It’s cap-and-gown season and, this month and next, nursing students are receiving degrees and getting ready to meet new challenges. According to a number of experts in nursing education, these new graduates’ experiences in nursing school were very different than those of the generation that preceded them, due to changes in methods of instruction, curriculum and the student population itself. Similarly, the job market they will encounter is dramatically different, according to educators associated with the Robert Wood Johnson Foundation’s (RWJF’s) Quality and Safety Education for Nurses project (QSEN).
Instructional methods have evolved markedly in the last decade, experts say, with the increased use of high-fidelity simulations among the most transformative changes. Mannequins used in lab classes now offer a wider range of educational opportunities than did their synthetic cousins of a decade ago, responding to stimuli—injections, for example—with dilated pupils, urine output and more. Some even effectively simulate labor and birth.
“We have simulation exercises in each of our clinical courses, and the focus is on clinical reasoning and safety,” says Amy Barton, Ph.D., R.N., QSEN collaborative member and associate dean for clinical and community affairs at the University of Colorado Denver, College of Nursing. “We’re able to pre-program the mannequin, or program it on the fly as the simulation develops, so we can manually change how the mannequin is responding based on what the student is doing…. I facilitate a simulation with an asthmatic ‘patient’ who presents in the emergency department. It’s an inter-professional simulation with nursing and medical students, and the focus for us is on communicating within the team.”
Barton’s lab exemplifies how today’s nursing schools are revamping their curriculum and harnessing technology to expose students to clinical reasoning and safety, making them better prepared to enter the workforce than prior graduates.
Her lab fits well with the QSEN goal of developing nursing curriculum to meet the challenge of preparing future nurses who have the knowledge, skills and attitudes necessary to continually improve the quality and safety of the health care system within which they work. With a focus on patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety and informatics, QSEN seeks to prepare health professionals to lead the continual improvement of the quality, safety and value of health care.
A big part of that entails preparing students to exhibit sound clinical judgment.
“High-fidelity simulation really came into use in the last decade,” says Linda Cronenwett, Ph.D., R.N., F.A.A.N., professor and dean emeriti of the University of North Carolina-Chapel Hill School of Nursing and principal investigator for QSEN. “In a clinical setting, the patient needs that students are exposed to are rather unpredictable, and the whole notion now is that there may be certain situations requiring clinical judgment that we should ensure students have experienced.”
Simulation labs are just one example of how nursing schools are better preparing students for the workforce. Cronenwett also notes the emergence of capstone courses in which students are precepted by staff nurses in the practice setting.
“It’s a function of increased academic-practice partnerships, including dedicated education unit models (DEU), which allow students greater exposure to expert nurses,” she says. “I think everyone believes that these intensive precepted experiences have produced students who are better prepared than they were previously.”
The College of Nursing and Health Sciences at the University of Massachusetts, Boston, employs such a DEU model for its students, working with Partners Healthcare in Boston. JoAnn Mulready-Shick, Ed.D., R.N., C.N.E., Undergraduate Nursing Program Director and QSEN collaborative member, sees it as a way to “bridge the gap between nursing practice and education—in both directions, because it allows students to learn from practicing nurses while giving nurses access to academia.”
The approach also enables nursing schools to educate more students, while practicing nurses in the DEUs provide hands-on instruction.
Another technology-related change in nursing education during the past decade is the increased use of distance education. “Our R.N. to B.S.N. program has really taken off,” Mulready-Shick says, “and it’s all online education. It’s a great match for busy practicing nurses who want more education, but have trouble making time for it.”
She notes that online education is also popular with students getting post-master’s certificates. The post-master’s program has graduated more than 400 students nationwide. Although the coursework is all online, the practicum occurs in the students’ communities.
More generally, Mulready-Shick sees a transformation in the classroom from lecture-based classes to an emphasis on active learning.
“We’re trying to have students become active participants, engaged in helping to co-create their learning experience to the extent possible,” she says. “Faculty used to talk 95 percent of the time, and then ask if there were questions. Now students are expected to have completed the basic reading before coming into the classroom, so that class time is really the conversation, the dialogue and learning activities that help to build on what’s in the textbooks, and what’s already known from students’ experiences.”
What Students Learn
Some of the substance of the instruction has changed, too. Cronenwett sees four chief differences in nursing school curriculum that have taken root over the past decade: increased focus on cultural awareness and competency; a growing body of instruction related to genetics that prepares nurses for the health care implications of the mapping of the human genome; more attention to the health care needs of older adults and the frail elderly in particular; and increased attention to quality and safety.
Barton relates some of the changes in the substance of nursing education to the increased reliance on partnerships. “Nursing education has really evolved to incorporate much more in the way of quality and safety competencies than it ever had in the past,” she says. “I think the traditional divide between nursing practice and nursing education has been minimized by the shared agenda of education and clinical practice on...informatics, teamwork and collaboration and evidence-based practice.”
The Student Body
Data from the American Association of Colleges of Nursing (AACN) indicate that the last decade has seen a sharp increase in the number of nursing students seeking baccalaureate degrees or higher—from 100,000 entry-level baccalaureate, masters and doctorate students in 2000 to more than 210,000 in 2009. Data from the National League for Nursing show that associate degree programs continued to account for a majority of nursing students during the period, while diploma programs declined in popularity.
“For the bulk of this decade, demand has dramatically increased—leading to a much bigger applicant pool,” Cronenwett says. “So we’ve seen the opening of a lot of accelerated baccalaureate programs for applicants with other college degrees.…. In addition, we’ve expanded capacity in all types of pre-licensure education programs over the course of the decade, as predictions about the nursing shortage led to an uptick in the quantity and quality of the applicant pool.”
Another important trend for nursing schools is an increasingly diverse student population. “We need to keep the doors wide open for new students of diverse backgrounds,” Mulready-Shick adds, “including students of different ethnicities, varying ages, degree backgrounds, more.”
Data from the federal government demonstrate that the effort is making progress: Since 2000, the percentage of nurses who are Hispanic, Black or of other minority groups has increased from 12.5 percent to 16.8 percent, reflecting increased diversity in nursing school enrollment.
Meeting increased demand for slots in nursing schools is a focus of a number of RWJF initiatives. For example, the New Jersey Nursing Initiative’s Faculty Preparation program supports 46 nursing students in the state as they study for advanced degrees. Upon graduation, the scholars will be well prepared to pursue their goals as nurse faculty in New Jersey.
Where Do Grads Go from Here?
Despite the improved preparation that today’s graduates receive, the job market in the last year is as tight as it has been in recent memory. While expansion in the job market for health care jobs is helping to drive the nation’s economic recovery, some of those jobs are taken by practicing nurses working more hours or delaying retirement. As a result, this year’s crop of graduates faces a longer and tougher job search.
“The last of our December graduates landed a job this May,” says Barton. “More generally, our graduates are finding that they’re not getting their first choice—that they’re not ending up in the sector they’d like to be in. It’s also taking them longer to find a position.”
Cronenwett sees the same trend: “It’s not that there aren’t jobs, but it’s harder for them to find jobs in the units, health care settings or cities of choice.”