A Model for Transforming Nursing Education
By Lori Melichar, Ph.D., M.A.
Senior Program Officer, Research and Evaluation, Robert Wood Johnson Foundation
I recently attended a National League for Nursing meeting of top nursing researchers, educators and leaders. Among the purposes of the meeting was to identify gaps in and opportunities to create knowledge to improve nursing education.
While meeting participants discussed several exciting efforts currently underway to improve nursing education, journal editors attending lamented the fact that most of the published research on nursing education innovations is based on single-site studies, making it unlikely to convince faculty to adopt new models of education or change core curriculum. The editors, educators and researchers agreed that research linking teaching methods and curricular content to patient outcomes would bolster efforts to transform patient care in the U.S. Evidence in this area is crucial because curricula are packed, faculty are overworked, change takes effort, and students don't always know what's best for them.
Producing more rigorous evidence is a strategy I often support as a member of the department of research and evaluation at the Robert Wood Johnson Foundation (RWJF). The Research Initiative component of the Campaign for Action, along with the Foundation's Evaluating Innovations in Nursing Education Program, will seek funding for studies of educational innovation over the next couple of years. It occurred to me that a strategy that might be more successful in the goal of quickly transforming nursing education falls out of the Foundation's flagship nursing program, Transforming Care at the Bedside (TCAB).
I was a part of the team from RWJF and the Institute for Healthcare Improvement (IHI) that developed the TCAB program that taught front-line nurses and their managers the skills and methods of continuous quality improvement, and inspired and empowered them to make changes to transform care at the bedside. The idea was that, though evidence should always be considered when it exists, there are things one can try to improve outcomes that matter, without first proving effectiveness.
In the hospitals that embraced TCAB, it wasn't enough for nurses to simply comply with efforts to implement innovations related to shift change, medication management or hand washing. TCAB nurses themselves were responsible for driving, leading and sustaining change. They were expected to take acceptable risks and to abandon interventions that either failed, or were shown to be no better than the status quo. They were asked to focus not on their own satisfaction, confidence or skill proficiency, but on the needs of the patient.
TCAB has fostered and sustained a culture of continuous improvement. Staff do not dread or resist change in true TCAB units, they consider it a way of life and it continues to drive improvements years after the consultants have left. The lesson? Continuous Quality Improvement (QI) enables transformational change, not just improvement.
What does this mean for nursing educators? A nursing educator committed to Quality Improvement will stay current about the required competencies for the future of nursing and examine his/her students' proficiencies in these areas. This means he/she will work with others to identify the ways to most effectively convey these competencies to nursing students - learning from colleagues about how to keep students engaged and learning. More importantly, she or he will try new things that just might work and frequently reflect on how these innovations are working by assessing short-term outcomes of his or her work.
In the same way that some TCAB hospitals decided to disregard Joint Commission assessments because they distracted them from the work they found most important, a nursing educator skilled in QI may choose to throw traditional curricula out the window and draw on his/ her expertise and that of others to teach students what they really need to know (while tracking unintended consequences of innovative education practices). By engaging students in the process of revising curriculum and instruction to address their needs and preferences, teachers may find that long-held assumptions about how students learn are no longer relevant. Once faculty see their creative efforts result in improved student engagement, maybe they will be more inclined to stay in academia.
A nurse educator who sees class participation improve after implementing a strategy of having each person in the room vocalize something about their weekend before class starts will continue with this practice. A professor who notices variation in student satisfaction and performance with simulation methods can tailor education to the needs of the students. A teacher who sees attendance drop after posting slides online in advance of the class will abandon that innovation immediately.
There are undoubtedly non-hypothetical examples of nursing educators who have been influenced by the process of teaching others about QI... let's hear them! Reporting detailed descriptions and outcomes of QI initiatives will never result in publication in the Journal of the American Medical Association, but a synthesis of key success stories can go a long way to convince other faculty to try new approaches. And let’s figure out a way to teach and empower nursing educators to embrace continuous quality improvement in the academic setting.