, increasing the number of qualified nursing faculty may be achievable if arguments related to the appropriate degree necessary for teaching are replaced instead by the assessment of one's ability to teach. Before turning down a candidate because he or she has an MSN instead of a DNP or PhD, the person's capability as an educator should be evaluated. Promoting quality education versus faculty titles will, in the long run, more readily address the nursing shortage and the nursing faculty shortage. As a nurse educator, I will strive to advance all levels of nursing education.
Creating a More Formidable Production Plan-The Facilities
In the early 1900's, Maria Montessori abandoned a career in medicine to instead develop an alternative method of childhood education involving learning through "play" (Lillard, 2013). In this approach to learning, students are active participants in choosing what and when to learn. Naysayers to this type of education site classroom chaos and a limited number of students for whom this style of learning would be effective as barriers to adopting this strategy;but,in reality, the Montessori method has proven effective for a broad scope of children and has imbedded within its approach a very subtle, but firm, educational structure (Lillard, 2013).
The Montessori method professes to prepare students to "develop creativity, problem solve, critically think and develop time-management skills, care for the environment and each other, and contribute to society" (The International Montessori Index [Montessori], 2013, para. 1). Many of these outcomes resonate with the ANA (2010) Scope and standards of practice for nursing. For example, Standard 16: Environmental Health: "The registered nurse practices in an environmentally safe and healthy manner" (ANA, 2010, p.61); and, Standard 10: Quality of Practice: "The registered nurse uses creativity and innovation to enhance nursing care (ANA, 2010, p.52), both echo the rudimentary concepts of Montessori's teaching. As concern for the nursing faculty shortage and limited space for nursing education continue, it is time to learn from innovators like Maria Montessori and reimagine the environment and methods by which we educate future nurses.
Originally, nurses' training programswere housed within hospitals. In that setting, students learned by doingat the bedside and nursing instructors were expected to not only teach,but provide nursing care to patients when they themselves were not teaching (Finke, 2012).Beginning in the early 1900's, nursing education migrated outside of medical institutions to instead become housed in universities and colleges (NLN, 2005). With this move, the role of nursing faculty dramatically changed as well as the method by which student nurses were taught (Finke, 2012).
Today, nursing students divide their time between the didactic classroom, skills laboratory, and various clinical settings.The purpose of classroom instruction is to provide the foundational knowledge necessary to develop critical thinking; the purpose of the skills laboratory, to provide a safe environment for applying newly acquired knowledge to situations prior to performing them in "real life"; and, the purpose of the clinical setting is to put one's knowledge into action (Bradshaw & Lowenstein, 2014). Asignificant decline, however, in the number of suitable clinical sites for students is causing a need for increased utilization of the classroom and further integration of learning through simulation(MacIntyre, Murray, Teel, &Karshmer, 2009). And, as stated before, classroom space has been--and still is--a precious commodity. Furthermore, one of the concerns with a disproportionateamount of classroom instruction versus clinical time is the perpetuation of the existing theory-practice gap(Benner et al., 2010).
Despite the significant contribution simulation has provided in nursing education, nursing students still need the opportunity to integrate nursing theory into practice (MacIntyre et al., 2009). The most appropriate way to achieve this is through providing nursing care. For example, one cannot fully embrace Jean Watson's (1979) theory on human caring without caring for humans (Watson Caring Science Institute & International Caritas Consortium website, n.d.), nor can a student understandBandura's (1977) theory of self-efficacy as it applies to patients without interacting with patients (Peterson &Bredow, 2013). Bandura's theory is also applicable to students themselves in the clinical setting, as they engage in new experiences and discover they have the capability to perform and master essential nursing skills. All of this requires exposure to, and increased opportunities in, the clinical environment.
The Clinical Setting
As stated earlier within this paper, formal nurses' training originated within medical institutions where students of all levels of education were responsible for ongoing patient care. Today, however, student nurses' experience within the healthcare system has been reduced to a limited number of clinical hours with minimal exposure to patients and hands-on care (MacIntyre et al., 2009). While there are a number of reasons for the reduction in clinical opportunities, neither of these two approaches--full responsibility or primarily observation--provides adequate teaching and learning opportunities.
The healthcare environment.The increasing complexity of healthcare and the advancing technology within health systems makes the clinical environment a dynamic workplace. It can also, however, lead to less than desirable opportunities for novices who have a limited amount of time to familiarize themselves with an organization's practices and procedures (MacIntyre et al., 2009). In West Michigan alone, there are at least 5 schools of nursing, all of which require clinical placements for students. This need has led to the development of a nursing school consortium which meets during the summer to diplomatically determine which schools will utilize what hospitals and when (K. Butler, personal communication, October 24, 2013). The ongoing demand for clinical sites means nursing units are seldom without one, if not two, simultaneous clinical rotations. And, as pointed out by MacIntyre et al. (2009), "The priority for staff nurses is patient care, with student learning a secondary concern" (p. 448). In order for students to garner benefit from clinical rotations, they must have adequate time and exposure to first acclimate to the healthcare environment and thenapply theory to practice.
Attitudes of Staff Nurses. In a study conducted to describe the attitudes of staff nurses towards students,Hathorn, Machtmes, and Tillman (2009) reporta negative perception of nursing students by staff nurses. Staff nurses expressed feelings of increased workload, poor communication between the students and themselves and the students' instructor and themselves, and increased strain related to assuring quality patient care (Hathorn, Machtmes, & Tillman, 2009). These results are substantiated by a survey conducted on nursing students in which students perceptions of the staff/student relationship were measured. As documented by Benner (2009), "Students reported they were unwelcome and disparaged in a number of hospital settings" (p. 207). Creating effective relationships between staff nurses and nursing students is imperative to promote a welcoming environment for the next generation of nurses.
To highlight the perceived incivilityof healthcare and academia towards nursing students, I want to share some of my own experience during the MSN practicum. Although appropriate measures were taken to establish a relationship with an identified preceptor, once at the educational institution, I was told that due to being neither faculty nor student of the institution, I would have no parking pass, no ID badge, and no computer access by which to function in the university setting. Furthermore, upon arrival at the clinical site, I was also declined access to resources that would have made my interaction on the unit with students more successful because, again, I was neither academic faculty nor employee of the clinical site. Therefore, just as student nurses find themselves limited related to what they can and cannot do within the clinical setting, I found myself frequently road blocked related to performing the educator role. I, however, have the benefit of a 300 hour practicum by which to eventually prevail. Many student nurses, as of yet, do not have that luxury.
Students need to have extended exposure to, and participation in, the dynamic clinical setting. Experiential learning as described by Kolb (1984), requires time to allow for complete cycles of learning acquisition. To make this happen, innovative collaboration between healthcare systems and nursing institutions needs to occur.Several authors encourage rethinking the clinical experience, and nursing education in general, to provide more practice in the increasingly advanced and technologically challenging healthcare environment. As a nurse educator, I will incessantly work toward providing optimal learning experiences for my students.
Enlisting Staff Nurses
MacIntyre et al. (2009) recommend pairing individual students with staff nurses for an entire term rather than employing the traditional model of clinical rotations where students are exposed to a nursing unit for only a brief period of time. Didion, Kozy, Koffel, and Oneail (2013) discuss a similar innovation in which students remain at one clinical site for 15-30 weeks rather than shuffling from one clinical experience to the next. In this way, students develop a sense of the full scope of responsibilities of the professional nurse, rather than focusing on the care of one patient in one setting for a very short time (MacIntyre et al., 2009).Furthermore, students can acclimate to a specific environment and participate more fully in the procedures and/or technology utilized within that setting. They can engage in advancing care provision as their comfort level develops. Finally, by pairing students with individual nurse preceptors for extended periods of time, a relationship of trust and communication can be fostered between the two nurses.
Incentives. To promote staff participation in the training of student nurses, incentives will need to be available. As stated earlier in the paper, staff nurses express a notable increase in their workload when teamed with student nurses (Hathorn et al., 2009). Providing an incentive, such as meeting an expectation for advancement on a clinical ladder system or providing a minor hourly wage increase, may alleviate the strain placed on potential preceptors. Incentives may also help to recruit more staff to the preceptor role.
Training.Individuals identifying themselves as potential preceptors should receive training to enhance the preceptor/preceptee relationship (MacIntyre et al., 2009;Didion, Kozy, Koffel, &ONeail, 2013). Potential preceptors must be able to properly socialize students into the healthcare setting and commit to practicing according to established standards. Clear understanding of the students' knowledge base and the school's expectations during the clinical experience must be discussed (Didion et al., 2013). A preceptor class designed to support the development of mentoring skills could be designed. These classes have been shown to increase the effectiveness of nurses assuming the preceptor role (Horton, DePaoli, Hertach, & Bower, 2012).
Ideally, nursing faculty should provide a facilitative role in this new clinical design. To do this, nurse educators must be credentialed not only in the academic setting, but in the clinical setting as well. For example, MacIntyre et al. (2009) point out that nursing faculty who bring students to their home unit or institutions have enhanced learning facilitation; relationships of trust between the faculty nurse educator and staff nurses already exist. Furthermore, the faculty member is well-versed in the institutions policies and procedures and can participate in clinical instruction as needed.
If a faculty member is assigned to a healthcare environment in which he or sheisnot already practicing, assistance should be giventosecuring an orientation to the site and in attaining the credentials necessary to function in this new location. As Benner (2009) states, "If students and faculty are considered guests, students find being a legitimate member of a health team difficult" (p. 207). To support the students' experience, faculty must be able to fully function within the clinical environment (MacIntyre et al., 2009).
Despite ongoing recognition that more nurses are needed to address the healthcare needs of our nation, deficits in the numbers of nursing faculty, available classrooms, and financial support for nursing education continue to exist. Solutions to the problem extend further than simply throwing money into a broken system. Instead, efforts must involve innovative collaboration between educators with different levels of nursing degrees and partnerships between academic and clinical settings. Students must be provided with opportunities to close the theory-practice gap and staff nurses must be engaged to precept nursing students for longer clinical rotations. As healthcare continues to become increasingly complex and more technologically advanced, nurse educators must rise to the challenge of creating a system that produces qualified novice nurses who are ready to function and provide care in a challenging healthcare system.
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