The Future of Nursing Leading Change, Advancing Health (2011) / Chapter Skim
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I The Future of Nursing Education
I The Future of Nursing Education
Pages 477-564
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From page 477... ...
Inevitably, we kept coming back to the question: What would be useful to committee members who deserved a base for their deliberations that was focused and helpful? In the end, we decided that detailed descriptions of the current challenges and recommendations for the future of nursing education from two people were not the answer.
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• Competencies needed in new care delivery models − Population health and population-based care management (Tanner) − Care coordination (Tilden)
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− A llow community colleges to provide baccalaureate degrees (Dracup) • In post-graduate residency programs − Develop and test clinical education models that include post-graduate residency programs (Tanner)
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− Challenge current credit-heavy requirements and test teaching in novations that improve competence while reducing program credits (Gilliss) • Support the faculty development necessary to bring about the magnitude of reforms in nursing education recommended in the Carnegie study, necessitated by advances in nursing science and practice and guided by advances in the science of learning (Tanner)
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From page 481... ...
• Increase scholarships, loan forgiveness, and institutional capacity awards for graduate nurse education at master's and doctoral levels (Aiken, Dracup) • Redirect Medicare GME nursing education funds to support graduate nurse education (Aiken, Dracup, Tanner)
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From page 482... ...
• Use Perkins funds to incentivize community college nursing programs to increase the proportion of their nursing students who complete their initial education with a BSN (Aiken) • Increase programs that support greater production of nurse practitioners for primary care (and remove legal barriers to interprofessional educa tion and practice)
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From page 483... ...
Nursing, because of its versatility, has been an enabling force for change in health care along many dimensions including but not limited to the evolution of the high-technology hospital, the possibility for physicians to combine office and hospital practice, length of hospital stay among the shortest in the world, reductions in the work hours of resident physicians to improve patient safety, extending national primary care capacity, improving access to care for the poor and rural residents, and contributing to much needed care coordination for the chronically ill and frail (Aiken et al., 2009)
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From page 484... ...
At present comparative effectiveness research is more focused on drug and treatment intervention trials than on innovations in care delivery including workforce interventions. PRIORITY FUNDING TO INCREASE INITIAL BSN GRADUATES Every year the percent of new registered nurses graduating from associate degree programs increases, and it is now over 66 percent of all new nurse graduates.
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From page 485... ...
Secretary of Health and Human Services on nursing issues, urged almost 15 years ago that policy actions be taken to ensure that at least 66 percent of nurses would hold a baccalaureate or higher in nursing by 2010; the actual result is closer to 45 percent. As described in the sections below, growing evidence suggests that the shortage of nurses with BSN and higher education is adversely affecting a number of dimensions of health care delivery now and these problems will only become exaggerated in the future.
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. Increased use of advanced practice nurses is one of the very few practice innovations currently underconsidered in national health reform, including medical homes and chronic care coordination, that would yield net cost savings nationally according to Rand researchers (Hussey et al., 2009)
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What would be the expected yield in terms of nursing faculty that would be likely to obtain by increasing basic BSN education? To answer this we undertook an analysis of the National Sample Surveys of Registered Nurses over time to explore whether career trajectories of nurses with graduate education had changed over time.
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However, data suggest in the case of registered nurses that initial qualification for licensure at the associate degree level actually constrains educational and
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Coupled with increased funding for graduate nurse education, this could be an effective strategy for addressing the faculty shortage along with shortages of advanced practice nurse clinicians and administrators. IOM committee members in a previous discussion of this option asked what the yield would be for faculty positions in increasing baccalaureate graduates.
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Additionally, advanced practice nurses have enabled the largest expansion of Community Health Centers (CHCs) since the Great Society Program; CHCs currently provide over 16 million visits in 7,300 sites to largely underserved people.
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The percentage of registered nurses receiving training in associate degree programs was less than 2 percent in 1965 but is over 66 percent today. Baccalaureate nursing programs produced about 10 percent of new nurses in 1965, which increased to about a third of new nurses by 1980 and has been stable there for 30 years (Aiken and Gwyther, 1995)
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From page 492... ...
A high priority should be set on examining whether and how Perkins funds could be targeted to incentivize community college nursing programs to increase the proportion of their nursing students who complete their initial education with a BSN. There are numerous feasible strategies to do this including having community colleges offer the BSN as in Florida and other states as well as innovative partnerships with 4-year colleges and universities perhaps using state-of-the-art distance learning technologies supported by Perkins funding.
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: 1528-1532. Aiken L.H., et al., "Education Policy Initiatives to Address the Nurse Shortage," Health Affairs 28, no.
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The evidence of serious deficiencies in the performance of health care as a system is overwhelming and incontrovertible. It fueled the findings and recommendations of the landmark Institute of Medicine report, Crossing the Quality Chasm, in the year 2001, which claimed: "Between the health care we have and the care we could have lies not just a gap but a chasm" (IOM, 2001, p.
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Activities in health care policy, management, and payment have increased, with more or less coherence, in pursuit of those goals. Yet the response from health professionals (and the faculties who train them)
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to extend these ideas into all of nursing professional development is exciting. IHI's Open School for the Health Professions is an interprofessional educational community that helps students from all the health professions to acquire the skills to become change agents for health care improvement.
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Where "knowledge of systems" is less robust in the preparation of nurses (as well as most other health professionals) is in understanding the work of health care as a system.
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The task in modernization of nursing education is to generalize the pursuit of system knowledge into all that nursing is and does. Topics of relevance may include (a)
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System characteristics include, for example, waiting times and delays, rates of complication and outcomes of surgery and other interventions, infection, and mortality, patient satisfaction, costs and levels of waste and efficiency, safety levels and adverse events, and levels of variation in approaches to diagnosis and treatment. Many such measurements are appearing in new forms of accountability of health care organizations and professionals to payers, regulators, accreditation agencies, consumer groups, and licensing bodies.
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Individual nursing practice will, in that mode, include avid measurement and sophisticated interpretation to answer questions of the form: "How is our system doing at X, and what can the variation tell us about how to do better? " Measurement for improvement goes far beyond mere observation.
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, and proper change requires continual learning. A modern workforce, including modern nurses, is fully equipped to act as "scientists at work." When the nurse quoted at the top of this essay said, "I have two jobs: my job and improving my job," she was entering a world of continual trial and learning for both of those roles.
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These compose quality improvement projects. For a modern nurse, participation and leadership in such project work is the form taken of action based on "knowledge about how to gain knowledge." LEADERSHIP AND MANAGEMENT SKILLS The four areas of skill and knowledge explored above -- systems, variation, psychology, and epistemology -- compose a strong set of goals for modernized nursing education on behalf of quality improvement.
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2009b. Quality and safety education for advanced nursing practice.
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http://www.ihi.org/IHI/Results/WhitePapers/whitepapersindex.htm (accessed January 18, 2010)
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to end the bifurcation of nursing education between universities and community colleges and to ensure that graduation patterns did not result in a workforce with the majority of the country's nurses possessing the associate's degree as their highest level of educational preparation. Although features of each of Fagin and Lynaugh's (1992)
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From page 506... ...
predictions concerning the diminishing educational levels of the overall composition of the nursing workforce have come true. States invest in the above combination of nursing pre-licensure programs for many reasons, not the least of which are the lower costs in faculty salaries and student tuition/fees associated with associate degree programs.
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From page 507... ...
These graduates will expand the number of nurses in basic practice, but they will also address other critical needs, namely our shortages of nursing faculty and primary care advanced practice nurses. An additional benefit derives from the fact that students exposed to health care leaders at early stages in their career, as collegiate students are, are likely to become the nursing leaders of tomorrow.
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programs have been introduced, adding competencies related to organizational systems leadership for quality improvement, information systems and patient care technology, health care policy, interprofessional collaboration and clinical prevention for improving patient and
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feel tremendous pressure (whether or not they have the resources to mount quality DNP programs) to convert their master's or post-master's DNP programs to DNP programs that prepare NPs for entry into practice because of the American Association of Colleges of Nursing position statements on the DNP, as represented below: AACN members have endorsed the transition from specialty nursing practice education at the master's level to the DNP by the target goal of 2015.
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The irony is that the literature is replete with results of studies showing that the NP workforce, as currently trained, provides patient care of high quality. Pohl and colleagues (2010)
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of removing legal, regulatory, or reimbursement policy barriers to the ability of nurse practitioners to serve as primary care providers or leaders of patient centered medical homes or other methods of patient care delivery.
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To the point being raised here, the multiyear study concluded that there needs to be better integration of coursework with clinical experiences, so that coursework and classroom learning are tied to what actually happens in patient care rather than being studied in the abstract. Faculty, they argue, must help students make the connection between acquiring and using knowledge, so that students develop clinical reasoning skills for the diverse, complex practice that is nursing (Benner et al., 2009)
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From page 513... ...
are capstone courses with staff nurse preceptors, dedicated education units, faculty practices, inter-professional learning experiences, cross-appointing nursing staff on faculties and faculty members on patient care units, requiring teachers of undergraduate students to practice at least a day a week, hiring clinical experts to help faculty develop cases for simulated clinical teaching, and keeping student clinical experiences in one institution for greater depth in exposure to safety cultures, quality improvement projects, and electronic health records. More innovation is needed, along with studies that will help identify "best practices" for dissemination.
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2006b. The Essentials of Doctoral Education for Advanced Nursing Practice.
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2009b. Quality and safety education for advanced nursing practice.
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The complexity of care in many diverse settings, the role of advanced practice nurses as independent providers, and the growing recognition of the important role of scientific evidence upon which to base nursing practice have changed the way nurses are viewed by the public and the way they should be educated. The complex demands of practice combined with a shortage of experienced practitioners in many of the health care professionals have created opportunity and, in some areas, a state of potential crisis.
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. Thus, the numbers of nurse scientists working to create the empirical data upon which nursing practice is based is trivial compared to the need.
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Entry into the nursing profession at the associate degree level serves as a disincentive for the majority of nurse graduates to continue further study to the PhD level (Cleary et al., 2009)
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The reasons given by the organization at the time of adoption were the following: the rapid expansion of knowledge underlying nursing practice; increased complexity of patient care; national concerns about the quality of care and patient safety; shortages of nursing personnel which demands a higher level of preparation for leaders who can design and assess care; shortages of doctorally prepared nursing faculty; and increasing educational expectations for the preparation of other members of the health care team. The degree has been a source of contention within the profession and has evoked concerns by various physician and nursing organizations (AMA, 2010; Dracup et al., 2005)
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From page 520... ...
One way to compensate for low faculty salaries is for nursing students to be relieved of their educational debt. The Nurse Faculty Loan Program under Title VIII creates a student loan fund within individual schools of nursing that students can access.
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The tradition of educational isolation in the health care disciplines encourages the maintenance of historical stereotypes and discourages the communication skills and understandings that are essential for effective teams. Unfortunately, assembling multiple professionals together in a single clinical setting after graduation does not guarantee interprofessional collaboration will occur, despite the fact that it is increasingly recognized as fundamental to the quality and safety of patient care.
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Nursing programs are now housed in community colleges or in universities that do not have schools of medicine or other health disciplines. Curricula for different health professions were developed without collaboration from other disciplines.
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It seems that to ignore the major findings of the first systematic study of nursing education in decades would be folly. Briefly, the research team of Benner and colleagues focused on a variety of basic nursing programs by which students are prepared to take the NCLEX-RN examination and become registered nurses as well as one RN-to-BSN program.
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The review team found the variety of prerequisites across programs troubling, particularly in light of the large number of applicants coming with a degree from another bachelor's degree program. Some nursing programs had stringent science prerequisites while others had almost none.
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U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses, June 2006, http://bhpr.hrsa.gov/healthworkforce/ rnsurvey04/ (accessed January 16, 2009)
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From page 526... ...
My appointments have taken me to public and private institutions, secular and religious, and most often to large academic health centers. Over the last 25 years, my classroom and mentoring activities have focused on the preparation of advanced practice nurses for primary care and the preparation of nurse scientists; I have remained in contact with entering, second degree students in nursing by teaching a course on leadership.
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REFORM 1. Place greater emphasis on the development of committed partnerships that will enrich nursing education programs, specifically partnerships with nursing service, medical education, and a select group of disciplines that are especially relevant to health and health care delivery (engineering, business, policy, law, and the environment)
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Dually appointed faculty members were expected to teach and deliver care or provide leadership in the care delivery setting. Faculty complained that their days were unending and the combined work of delivering clinical care and teaching was impossible.
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The criteria for advancement in the academy represent yet another barrier. Adhering to the standards set by most universities, academic nursing programs impose specific, rigorous and rather narrow criteria for appointment and promotion.
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Reports suggesting that teams do affect better patient care outcomes (Grumbach and Bodenheimer, 2004) , but there is very little evidence that effective educational approaches for co-education of members of the health care team have been enacted, evaluated, and replicated.
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REFORM 2: Recognize the important role that translation will play in strengthening nursing education, improving nursing practice and connecting the two. The IOM report, To Err is Human: Building a Safer Health Care System estimated in 1999 that many as 98,000 people die in hospitals each year as a result of medical error (IOM, 1999)
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. The design and implementation of DNP programs has varied considerably from Columbia University's focus on the development of doctorally prepared advanced practice nurses who can utilize skills and knowledge to independently provide expert nursing care in all care settings (Columbia University, 2010)
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, and over 2,300 Clinical Nurse Specialists (CNSs) are providing advanced practice nursing in the United States.
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2005. Reflections on the doctorate of nursing practice.
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2009. 2008−2009 Salaries of Instructional and Administra tive Nursing Faculty in Baccalaureate and Graduate Programs in Nursing.
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The au thor notes that these changes will require significant investment in the reforms, as well as in nursing education research and faculty development. The return on investment would be improved educational capacity and a better prepared nurs ing workforce, responsive to emerging health care needs and rapidly changing health care delivery systems.
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From page 537... ...
There is a growing body of evidence that confirms registered nurses are indeed essential to patient safety (AHRQ, 2007) and experts warn of further compromise in patient safety and care quality as experienced nurses retire in droves and the ratio of new graduates to experienced nurses increases (Orsolini-Hain and Malone, 2007)
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Sixteen states have changed regulations to allow community colleges to offer baccalaureate degrees, and several have launched bachelors in nursing programs (Community College Baccalaureate Association, 2008)
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Eight community colleges and the five campuses of the public university school of nursing developed and implemented a shared, competency-based curriculum that culminates in a bachelors degree. What sets this model apart from traditional articulation agreements is that the curriculum is standard across all partner campuses: nursing faculty from full partner schools developed and approved a common curriculum plan (including competencies, benchmarks, course titles, descriptions, credit hour allocation and outcomes)
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From page 540... ...
Rationale Demands for a new kind of nurse have been abundant for the last two decades, fueled, in part, by vast changes in the nursing practice environment, including a tremendous increase in the complexity and acuity of patient care in the hospital setting, decreased lengths of stay and the shift of care and recovery to the home and community, explosion of new technologies, exponential growth of information and knowledge, clear identification of the "quality chasm" (IOM, 2001) and the recognition of the significance of nursing in patient safety (IOM, 2003)
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From page 541... ...
. It is critical that we revisit possible and optimal expectations for entry level nurses, based on population needs and likely changes in care delivery models, then align pre-licensure and residency programs accordingly.
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It is a problem which is unlikely to be successfully resolved by the individual faculty in the over 1,700 nursing programs across the county. Guidance from an expert panel, proposing curriculum models which meet the growing list of competencies, with processes for rapid cycle changes in curriculum content, will be necessary to lead essential changes in pre-licensure curricula.
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. Importantly, the pervasive use of this approach as the primary clinical education model results in limited capacity; the number clinical sites is cited as a major barrier to enrollment expansions (AACN, 2009)
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From page 544... ...
that are new graduates is rapidly increasing. It is clear that even the best nursing programs cannot adequately prepare new graduates to work in the current acute care environment (Goode et al., 2009)
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It follows that new types of residency programs appropriate for these types of roles need to be developed and become part of the regulatory framework. In sum, in order to increase educational capacity, improve educational outcomes, and better prepare graduates for the seismic shifts likely to occur in practice, there is an urgent need to develop and test new pre-licensure clinical education models including postgraduate residencies.
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From page 546... ...
It will require partnership across all levels of nursing education and health systems, redirecting Medicare funding from hospital based pre-licensure programs to postgraduate residency and advanced practice programs, expanding Title VIII funding, and other federal resources for support of educational reform. The return on investment would be improved educational capacity and a better prepared nursing workforce, responsive to emerging health care needs and rapidly changing health care delivery systems.
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(2009a) Expertise in Nursing Practice: Caring, Clinical Judg ment & Ethics.
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. Fostering geriatrics in associate degree nursing education: An assessment of current curricula and clinical experiences.
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. Model nursing practice act and model nursing administrative rules National Council of State Boards of Nursing.
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. Dialogue and reflection: NLN survey on clinical education points to barriers to ef fective clinical education in pre-licensure nursing programs and need for continued research Retrieved from http://www.nln.org/newsreleases/surveyofclined_082809.htm.
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From page 551... ...
. Since the publication of the IOM's quality chasm reports, numerous organizations have called for changing not only systems of care, but also systems of health professions education, realizing that it will be the clinicians of the future who can most effectively change how care is delivered.
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From page 552... ...
Focus of the Paper This paper focuses on three target areas for emphasis in nursing education -- interprofessional education, education for care coordination, and education for health policy -- each essential for a transformed health care system. In such a system, nursing care must be recognized by the American public, policy makers, and others on the health care team as an indispensable ingredient to quality care.
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From page 553... ...
The nursing profession's inability to insist that professional nursing requires a minimum of a 4-year baccalaureate degree gravely impedes the stature of the profession. Because associate degree students are less likely to be educated in academic health centers, they have less proximity and exposure to students of medicine or most other health professions.
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From page 554... ...
Although empirical evidence is mixed, there is widespread theoretical agreement and anecdotal evidence that students who demonstrate teamwork skills in the simulation lab or at the bed- or chair-side with patients will apply them beyond the walls of their academic programs, particularly if valued and reinforced by the care environments in which they later work. In the early days of IPE, students graduated into patient care environments in which siloed and hierarchical systems predominated, thus creating a significant disconnect between their college-based learning and post-graduation experience.
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3. Nursing faculty need development in IPE teaching, which requires structure and funding.
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EDUCATION IN CARE COORDINATION Both the health professions literature and the popular press note that failures in patient care coordination are widespread in the United States. Indeed, fragmented care, lost records, hand-offs without full information, poor return of information from specialty care after referral, unnecessary and redundant procedures and services -- and the attendant patient fatigue, frustration, and costs -- are the very heart of the quality chasm.
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From page 557... ...
Care coordination requires linguistically and culturally competent communication with the patient and family, and seeks and responds to patient/ family questions and feedback. Yawning gaps in care coordination are rallying many health professions organizations to search for solutions.
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From page 558... ...
Often the master's level Clinical Nurse Specialist program is the only track with a course or parts of courses that address care transitions and care coordination, and this content may be confused with case management, the latter being a more limited concept usually applied to containing costs within reimbursement systems. Interprofessional education discussed above will by itself, improve graduates' competence in care coordination because many of the competencies students learn in IPE are relevant.
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From page 559... ...
3. Across education levels of nursing education, care coordination should be structured around knowledge, skills and competencies to include: advanced assessment skills appropriate for senior baccalaureate and master's/DNP students; interpersonal and communication skills necessary for the ability to communicate with patients and families with a high degree of sensitiv ity and cultural competence, as well as the science-based skills necessary to communicate effectively with physicians and others on the health care team; competencies in care planning that integrate the biological, social, and psychological needs of patients; understanding of and ability to seek and ap ply evidence-based protocols and national standards for patient conditions; and payment and social services systems to better address the full range of patients' and families' needs.
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The Healthy People Curriculum Task Force, convened by the Association of Academic Health Centers and the Association of Teachers of Preventive Medicine, with representatives from medicine, nursing, pharmacy, and physician assistants, as well as their educational associations recommended the following four domains fundamental to health professions curricula on health policy (http:// www.atpm.org/CPPH_Framework/index.html) : • Organization of clinical and public health systems (connecting the pieces of the system; connecting clinical care to public health structures)
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From page 561... ...
cycles for gathering data to influence patient care policies. Faculty should engage baccalaureate students in this TCAB literature, with application in clinical assignments and an emphasis on policy implications and processes.
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From page 562... ...
EPILOGUE The RWJF/IOM Initiative on the Future of Nursing will yield transformational recommendations for the nursing profession at a critical time in history for nursing and for America's health care system. There is much to reform in nursing education, from agreement about the minimum degree for entry into practice to
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Priorities for patient care differed among health care providers. Advances in Patient Safety, Volume 1.
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From page 564... ...
The Fourth Report of the Pew Health Professions Commission, December, 1998. Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Hammick, M., and Koppel, I
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