1/9/17

The Preparation of Nurses to Enter Complex Practice



The unprecedented need for more nurses has led to an examination of the state of nursing education in the nation. This article will present several recent views that discuss both the need for a greater number of nurses and increasing the quality and relevance of nursing education.

A number of factors are preventing nursing education from reaching its full potential.  Nursing education has not changed significantly in the last half century. Clinical training availability is of paramount concern. RNs typically have little financial incentive to leave clinical nursing to become instructors. Half of all present faculty will retire within this decade. They are not being replaced at the same rate and yet there will be a need for even more instructors quite soon.

It has been suggested that the many ways to enter nursing does not encourage enough graduates to continue on past the ADN or BSN therefore missing the opportunity to become instructors.  Without faculty, potential applicants will not become nurses. Unfortunately, many thousands of applicants are turned away yearly.  How to correct this situation?

In Educating Nurses A Call for Radical Transformation Patricia Benner set out to investigate present nursing education with this question: Are nurses graduates adequately prepared to practice to their maximum potential? The answer she found was no. There were strong points in present nursing education but areas where changes could be made. This is not entirely because of any shortfall of nursing education. There are pressures, challenges, and issues that place unprecedented demand on the nursing profession. Many of them originate outside of the nursing profession.

The first challenge is the state of professions in general. The author mentions that one hallmark that distinguishes professions from other career paths is it’s sense of social responsibility. Professions must advance society’s good. Yet in recent decades society and therefore the professions have placed more of an emphasis on technical knowledge and adherence to the business model. Health care professions and nursing have not been immune to this philosophical shift in the professions. Nurses must often feel caught between their core values and fulfilling the bottom line, especially given that much of health care in the nation is private and for profit.

The turmoil in the health care system does not create the ideal environment for nurses to be adequately prepared on graduation. Turmoil and change can often result in philosophies that deal with crises in a short term way, often sacrificing long term vision as a result. For example the enormous need for more nurses puts pressure on educational institutions to lower admission requirements and to fast track students to achieve the numbers over quality. That urgency will only increase this decade, so nursing education needs to transform as Benner stated.

What does this transformation look like? She emphasizes the importance of integration of the 3 foundations of nursing education.

All three foundations must be integrated and not taught in isolation. The first foundation is nursing knowledge and science. Yet the acquisition of knowledge is not the end goal. Learning must be experiential, situated coaching in a community of practice. She stresses clinical reasoning and teaching for a sense of salience which she describes as gauging what is important to know and do for a patient and his/ her particular situation. It is knowing how to use the knowledge the student has acquired. Health care is unpredictable and open ended so the student must be able to evaluate what is the best course of action. She cites 2 examples of this from her interviews with instructors:

The student didn’t realize that 7 days was too long for a patient with an appendectomy to be in hospital. So they examined the patient and took a better history. Although they looked at the report it wasn’t as thorough as it could be; it did not provide any clues. Through investigation they discovered gangrene in his colon; that was why he was there so long.

In her second example a supposedly stable patient was deteriorating rapidly. Yet the staff nurse responsible for the patient did not think the changes warranted action. The instructor insisted the patient should go to ICU. She engaged the student by asking her What one test could we do to prove the deterioration? They decided on the blood gasses test which was done immediately. The test showed the patient needed to go to ICU.

 The last pillar is ethical formation and ‘comportment’. Formation involves looking beyond technical skill of the profession to the moral content eg obligations and demands which involves character formation. For instance when students see less than ideal practice that involves nurses treating patients badly how does one deal with that as a nurse?  How does a nurse help peers look at their practice to make positive change? Is that possible when in the beginning one doesn’t have institutional authority? Can a nurse help make changes in the professionalism of their peers? What about when a patient refuses a simple life prolonging intervention?

At present only around 20% of ADN graduates go on to the BSN. This is in part due to the time it can take to get any degree, which is time taken away from work and family. The goal of articulated programs is to streamline the process from ADN to BSN and beyond.  Regional innovations in nursing education are addressing this challenge. One of them is the Oregon Consortium of Nursing Education. Schools in Oregon have partnered to first of all envision the type of nurse that the population would need. Building on this vision they created a common curriculum and share resources. The consortium is committed to ongoing faculty development. City University of New York has received a Robert Wood Johnson Foundation grant for their program.

Because nursing practices in the space between medical diagnosis /treatment and the patients experience of wellness and illness a nurse requires both technical knowledge and expert relational skills. The education of nurses must prepare them to be lifelong clinical learners.

As one student said: “I have the honor of being present with and learning from patients in intimate, vulnerable, scary situations. I get to regularly advocate for the underserved in the hospital setting. I have access to environments I would otherwise never been exposed to, I have learned, grown and broadened my world perspective. I better understand how our system works and hope some day this knowledge will help me make changes in the system.”

Health care systems and society must recognize that improving education of nurses is a high priority. But nurses must take the initiative if they do not.

Educating Nurses: A Call For Radical Transformation. P Benner et al. The Carnegie Foundation for the Advancement of Teaching 2010 Jossey Bass