The Future of NursingEducation: A Collaborative

Perspective

Christine A. Tanner, RN, PhDOregon Health & Science

UniversitySchool of Nursing

Calls for Reform

Reexamination of curricular structures & processes (The Curriculum Revolution)

Preparing a new kind of nurse

The Curriculum Revolution

New pedagogies Preparing tomorrows leaders Multicultural diversity Caring Curriculum

Demands for a New Kind of Nurse

Fueled by changes in the nursing practice environment:

Increasing complexity and acuityDecreased length of stayShift of care to home & communityExponential growth of knowledgeExplosion of technologiesIdentification of the “Quality Chasm”

Demands for a New Kind of Nurse

Fueled by changes in demographics:Aging population with increased

prevalence of chronic illness Families increasingly engaged in care

giving with little or no nursing support

Increased attention to health-promotion

Central Competencies

Critical thinking

Critical thinking = Thinking Like a Nurse?

A Short History ofNursing Process

Clinical Problem SolvingClinical Decision Making

Diagnostic ReasoningCritical Thinking

in other words . . .Thinking Like a Nurse

Two decades of Research on CT

Critical thinking and clinical thinking (i.e., decision making, clinical judgment) are different constructs.

No relationship between education & critical thinking.

No relationship between critical thinking and patient outcomes

Central Competencies

Clinical Judgment:• Case based• Contextually bound• Interpretive reasoning

Central Competencies

Clinical Judgment requires deep background knowledge for:• Noticing• Considering plausible interpretations• Collecting reasonable evidence• Choosing the best course of action

Central Competencies

Clinical Judgment is always within• the context of a particular patient• A deep understanding the patient’s

experience, values and preferences• Ethical standards of the discipline

Central Competencies

Understanding clinical judgment in this way • Renews interest in case-based

approaches to instruction• Demand new approaches to clinical

education• Provides guidance to use of simulation

in nursing education

Central Competencies:Quality-Safety Initiative

Patient-centered care Team-work and collaboration Evidence-based practice Quality improvement Informatics

Preparing More Nurses

Preparing More Nurses

In the face of a profound faculty shortage

Preparing More Nurses

In the face of a profound faculty shortage

Limitation in the number, type and quality of sites for clinical education.

Current practices in clinicaleducation

A very short history of clinicaleducation

Challenges in Clinical Education

Traditional clinical learning driven by placement opportunities and challenges

Insufficient number of “placements” using total patient care model

High acuity, greater risk with neophyte students

Staff nurse burden for supervision of students in rapidly changing situations

Learning is dependent on…• Available patient population• Facility’s schedule availability • Availability of faculty with required expertise

Summary: Driving Forces for Reform

Demands for Reform in Nursing Education 1985-2005• Study of Curricular processes• Evidence of poorly prepared graduates

even for acute care• Quality-safety

Summary: Driving Forces for Reform

Demands for Reform in Nursing Education 1985-2005

Need for a “new” nurseChanges in the practice environmentEmerging health care needsPractice in environment of severe

shortage

Summary: Driving Forces for Reform

Demands for Reform in Nursing Education 1985-2005

Need for a “new” nurse Other pressures:

Content explosionAdvances in the science of learningOutdated model of Clinical education

Part II: The Oregon Consortium for Nursing Education

OCNE

A collaboration among 8 community colleges and 5 campuses of OHSU to:• Deliver a standard competency based

curriculum with an AAS exit and completion of Baccalaureate in nursing on “home” campus

• Increase the number of nurses prepared with baccalaureate degree

• Transform nursing education to more closely align with emerging health care needs

A very short history of OCNE 2000: Study of nursing shortage in Oregon 2001: Strategic plan developed by Oregon Nursing leaders 2002: Education plan unveiled and political turmoil ensued 2003: Launched OCNE with Project Director 2004: Began curriculum development & Phase I of Faculty

Development 2005: Curriculum change approved by OSBN, NLNAC &

CCNE 2006: Phase I Clinical Education Project launched 2006: First class of 255 students admitted on 6 campuses

to nursing courses 2007: Phase II Faculty Development 2008: Preceptor Development 2009: First Baccalaureate class graduates

OCNE as a response to these challenges

Committed to collaboration across programs enabling the best use of scarce resources

Standard, competency based curriculum focused on preparing the “new” nurse.

Teaching approaches that rest on the science of learning

Faculty development as an integral part of curriculum development

Reform of clinical education

Guiding Principles in Curriculum Design

Responsive to demands for reform• NCSBN – 2001 – lack of preparation of

grads• JCAHO (2002) – continental divide

between education and practice• IOM reports

Guiding Principles in Curriculum Design

Responsive to demands for reform Emerging health care needs

• Aging population• Increasing acuity• Increasing prevalence of chronic

illnesses• Demands placed on caregiving families

with inadequate nursing care support

Guiding Principles in Curriculum Design

Responsive to demands for reform Emerging health care needs Graduates would be practicing in an

environment of chronic, severe RN shortages

More efficient & effective with dwindling supply of nursing faculty

Competencies of the “new” nurse would require at least 4 years, but there would need to be AD exit

Overview of the Curriculum

First year: Prerequisites Second year & first two quarters of the

third year:• Required non-nursing courses• Standard nursing courses on all campuses

Third quarter of the third year:• Complete Precepted Scope of Practice

Practicum, graduate with AAS and be eligible to sit for NCLEX OR

• Continue directly into 400 level nursing courses for 4 remaining quarters, complete 15 credits of upper division arts & science, and graduate with BS

Transformation of the Nursing Curriculum:Some Features

Courses organized around foci of care:• Health Promotion• Chronic Illness Management• Acute Care• End-of-Life Care

Transformation of the Nursing Curriculum: Some Features

Last 4 clinical nursing courses toward Bachelors degree, students may select a population for focus in:• Public health and population-based

care• Leadership and outcomes

management• Clinical immersion or integrative

practicum for twenty weeks

Transformation of the Nursing Curriculum: Some Features

Redefines nursing fundamentals to:• Clinical Judgment• Evidence-based Practice• Patient-centered care• Leadership

Transformation of the Nursing Curriculum: ApplyingThe New

Pedagogy Draws on tremendous advances in

the science of learning from a variety of disciplines (cognitive science, psychology, higher education)

The New Pedagogy

Emphasizes deep understanding of the discipline’s most central concepts ---• Purposeful REDUCTION in content• Selection of content based on:

Prevalence of condition Useful to teach integration across

competencies• (e.g. ethical comportment, clinical judgment,

evidence-based practice, health systems issues & leadership,

The New Pedagogy

Emphasizes deep understanding of the discipline’s most central concepts

Active learning through case-based instruction, integration among theory, clinical and simulation.

The New Pedagogy

Emphasizes deep understanding of the discipline’s most central concepts

Active learning through case-based instruction, integration among theory, clinical and simulation.

Authentic performance assessment & promotion of self-directed learning

Process for Consensus Building during Curriculum Development

Institutional representatives Leadership model Faculty development combined with

curriculum development Frequent Review & Counsel by

groups with expertise & vested interests:• Faculty on each of the 12 campuses• Specialty task forces

Challenges in Clinical Education

Traditional clinical learning driven by placement opportunities and challenges

Insufficient number of “placements” using total patient care model

High acuity, greater risk with neophyte students

Staff nurse burden for supervision of students in rapidly changing situations

Learning is dependent on…• Available patient population• Facility’s schedule availability • Availability of faculty with required expertise

Desired Features of New Clinical Education Model

Relationship-centered care keeping the patient and family at the center

Science of learning and findings of the Carnegie study• (i.e. integration across apprenticeships,

retain prep, coaching and debriefing and other best practices)

Desired Features of New Clinical Education Model

Relies on Clinical learning activities that:• Are designed to support attainment of

Competencies• Include, but not dominated by “Total Patient

Care”• Developmentally appropriate for level of

student• Vary faculty–student ratios & nursing staff roles

by level of student, acuity of patient, nature of learning activity

• Culminate in one or more Immersion experiences.

Types of Clinical Learning Experiences

Focused direct care experiences• Patient-centered care• Therapeutic relationship• Individualized care

Types of Clinical Learning Experiences

Focused direct care experiences Concept-based experiences: focus

on learning concepts (e.g. oxygenation) through seeing many patients who exemplify the concept

Types of Clinical Learning Experiences

Focused direct care experiences Concept-based experiences Case-based experiences: focused on

learning clinical judgment through working through clinical problems presented in text-based through fully simulated scenarios.

Types of Clinical Learning Experiences

Focused direct care experiences Concept-based experiences Case-based experiences Skill-based experiences: focused on

learning basic skills through repetitive practice, includes psychomotor skills, such as interviewing.

Types of Clinical Learning Experiences

Focused direct care experiences Concept-based experiences Case-based experiences Skill-based experiences Integrative experiences: opportunity

to integrate prior learning and linking learning activities to RN role in clinical agency.

Types of Clinical Learning Experiences: Differentiated by:

Type of learning and appropriate pedagogy

Degree of accountability for patient care

Transformation of Clinical Education

Phase I & II: consensus building on need for change

Phase III: 8 pilot projects, evaluating innovative clinical learning activities that when combined may lead to a new model

Phase IV: development of and consensus building on new model

Phase V: statewide demonstration of new model through 3 years of OCNE nursing curriculum

6 Major Components ofConsortium Development

Developmental Processes & Infrastructure

Faculty Development Simulation Capacity Curriculum Development Clinical Education Capacity Comprehensive evaluation

A relationship-centered change process

Driven by our passions with . . . Commitment to health of Oregonians Strong Leadership & persistence One leap of faith after another

An African Proverb:

To go quickly, go alone.To go far, go together.

For more information

Visit us at www.ocne.org