Book Highlights from Educating Nurses: A Call for Radical Transformation
By Patricia Benner, Molly Sutphen, Victoria Leonard and Lisa Day
With this text, Patricia Benner and colleagues have reset the agenda for nursing education and it could not have come at a more critically important moment. Through careful discovery and thoughtful comparison, the authors have identified key areas for improvement in the structure and process of preparing the next generation of nurses for the deceptively complex work of caring for people and their families. It is a landmark publication.
–Catherine L. Gilliss, DNSc, RN, FAAN
Helene Fuld Health Trust Professor of Nursing
Dean, Duke University School of Nursing
Vice Chancellor for Nursing Affairs, Duke Medicine
Educating Nurses: A Call for Radical Transformation is part of a multiyear comparative study of professional education in the United States called the Preparation for the Professions Program (PPP) at The Carnegie Foundation for the Advancement of Teaching. Conceived of as a way to understand how professionals are prepared to practice, PPP examines common themes and identifies practices distinct to various forms of professional education. Over the last decade, PPP has conducted national studies on the education of clergy, lawyers, engineers, physicians and nurses. The project was funded by Carnegie and The Atlantic Philanthropies.
These highlights are based on the Carnegie/Jossey-Bass publication of the same title, Educating Nurses: A Call for Radical Transformation (December 2009). To order, visit the Jossey-Bass website.
The profession of nursing in the United States is at a significant moment. It must contend with enormous pressures, from the chaotic health care system and the economic forces that drive it to profound changes in science, technology and patient activism. These demands, combined with ongoing shortages in the ranks of nurses and shifts in the nature and settings of nursing practice, have an impact on the profession’s ability to uphold and transmit its core values: to provide astute clinical judgment, to keep patients safe, and to ameliorate human suffering.
It is in this environment that The Carnegie Foundation for the Advancement of Teaching releases the results of the first national nursing education study in 30 years. Educating Nurses: A Call for Radical Transformation explores the strengths and weaknesses in nursing education and the external challenges the profession faces. It identifies the most effective practices for teaching nursing and persuasively argues that nursing education must be remade. Indeed, the authors call for radical advances in the pathways to nursing licensure and a radical new understanding of the curriculum.
Based on extensive field research conducted at a wide variety of nursing schools, and a national survey of teachers and students administered in cooperation with the National League for Nursing (NLN), the American Association of Colleges of Nursing (AACN) and the National Student Nurses’ Association (NSNA), Educating Nurses offers recommendations to realign and transform nursing education.
Educating Nurses is the fourth volume in a series of comparative studies by the Carnegie Foundation that examines how the members of different professions are educated for their responsibilities in the communities they serve.
OVERVIEW OF NURSING EDUCATION
Nurses, the largest of the health care professional groups, spend the most direct time with patients; thus, their role in health outcomes is critical. They conduct most bedside monitoring, assist and teach aging patients to manage multiple chronic illnesses, and provide much of everyday primary care. Nurses also work in widely diverse settings, including specialized, acute hospital bedside care; in-home and long-term nursing care; as well as working in schools and the community.
While nurses are charged with caring for patients with increasingly complicated diagnostic and treatment regimes, they must learn and work under less than optimal circumstances. Currently, health care institutions are not well designed for good nursing and medical practice—or for education. Nurses and nursing students must function within the complicated, and many would say, chaotic and dysfunctional U.S. health care system. To further complicate matters, since 1998 there’s been a growing shortage of nurses, causing 93 percent of hospital-based registered nurses to report a lack of sufficient time and staff to maintain patient safety, detect complications early, and collaborate with other health care team members.
To meet current and projected shortages, nursing education programs need to increase their capacity by approximately 90 percent. However, these programs are faced with a severe shortage of faculty, making it difficult to expand; and the already small pool of qualified faculty is rapidly shrinking—almost a third are over the age of 55 and there is a dearth of baccalaureate-level nurses eligible to enter graduate programs. This has caused a sixfold increase in the number of applicants denied admission to nursing schools since 2002.
As faculty retire, nursing schools lose some of their most experienced teachers and face the challenge of finding and mentoring new faculty. Retention of novice teachers is also problematic as they can earn a higher salary in practice; and while those new to teaching often bring enthusiasm and up-to-date clinical knowledge, few graduating with master’s and doctoral degrees have been prepared for teaching.
For the past 30 years faculty and administrators of graduate nursing programs have focused their attention on developing robust nursing research, ignoring the need to prepare new faculty to address the specific educational demands of teaching the complex practice of nursing. Also, unlike their colleague educators preparing lawyers, clergy, physicians and engineers, nursing faculty and preceptors have relatively little time to build a robust knowledge base and guide students in professional formation.
There is also disagreement over what education nursing practice requires, as the multiple points of entry to the profession indicates. While the American Organization of Nurse Executives and the American Association of Colleges of Nursing have called for a mandated baccalaureate degree as a point of entry to nursing practice—a recommendation the ANA made in 1965—and studies have demonstrated that better patient outcomes are achieved in hospitals staffed by a
greater proportion of nurses with baccalaureate degrees to those with associate degrees, there has not been the political will to make it so. Even more serious than the different points of entry to the practice are the quality gaps in the educational preparation and teaching development of nursing faculty seen across all types of nursing programs.
Despite these enormous external challenges facing nursing practice and nursing education, the authors argue change in nursing education must come now, from within the schools and the profession. For as nursing education copes with these mounting pressures, the risk is to lower standards and aspirations; but at such a time of crisis, it is especially critical to have a clear vision of what high-quality nursing education is and what programs must do to meet those standards.
The Carnegie National Nursing Education Study examined three dimensions of nursing education and formation: 1) the learning of theory and scientific methods; 2) the mastery of skillful practice; and 3) the formation of professional identity and agency. These “three apprenticeships” are integrated in the identity and actions of the professional nurse; thus, the research team explored the relationship among the apprenticeships throughout the study’s two stages.
In the first phase of the study, the research team conducted site visits to nine geographically and academically diverse schools, including a community college, a private liberal arts college, and a graduate-level state university focused exclusively on the health care professions. The programs examined ranged from pre-licensure to master’s-entry level programs, to those that grant the diploma, the associate degree, or the baccalaureate degree (both fast-track and traditional programs).
In preparation for the site visits, extensive telephone interviews were conducted with administrators and faculty. On-site, the team observed classes and again interviewed administrators and faculty, as well as staff and students. Students were also observed in clinical settings and during skills and simulation laboratories.
To complement the site visits, the second phase of research included a national survey of faculty and students, conducted in collaboration with the American Association of Critical Care Nurses (AACN), National League of Nursing (NLN) and National Student Nurses’ Association (NSNA)—leading nursing organizations. The findings from these surveys were incorporated into the report, along with student and faculty comments.
The survey instruments can be viewed at: www.carnegiefoundation.org/previous-work/professional-graduate-education/nursing-education-surveys
KEY OBSERVATIONS OR FINDINGS
A major finding from the study is that today’s nurses are undereducated for the demands of practice. Previous researchers worried about the education-¬practice gap; that is, the ability of practice settings to adopt and reflect what was being taught in academic institutions. Now, according to the authors, the tables are turned: nurse administrators worry about the practice¬-education gap, as it becomes harder for nursing education to keep pace with the rapid changes driven by research and new technologies.
Three other key findings informed the authors’ recommendations. These include:
1. U.S. nursing programs are very effective in forming professional identity and ethical comportment.
While nursing education helps students develop a deep commitment to the values of the profession, there was a significant difference between what educators and students articulate as their understanding of ethical comportment and the actual teaching toward it. Educators and students often described “ethics” primarily in terms of learning the principles of bioethics; yet, in the process of teaching and learning in clinical situations, they actually focused on everyday ethical comportment, on becoming good practitioners, and on continuously improving their practice, always with the patient in mind.
2. Clinical practice assignments provide powerful learning experiences, especially in programs where educators integrate clinical and classroom teaching.
One strength of U.S. nursing education is that students work directly with patients and the health care team. Moreover, as they progress through their programs, they are given ever-increasing responsibilities in clinical situations. In describing how they learned to become a nurse or “think like a nurse,” students invariably pointed to clinical situations. However, when the clinical and classroom instruction were not integrated, students reported a fragmented experience.
3. U.S. nursing programs are not effective in teaching nursing science, natural sciences, social sciences, technology and the humanities.
The lack of rigorous scholarship demanded of nursing students in these areas, and a failure of nursing education to connect the liberal arts to the development of sound nursing practice, was a sharp contrast to the skillful and effective approaches used in clinical situations. Material in these courses was typically delivered through standardized lectures. Developing knowledge that is to be used in a complex, high-stakes practice such as nursing calls for an ongoing dialogue between information and practice, so that students build an evidence base for care and thus learn to make decisions about appropriate interventions for a particular patient.
RECOMMENDATIONS FOR PROGRAMS
The authors suggest that nursing educators make four shifts in their thinking about teaching and in their approaches to fostering student learning.
1. From a focus on covering decontextualized knowledge to an emphasis on teaching for a sense of salience, situated cognition and action in particular situations.
Many teachers organize their classes around lists of abstract theory, giving their students little or no indication about how to integrate the knowledge they present in a practice context. Instead of presenting flat representations of taxonomic structures or “cataloguing,” nurse educators should help students learn to use nursing knowledge and science.
2. From a sharp separation of clinical and classroom teaching to an integration of the two.
At all the schools visited, there was a sharp divide between classroom and clinical teaching. For instance, when students learn to measure blood pressure, it’s often in a decontextualized situation where the measurements are taken of healthy individuals. While a good starting point, this does not prepare a student to make a clinical assessment about a hypertensive patient in labor and delivery. When teachers provide only simple, stripped-down examples or test students on elemental competencies, they may not be helping students to prepare for diverse clinical situations.
3. From an emphasis on critical thinking to an emphasis on clinical reasoning and multiple ways of thinking.
Critical thinking alone cannot develop students’ perceptual acuity or clinical imagination; and cynicism and excessive doubt are often the by-product of the over-use of critical thinking. Nurses need multiple ways of thinking, including clinical reasoning—the ability to reason as a clinical situation changes, taking into account the context and concerns of the patient and family—helping nurses to capture a patient’s trends and trajectories. Clinical imagination, which requires students to grasp the nature of patients’ needs as they change over time, is also needed, as well as critical, creative and scientific reasoning.
4. From an emphasis on socialization and role-taking to an emphasis on formation.
Formation includes those changes in identity and self-understanding that occur in moving from a lay person to a professional. Nursing education must make more intentional use of these transformational experiences, focusing on the formation of professional identity rather than on socialization. Experiential learning environments across the nursing curriculum are also needed to support formation.
RECOMMENDATIONS FOR POLICY CHANGE
Resulting from the study are a set of specific policy recommendations. These will require that the entire nursing profession work together to transform nursing education.
ENTRY AND PATHWAYS
Come to agreement about a set of clinically relevant prerequisites.
A national advisory group should determine what prospective students need to know in the humanities, natural sciences and social sciences—and their relevance to clinical practice. The group should also agree on the prerequisites for students entering nursing school with baccalaureates and advanced degrees.
Require the Bachelor of Science in Nursing (BSN) for entry to practice.
The minimal educational level for entry into nursing practice should be the baccalaureate degree. To make this so, the profession needs to agree on how to transform the current diverse pathways into a unified whole.
Develop local articulation programs to ensure a smooth, timely transition from the Associate’s Degree in Nursing (ADN) to the Bachelor of Science in Nursing (BSN).
Unifying nursing education’s various pathways will be a lengthy process. In the meantime, a redesign and reconfiguration of the roles of diploma and community colleges must occur; and local and regional consortiums should create a seamless transition from the ADN program to the BSN, moving away from ADN programs that offer the baccalaureate degree in nursing.
Develop more Associate’s Degree in Nursing (AND) to Master of Science in Nursing (MSN) programs.
An increase in the number of ADN to MSN programs is needed, offering practicing ADNs, a realistic incentive to return to school for increased job opportunities and salaries; additionally, this would increase the applicant pool for doctoral study and enlarge the faculty pipeline.
Recruit a more diverse faculty and student body.
At the high school level, outreach and pipeline programs should be strengthened through financial support, recruitment and retention infrastructures. Health care institutions could also show their commitment to diversity through increased scholarships for minority nurses, offering additional incentives for minority nurses to become nurse educators, and actively recruiting minority nurses to pursue graduate education.
Provide more financial aid, whether from public or private sources, for all students, at all levels.
More focused attention by federal, state and local authorities is needed to support the education of nurses. For example, education taxes placed on new health care facility extensions would encourage state governments to offer more entitlements for nursing scholarships. Health science education centers could add fellowships to annual campaigns; and health care organizations could increase programs that provide loans that are reduced or forgiven if the graduate works for the organization.
THE STUDENT EXPERIENCE
Introduce pre-nursing students to nursing early in their education.
Programs should take the earliest opportunity to introduce students to the profession, requiring students to take prerequisites for clinical courses during the first two years of college.
Broaden the clinical experience.
More than 50 percent of nurses work outside the hospital setting, but much of a student’s clinical time is focused on acute-care hospital practice. The variety of clinical settings should be increased to not only make the profession more visible to a broader population of prospective students, but to also allow for greater flexibility in accommodating students’ home and work schedules.
Preserve post-clinical conferences and small patient-care assignments.
Few schools have clinical curricula that allow students to follow patients and families across time and institutional settings; and many programs operate on an untested assumption that handling larger patient care loads will make students more efficient upon graduation. Students thus focus on acute and episodic assignments in hospital settings. Instead, programs should ensure students receive small patient-care assignments at the start of each new clinical rotation, and students should have the opportunity to work with nurses with clinical specialties such as infection control, quality and safety improvement, and discharge planning.
Develop teaching methods that keep students focused on the patient’s experience.
Support is needed for teachers to learn to scaffold their courses around patient care. Medical pathology and disease mechanisms should be taught in direct association with patients’ illness experiences, including the psychosocial aspects of illness, patient-and family-coping, and the teaching of self-care. By coaching students to focus on patients in specific situations, teachers provide students opportunities to rehearse the appropriate care for patients and their families. Examples of such strategies include simulation exercises, the use of unfolding cases, narrative structures for making a case, and interviews of patients in class. Further, the authors recommend that regional and national resources be made available for developing effective and sophisticated clinical simulation exercises designed to help students integrate knowledge, skilled know-how, and ethical comportment.
Vary the means of assessing student performance.
Educators should use both formative and summative assessments, including simulation exercises, skills laboratories, classrooms with actor patients, and assessments done directly in the clinical setting. Indicators of clinical performance should include how well students are able to set priorities in particular clinical situations, develop rationales for patient care, and respond to changes in patients. Students should also be assessed on their skills of clinical reasoning and their ability to solve clinical puzzles.
Promote and support learning the skills of inquiry and research.
Faculty should require students to follow through on the care of their patients. By examining discharge outcomes, students discover the consequences of their patient care, as well as learn about the hospital trajectory for patient care and discharge planning. Students should also be expected to learn research skills and access the nursing literature.
Redesign the ethics curricula.
Nurse educators need to focus on not only critical and dilemma ethics, but also everyday ethical comportment related to relational or care ethics. Narrative strategies, such as debriefing and reflecting on practice, or the use of journals, provide effective ways to uncover and articulate everyday ethical comportment central to nursing practice.
Support students in becoming agents of change.
In order for today’s students to be prepared to meet the reform challenges in practice settings—and be influential leaders in the political and public arenas for improved health care systems—they will need to learn theories of organizational development and policy-making, as well as strategies to change organizations. All levels of nursing education should prepare students for the complex bureaucratic settings where they will practice, learn and teach.
Support robust, ongoing faculty development for all who educate student nurses.
A central challenge to elevating the quality and effectiveness of nursing education is the lack of focus on teaching and basic teacher preparation in graduate nursing schools. Individual teachers, programs, institutions, state boards and professional societies should convene with the aim of (1) enhancing the practice of teaching in the profession; (2) improving faculty development incentives and rewards for good teaching; and (3) developing curricula and strategies that foster lifelong learning and clinical inquiry skills in student nurses.
Rich faculty development opportunities at the local, regional and national levels are also needed; and a greater focus on the scholarship of teaching and learning will require increased support on the part of schools, federal and state governments, and philanthropies.
Include teacher education courses in master’s and doctoral programs.
To better prepare future nursing faculty for teaching, all master’s and doctoral level programs should include teacher education courses. Master’s programs with a nursing education major must also ensure advanced clinical practice preparation for future teachers.
Provide opportunities for educators to learn how to teach students to reflect on their practice.
Programs and professional organizations must support educators in learning how to create a safe climate for students to reflect on their learning experiences. Such strategies might include small group discussions like those in post-clinical conferences.
Support faculty in learning how to coach.
Rich and situated coaching on practical clinical reasoning should be extended to the classroom, so that students are asked to problem solve in situations that closely resemble what they will encounter in practice.
Support educators in learning how to use “narrative” strategies.
Learning to think like a nurse involves developing one’s skill with narrative structures and narrative thinking. This includes the ability to understand the clinical situation, to find science-based answers to signs and symptoms; and to listen to and clarify patient and family concerns. Programs and professional organizations should support educators in learning how to use narrative strategies in the classroom and skills labs.
Provide faculty with resources to stay clinically current.
Some classroom teachers have not been in practice for many years. To bring them up-to-date, faculty enrichment and development might take the form of inviting expert clinical nurse specialists or other specialists to provide current knowledge about a particular clinical practice area.
Improve the work environment for staff nurses and support them in learning to teach.
Clinical placements are often overcrowded, and some students experienced uncivil behavior from staff nurses. Improved work environments are needed, as well as a zero tolerance policy for uncivil behavior toward any member of the health care team. At the same time, employers should provide ongoing opportunities for nurses in practice settings to learn how to teach and coach students.
Address the faculty shortage.
Efforts to recruit students into graduate programs that could lead to teaching positions will continue to be futile unless faculty salaries are increased and brought into line with clinical salaries and teaching positions in other disciplines. Health care organizations and nursing schools (and their institutions) must come to agreement about flexible practice schedules and salaries. At the same time, schools of nursing must become more flexible and forward-thinking in their personnel policies.
ENTRY TO PRACTICE
Develop clinical residencies for all new graduates.
Graduates should be required to complete a one-year residency program focused on one clinical area of specialization. A lower entry-level salary for the residency year can offset the costs of these programs.
Change the requirements for licensure.
The Boards of Registered Nurses should require graduates who pass the NCLEX-RN examination (one of two licensure examinations) after 2012 to earn a master’s degree within ten years.
Require performance assessments for licensure.
Nursing students should be exposed to competency evaluations during their undergraduate programs to better prepare them for competency clinical performance exams, which occur during their professional lives. To do so, the National Council for State Boards of Nursing need to develop a new set of student performance assessments, with three national examinations of performance. The first exam should start at the beginning of the last year of nursing school; the next should be given at the same time the student sits for the NCLEX-RN examination (one of two licensure examinations); and the last exam should take place at the end of a one year post-licensure residency.
Cooperate on accreditation.
The accrediting arms of National League for Nursing and American Association of Critical Care Nurses should collaborate with other professional organizations, nursing administrators, faculty and preceptors to agree on student outcomes, articulation of Associate’s Degree in Nursing (AND), Bachelor of Science in Nursing (BSN), and Master of Science in Nursing (MSN) programs and student transitions. They should also set meaningful standards for robust, ongoing faculty development to ensure that educators are appropriately supported in their professional practice of teaching.
These accrediting agencies should also cooperate on interdisciplinary education. Learning to practice in an interdisciplinary setting can help students work more effectively on a health care team and better integrate knowledge, skilled know-how, and ethical comportment in practice. Finally, the agencies should work together to systematically review current demands for knowledge and to scan for future trends for nursing practice.
CALL TO ACTION
Redesigning nursing education is an urgent societal agenda. The profound changes in nursing practice call for equally profound changes in the education of nurses and the preparation of nurse educators. Unfortunately, the current climate rewards short-term focus and cost-savings over the quality of nursing education and patient care. The challenge will be to create health care institutions and management systems that will educate nurses in a climate that fosters professional attentiveness, responsibility and excellence.
The Carnegie Foundation studies on professional education point to a new moral vision for the professions, where professional responsibility, accountability and ethical comportment provide the fulcrum for their identity and action. Now the nursing profession must unite and act to regain excellence in nursing education. This will take bold action on the part of educators.
Written for nurse educators and students; administrators of nursing schools; college and university leaders; administrators in health care settings; accrediting agency staff and leaders; and other leaders in the profession and education, Educating Nurses is a catalyst for conversation and debate, self-assessment and, above all, change.
About the Authors
Patricia Benner, R.N., Ph.D.
Dr. Benner was a Senior Scholar with The Carnegie Foundation or the Advancement of Teaching. She is also a Professor Emerita at the University of California School of Nursing. She is a noted nursing educator and author of From Novice to Expert: Excellence and Power in Nursing Practice, which has been translated into eleven languages. She was the Director of this Carnegie Foundation National Nursing Education Study, which is the first such study in 40 years. She additionally collaborated with the Carnegie Preparation for the Professions studies of Clergy, Engineering, Law and Medicine. Dr. Benner is a Fellow of the American Academy of Nursing. She was elected an honorary fellow of the Royal College of Nursing. Her work has influence beyond nursing in the areas of clinical practice and clinical ethics. She has received two honorary doctorates. She is the first author of Expertise in Nursing Practice: Caring, Ethics and Clinical Judgment with Christine Tanner and Catherine Chesla, and has co-authored 12 other notable books.
Molly Sutphen, Ph.D.
Dr. Molly Sutphen was a Research Scholar at The Carnegie Foundation for the Advancement of Teaching and Co-Director of this Carnegie Foundation National Nursing Education Study. She is also an Assistant Adjunct Professor in the Department of Social and Behavioral Sciences at the University of California San Francisco. She is an historian of public health, medicine and nursing. She has taught history to medical, pharmacy and nursing students, and taught ethics in the School of Nursing at the University of California San Francisco. She received her doctorate from Yale University in the history of medicine and the life sciences.
Vickie Leonard, R.N., F.N.P, Ph.D.
Dr. Leonard is a family nurse practitioner and Child Care Health Consultant at the UCSF California Childcare Health Program (CCHP). She is a trainer for Child Care Health Consultants in California, and does trainings, presentations and writes educational materials on health and safety issues for child care providers in the state. She has taught Health Policy and Ethics and Pediatrics in the nurse practitioner program at the University of San Francisco, and has worked with children and families with chronic illnesses in pediatric subspecialty clinics. Dr. Leonard was a research associate for the Carnegie National Nursing Education Study and participated in the data collection, analysis and writing up of the findings. She has also consulted on a longitudinal research study of teen mothers and their infants for the past 15 years. She received her Ph.D. from the School of Nursing, University of California San Francisco.
Lisa Day, B.S.N., M.S., Ph.D.
Lisa Day graduated from Long Beach City College in California with an Associate Degree in Nursing in 1984. She has worked as a nurse in a post-anesthesia recovery room, a medical cardiac intensive care unit, and a neuroscience-critical care unit, and completed her B.S.N, M.S. and Ph.D. (with Patricia Benner) at UCSF School of Nursing. She taught pre-licensure nursing in an accelerated second degree program for eight years before recently returning to clinical practice and is now the Clinical Nurse Specialist for Neuroscience and Critical Care at UCSF Medical Center. Dr. Day has been involved as a consultant in several projects related to nursing education including the RWJ-funded Quality and Safety Education in Nursing (QSEN); the Helene Fuld Health Trust-funded project, Evaluating the Outcomes of Accelerated Nursing Education; evaluation of the Oregon Consortium for Nursing Education (OCNE); and participated in the 2008 National League for Nursing think tank on Transforming Clinical Nursing Education.