A Summary of the February 2010 Forum on the Future of Nursing: Education (2010)

The topic “Where to Teach” in nursing education inevitably overlaps with the previous armchair discussions that explored the topics “What to Teach” and “How to Teach,” said Jennie Chin Hansen, senior fellow at the Center for the Health Professions of the University of California–San Francisco, and 2008–2010 president of AARP, who moderated the third armchair discussion at the forum. Schools and educational programs operate in dynamic environments with a variety of factors that define and shape the education of nurses and health care providers across the nation. Few medical or nursing schools can be created from the ground up, meaning that institutions inevitably need to deal with existing structures—both physical and administrative—and cultures. At the same time, job demands, institutional resources, and available technologies are constantly changing and influencing the direction of nursing education. Meanwhile, cities and states need to plan for their own futures and identify the health needs of their populations, which means that educational and health care institutions become economic and civic concerns.

Led by Chin Hansen, this armchair discussion included insights from four experts in nursing education: Dr. Willis N. Holcombe, chancellor of the Florida College System; Catherine Rick, chief nursing officer for the Department of Veterans Affairs; Dr. Christine A. Tanner, A. B. Youmans-Spaulding Distinguished Professor for the School of Nursing at the Oregon Health & Science University (OHSU); and Rose Yuhos, executive director of the Area Health Education Center of Southern Nevada. The armchair discussion examined several unique, successful models of nursing education that have transcended traditional classroom models of education. Discussants also identified a number of unresolved questions. As Chin Hansen said, quoting a speaker from the

first forum on the future of nursing that focused on acute care, “the future is here, it’s just not everywhere.”

One of the most pressing challenges facing the nursing profession is how to prepare nurses who can be responsive to emerging health care needs and practice in the rapidly changing health care environment, given that the capacity of the education system is limited by faculty shortages and lack of clinical training sites, Tanner said. The state of Oregon has taken an innovative approach to nursing education by not focusing exclusively on the degrees that nurses should earn, Tanner noted. Instead, the state has framed its improvement efforts in nursing education around the competencies that nurses need to practice effectively and the capacity required to educate these nurses. To achieve these overlapping goals, the Oregon Consortium for Nursing Education (OCNE) was established in 2001. The consortium consists of eight community colleges and five campuses of OHSU.

To establish a common education base, the consortium faculty created a shared nursing curriculum that is used on all participating community college and OHSU campuses. The curriculum redefines the fundamentals of nursing to reflect health promotion, evidence-based practice, clinical judgment, relationship-centered care, and leadership. The competencies that are integrated into the curriculum were identified based on an analysis of emerging health care needs and alternative scenarios of how the practice of nursing could change to address those needs. For example, the curriculum includes two courses in the management of chronic illnesses, reflecting the changing demographics of Americans and the need to help students gain competencies in those areas. The curriculum also has an integrative practicum that was developed to provide a better transition to practice for nursing students.

When accepted into the OCNE program, students are co-admitted into both the associate and baccalaureate degree programs. This provides a seamless transition for students who start the program in a community college and move into the baccalaureate program at the university. “We

are trying to eliminate every barrier to students continuing for a bachelor’s degree,” said Tanner. The curriculum is viewed as a continuous course of study that students can complete in 4 years.

In addition to the shared curriculum and co-admission, the OCNE program features shared instructional resources, faculty who teach across campuses to maximize use of available expertise, and continued innovation in classroom and clinical instruction, said Tanner. The consortium is committed to incorporating best practices into teaching and learning throughout the curriculum. It is creating a new clinical education model that integrates simulation throughout the education of nurses. “We are rolling that [model] out on four of our campuses and evaluating the outcomes,” Tanner noted.

Tanner offered three recommendations for the committee’s consideration:

• Create new nursing education systems that use existing resources in community colleges and universities and provide for common prerequisites, a competency-based nursing curriculum, and shared instructional resources;

• Convene one or more expert panels to develop a model prelicensure curriculum that can be used as a framework by faculty in community college–university partnerships. This model prelicensure curriculum should be used as the basis for local curriculum, be based on emerging health care needs, incorporate widely accepted nursing competencies, as interpreted for new care delivery models, and integrate best practices in teaching and learning; and

• Invest in a national initiative to develop and evaluate new approaches to prelicensure clinical education, including a required postgraduate residency under a restricted license.

The state of Florida has identified three workforce shortage areas where it is not producing enough graduates to meet growing demands within the state: teaching, nursing, and applied technology, Holcombe said. In 2009, the Florida legislature questioned why the Florida College System¹ could not help close workforce gaps by going beyond associate degrees to produce graduates with baccalaureate degrees in the defined shortage areas. The system, which is made up of 28 community colleges, has responded to this challenge. So far, 14 of the 28 community colleges in the Florida College System have been given the authority to grant baccalaureate degrees, 9 of which are now granting baccalaureate degrees in nursing (B.S.N.s).

Establishing baccalaureate degree programs within the community college system required significant collaboration among institutions within the public university system, Holcombe noted. Universities and private colleges in the state have an opportunity to weigh in on proposals made by the community colleges in generating new baccalaureate degree programs. As new programs are instituted, the feedback process has provided collaboration beyond the faculty level to the overall higher education system in Florida. “If there is not collaboration and dialogue, the program does not go forward and does not get approval,” he said.

Florida must continue to build on its associate degrees in nursing (A.D.N.) programs as a base because of the state’s acute nursing shortage, Holcombe stated. If new competencies must be mastered by nurses, then the curriculums of the A.D.N. programs must be revised to incorporate these new expectations. More than two-thirds of nurses in Florida come through associate degree programs, so the colleges are expanding these programs even as they begin establishing their baccalaureate degree programs.

During his remarks, Holcombe offered two recommendations to the committee in terms of advancing education and advancing nurses within the education pipeline to achieve higher levels of competence and education:

• Include associate degree nursing programs in the dialogue about “What to Teach” so that new competencies are incorporated into all nursing education programs; and

• Increase the emphasis on creating opportunities for educational advancement from A.D.N. to B.S.N. to M.S.N. and beyond. These opportunities should be widely available, collaborative among institutions including both community colleges and universities, and technologically sophisticated.

The Veterans Health Administration under the Department of Veterans Affairs (VA) has four key missions: providing clinical care, educating and preparing health professionals, researching across the continuum of scientific endeavors, and providing backup for the Department of Defense in areas such as emergency preparedness. All four of those goals require having great talent in the VA system, said Rick.

The integrated VA health care system provides a full range of services across the care continuum, including acute, primary, home health, and long-term care and telehealth services. The system has more than 75,000 nursing personnel, including more than 55,000 Registered Nurses (R.N.s). These nurses fill vital roles, including leadership positions, staff clinicians, clinical nurse leaders, nurse informaticians, clinical nurse specialists, and nurse practitioners. Approximately 22,000 of these R.N.s are eligible for retirement in 2010, Rick said.

To identify and meet its human capital needs, the VA Office of Nursing Services developed a national nursing strategic plan in 2000 that emphasized career development and workforce management. In 2002, a

2-year external commission on the future of nursing at the VA, chaired by Linda Burnes Bolton, recommended that the VA establish a nursing academic model similar to its medical academic model. A model of this type would promote VA partnerships with the academic community to leverage available resources, increase research within VA practice settings, and realize the potential for enhanced recruitment and retention. In 2005, the VA began an early initiative to respond to the commission’s recommendation to develop academic-practice partnerships and recognize the need for faculty development. The program was called TEACH (Transforming Educational Affiliations for Clinical Horizons). It offered small block grants to VA health care facilities to create innovative partnerships with academic affiliates.

Building on the TEACH program and the promise of academic-practice partnerships, the VA launched the VA Nursing Academy (VANA) in 2007. VANA is a 5-year, $40 million pilot program. Its primary goals are to develop partnerships with academic nursing institutes, expand the number of faculty for baccalaureate programs, establish partnerships to enhance faculty development, and increase baccalaureate enrollment to increase the nursing supply, not solely for the VA, but for the country at large. It also was aimed at encouraging interprofessional programs and increasing the retention and recruitment of VA nurses.

The program has been in place for 2.5 years; in that time, three cycles of requests for proposals were sent to more than 600 colleges and schools of nursing, as well as to institutions within the VA system. Fifteen geographically and demographically diverse pilot sites were selected to participate in VANA based on the strength of their proposals, Rick noted. The third cycle of requests also emphasized creating a cohort of smaller facilities because they were not competing in the program as well as the highly academic, urban universities and institutions.

Each funded VANA partnership is required to have a rigorous evaluation plan to measure outcomes, Rick explained. Outcomes observed by the partnerships are expected to include increased staff, patient, student, and faculty satisfaction; greater scholarly output; enhanced professional development; better continuity and coordination of care; more reliance on evidence-based practice; and enhanced interprofessional learning. Each selected school is also expected to increase enrollment by at least 20 students a year.

The initial evidence regarding faculty recruitment and retention has been “very positive,” Rick said. She highlighted a number of innovative strategies that have been implemented across VANA partnerships. Faculty have been embedded within designated educational units, commonly referred to as DEUs, to work on evidence-based practice projects. Advanced residency and internship programs have been developed and implemented, and institutions have developed clinical nurse leader programs. Adjunct VA faculty have been added as guest lecturers, instructors, and researchers, and students have been given new clinical opportunities.

Altogether the program has resulted in 2,700 new students, with 620 receiving the majority of their clinical rotation experiences at the VA, Rick said. The number of nursing school faculty has increased by 176, and the number of VA faculty by 264.

In her concluding remarks, Rick offered the committee recommendations for advancing nursing education. Educational programs must prepare nurses for varied levels of complex roles, with degree-granting strategies designed to address defined competencies and parity with partners in health care teams, said Rick. Growing evidence points to improvements in efficiency and effectiveness related to nursing practice that supports master’s-prepared nurse clinicians at the point of care and doctoral preparation for advanced practice roles.

Academic-practice partnerships that increase the numbers of clinicians who teach and the number of faculty who practice are essential to meeting the educational needs of nursing. This may require restructuring of accreditation standards or legislated incentives, Rick said. Such part-

nerships should include internships and residencies that provide appropriate clinical experiences, with defined structures for instruction that align practice and academic approaches for all levels of nursing in wide-ranging roles and settings.

Area Health Education Centers (AHECs) link communities with academic and nursing practice by developing clinical rotation experiences for students, said Yuhos of Southern Nevada’s AHEC. These centers are distributed throughout the nation and have traditionally been funded and operated through medical schools. However, in states without medical schools, health science institutions are beginning to apply for and develop AHEC programs. The centers have developed their clinical practice model around a medical education model, but are moving toward a clinical practice model that is more community focused. This shift and additional involvement from other disciplines, such as nursing, have fostered a move toward interdisciplinary training experiences for a broad array of health science students.

Yuhos described an AHEC system in Nevada that had created an interdisciplinary training experience in which teams of students participate in case-based learning that focuses on providing patient-centered care. This AHEC is in a rural ambulatory clinical setting that provides students with an opportunity to work in a resource-scarce environment. Teams are encouraged to use innovative techniques that stretch the boundaries of the team to include the community, Yuhos explained.

In the AHEC training environment, students have an opportunity to represent their discipline while participating as active members and leaders of teams. For many students, these are new and different experiences. For example, in some cases nursing students are given an opportunity to lead a team, while medical students play more of a supporting role. These opportunities help students learn about the dynamics of working in interdisciplinary teams and provide them with competencies in leadership and team support, which are not traditionally taught. Participating in a collaborative team also allows students “to appreciate the diversity of

what each discipline brings to the team and to the concept of care for that patient or that community,” Yuhos said.

At the same time, faculty who participate in the AHEC model become more clinically experienced and benefit from providing students with training experiences in interdisciplinary teams. The AHEC model creates an environment where faculty need to work across disciplines to design unique experiences and programs that feature their own discipline as well as others.

In the future, clinical simulations will play an important role in the development of skill-based training for students, Yuhos said. “But I firmly believe that it is, and always will be, important to get the student in the community, so he or she can experience community dynamics that they can’t experience in the sim lab,” she said. Future nursing education in the future will occur in both the sim lab and the community. Students should be in the community, working with families and learning about the socioeconomic, cultural, and ethnic dynamics of families. The community has to be an important part of each student’s experience, Yuhos concluded.

Yuhos had two recommendations for the committee to consider in regard to enhancing nursing education through the use of interdisciplinary collaboration:

• Identify and promote evidence-based clinical training models that include nursing students as part of the interdisciplinary team; and

• Identify and promote evidence-based interdisciplinary faculty development and clinical training models that include nurses as part of the interdisciplinary team.

During a brief question and answer session with the committee, the discussants focused on advancing interprofessional education. Tanner and Rick concurred that interprofessional education is a valuable aspect of nursing education. Tanner said that successful interprofessional education requires a strategic initiative that has both grassroots support and support from university leadership and administration. She noted that a great deal of grassroots work has been done with regional Oregon AHECs to establish interprofessional clinical experiences for health professional students in rural settings. It is very important that students across the state have an opportunity to work collaboratively, no matter where the setting is located.

Rick noted that the VANA program includes interprofessional collaboration as part of its scoring criteria for selection of its partners. She noted that bridges need to be built to overcome some of the challenges and culture differences that have been experienced between the practice and academic communities, as well as across the different disciplines. Rick described one of the promising models that had been featured as part of a possible pilot; the model included nurses as formal preceptors for medical students. She said interprofessional collaboration is ingrained in the vision of the VANA program, and perhaps one day the nursing academy could instead be called the interprofessional academy.