The Future of Nursing Education: A Collaborative Perspective Christine A. Tanner, RN, PhD Oregon Health & Science University School 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 acuity Decreased length of stay Shift of care to home & community Exponential growth of knowledge Explosion of technologies Identification 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 of Nursing Process Clinical Problem Solving Clinical Decision Making Diagnostic Reasoning Critical 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 It is always in the context of the particular patient, a deep understanding of the patient’s experience, preferences and values, within the ethical standards of the discipline. It takes account of the uncertainty, the unpredicted but potentially significant variables and the process of change over time. It is more like the practical reasoning described by Aristotle as phronesis than the scientific rationality of modernity

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 clinical education

A very short history of clinical education

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” nurse Changes in the practice environment Emerging health care needs Practice 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 explosion Advances in the science of learning Outdated 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 of Consortium 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