U.S. health care is changing fast. Between the Affordable Care Act’s reforms, demographic trends, ongoing cost-control efforts, and technological and delivery system innovations, it’s clear that the health care workforce needs a range of skills it did not need 30 years ago.
According to the latest issue of Charting Nursing’s Future, the Robert Wood Johnson Foundation’s issue brief series focused on the future of nursing, most clinical nursing education programs in both associate (ADN) and baccalaureate (BSN) degrees still emphasize hospital-based care, as they have for decades, even though much care has shifted to community settings. The result is a widening gap between clinical nursing education and the 21st-century competencies that nurses need.
However, as the brief also points out, many educators are striving to transform clinical education, embracing curricular innovations to ensure that new nursing graduates are better prepared for tomorrow’s challenges, including working collaboratively in teams, providing evidence-based care, managing chronic conditions, coordinating complex care, promoting a culture of health, and more.
New Approaches for a New Era
Some educators are advocating a re-sequencing of the nursing school curriculum to blend didactic and clinical education. In practice, that might involve mixing and matching study modules to meet individual students’ learning needs, creating an integrated curriculum that combines basic and clinical sciences, or the use of a “concept-based” approach to education.
The University of Kansas School of Nursing is pursuing the concept-based approach, teaching such concepts as fatigue, oxygenation and perfusion, instead of pediatrics, obstetrics and medical and surgical care. The idea is to convey content by focusing on concepts, then rely on students’ clinical experience to reinforce and extend their learning. The brief casts the reform as a response to the “knowledge explosion” of recent decades, which has made it all but impossible to cover every possible subject in nursing school.
Another innovation is reflected in the Texas Tech University Health Sciences Center School of Nursing’s use of the “coach model,” in which students in an online BSN program are paired with nurse coaches. Together they work a number of 8- or 12-hour shifts each week for a full year. Students also meet with Texas Tech faculty once a week, creating a coach-student-faculty triad.
Yet another innovation reflects new realities about where care is delivered today. Traditionally, clinical education in nursing has featured twice-weekly hospital rotations in such specialties as medicine, surgery, pediatrics, obstetrics and psychiatry. But that approach may not be well suited to today’s health care system, in which care is delivered in a rich variety of settings.
The brief notes that “Academic/practice partnerships in primary and palliative care, public health, geriatrics, health promotion and disease prevention, and corporate health and wellness—growing specialties of the future—hold great potential as laboratories for clinical learning.” At Lewis and Clark Community College in Godfrey, Ill., for example, students rotate through a family health clinic to learn about community health, and through a local Head Start program where they learn to conduct physical health assessments with nurse practitioners (NPs). “We need a much greater portion of clinical nursing education to take place in Head Start programs, public health departments, outpatient clinics, and local school districts,” says Donna Meyer, MSN, BSN, Lewis and Clark’s health sciences dean and president of the National Organization for Associate Degree Nursing. “Long-term care and post-acute rehabilitation facilities, hospice, and home health offer exceptional learning experiences as well.”
A number of nursing schools are restructuring their students’ clinical experiences, embracing:
Simulation, using actors posing as patients, complex high-fidelity mannequins, or virtual reality. The brief notes that simulation allows students to work through their responses—and make mistakes—before encountering high-risk scenarios with actual patients. “In the real clinical world, when the student is a novice and something potentially life-threatening occurs, somebody will take over,” says Pamela Jeffries, PhD, RN, ANEF, vice provost for digital initiatives at Johns Hopkins University School of Nursing and current president of the Society for Simulation in Healthcare. “In the sim lab, it’s the student who has to make a decision.” A newly released and eagerly awaited study by the National Council of State Boards of Nursing (NCSBN) offers powerful support for the trend toward simulation. It found no differences in licensure pass rates or other measures of overall readiness for practice between new graduates who had traditional clinical experiences and those who spent up to 50 percent of their clinical hours in simulation.
Interprofessional education with the goal of overcoming learning silos that divide clinicians, thus encouraging the habits of collaboration. At Emory University, about 20 nursing students in the school’s community health class work each semester with physical therapy, pharmacy, and dental hygiene students in a family health program at a migrant labor camp in Moultrie, Ga. “They are literally working side by side with different professions,” says Elizabeth Downes, DNP, MPH, FAANP, an assistant clinical nursing professor who helps run the program. “It’s a very rich two-week immersion.”
Dedicated Education Units (DEUs) that assign a group of nursing students to an entire unit of a care facility and engage staff nurses along with clinical faculty in instructing students over an extended period. “Hospitals tell us it makes them better nurses,” says Joane Moceri, RN, PhD, associate dean for the undergraduate nursing program at the University of Portland. “When they are teaching students what they know, it keeps them on their toes, [and] it keeps them up with the latest evidence-based nursing.” Facilities also gain access to a tested group of student nurses they can later hire. Meanwhile, students can experience a richer clinical learning environment and develop a greater sense of belonging to a health care team.
Nurse residencies intended to fortify clinical competencies with several months of structured guidance and acclimation to the profession. Such programs are far more comprehensive than the orientations new nurses typically receive. Residencies allow new nurses to hone their clinical abilities and develop confidence, and programs are typically tailored to the sponsoring employer’s priorities. It can cost employers a few thousand dollars per nurse to operate their own residency programs, but residency programs dramatically reduce nurse turnover, which is many times more costly.
Barriers to Change
Despite the enormous changes in health care in the past decade and the promise of more to come, clinical education for many of the nation’s nursing students is essentially the same as it has been for years. The innovations described above have begun to take root, but as the brief notes, they remain the exception, not the rule.
To help speed progress, in 2009, NCSBN developed a Model Act and Rules that state boards of nursing could adapt to encourage innovative education pilots. Many states have followed up, revising their rules along the lines proposed by NCSBN. “A common misperception is that boards of nursing, in their regulatory oversight of nursing education programs, are overly prescriptive,” says Kathy Apple, NCSBN’s chief executive officer. “In fact, most boards of nursing are not. For example, most boards of nursing do not require a fixed number of clinical hours. Rather, they describe sufficient clinical experiences to meet the program’s outcomes with the concept of ‘sufficient’ including quality as well as quantity.”
Despite this progress, the brief points out, innovation is still hampered by a lack of communication between educators and state boards, inflexible rules for faculty qualifications, and the sometimes cumbersome process of curriculum change.