The Future of Nursing Education: A Collaborative Perspective Christine A. Tanner, RN, PhD Oregon Health & Science University School of Nursing.

The Future of NursingThe Future of NursingEducation: A CollaborativeEducation: A Collaborative

PerspectivePerspective

Christine A. Tanner, RN, PhDChristine A. Tanner, RN, PhDOregon Health & Science Oregon Health & Science

UniversityUniversitySchool of NursingSchool of Nursing

Calls for ReformCalls for Reform

Reexamination of curricular Reexamination of curricular structures & processes (The structures & processes (The Curriculum Revolution)Curriculum Revolution)

Preparing a new kind of nursePreparing a new kind of nurse

The Curriculum RevolutionThe Curriculum Revolution

New pedagogiesNew pedagogies Preparing tomorrows leadersPreparing tomorrows leaders Multicultural diversityMulticultural diversity Caring CurriculumCaring Curriculum

Demands for a New Kind of NurseDemands for a New Kind of Nurse

Fueled by changes in the nursing Fueled by changes in the nursing practice environment:practice environment:

Increasing complexity and acuityIncreasing complexity and acuityDecreased length of stayDecreased length of stayShift of care to home & communityShift of care to home & communityExponential growth of knowledgeExponential growth of knowledgeExplosion of technologiesExplosion of technologiesIdentification of the “Quality Chasm”Identification of the “Quality Chasm”

Demands for a New Kind of NurseDemands for a New Kind of Nurse

Fueled by changes in demographics:Fueled by changes in demographics:

Aging population with increasedAging population with increased

prevalence of chronic illness prevalence of chronic illness

Families increasingly engaged in care Families increasingly engaged in care giving with little or no nursing giving with little or no nursing supportsupport

Increased attention to health-Increased attention to health-promotionpromotion

Central CompetenciesCentral Competencies

Critical thinkingCritical thinking

Critical thinking = Critical thinking = Thinking Like a Nurse?Thinking Like a Nurse?

A Short History ofA Short History ofNursing ProcessNursing Process

Clinical Problem SolvingClinical Problem SolvingClinical Decision MakingClinical Decision Making

Diagnostic ReasoningDiagnostic ReasoningCritical ThinkingCritical Thinking

in other words . . .in other words . . .Thinking Like a NurseThinking Like a Nurse

Two decades of Research on CTTwo decades of Research on CT

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

No relationship between education & No relationship between education & critical thinking. critical thinking.

No relationship between critical No relationship between critical thinking and patient outcomesthinking and patient outcomes

Central CompetenciesCentral Competencies

Clinical Judgment:Clinical Judgment:• Case basedCase based• Contextually boundContextually bound• Interpretive reasoningInterpretive reasoning

Central CompetenciesCentral Competencies

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

Central CompetenciesCentral Competencies

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

experience, values and preferencesexperience, values and preferences• Ethical standards of the disciplineEthical standards of the discipline

Central CompetenciesCentral Competencies

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

approaches to instructionapproaches to instruction• Demand new approaches to clinical Demand new approaches to clinical

educationeducation• Provides guidance to use of simulation Provides guidance to use of simulation

in nursing educationin nursing education

Central Competencies:Central Competencies:Quality-Safety InitiativeQuality-Safety Initiative

Patient-centered carePatient-centered care Team-work and collaborationTeam-work and collaboration Evidence-based practiceEvidence-based practice Quality improvementQuality improvement InformaticsInformatics

Preparing More NursesPreparing More Nurses

Preparing More NursesPreparing More Nurses

In the face of a profound faculty In the face of a profound faculty shortageshortage

Preparing More NursesPreparing More Nurses

In the face of a profound faculty In the face of a profound faculty shortageshortage

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

Current practices in clinicalCurrent practices in clinicaleducationeducation

A very short history of clinicalA very short history of clinicaleducationeducation

Challenges in Clinical Challenges in Clinical EducationEducation

Traditional clinical learning driven by placement Traditional clinical learning driven by placement opportunities and challengesopportunities and challenges

Insufficient number of “placements” using total Insufficient number of “placements” using total patient care modelpatient care model

High acuity, greater risk with neophyte studentsHigh acuity, greater risk with neophyte students Staff nurse burden for supervision of students in Staff nurse burden for supervision of students in

rapidly changing situationsrapidly changing situations Learning is dependent on…Learning is dependent on…

• Available patient populationAvailable patient population• Facility’s schedule availability Facility’s schedule availability • Availability of faculty with required expertiseAvailability of faculty with required expertise

Summary: Driving Forces for Summary: Driving Forces for ReformReform

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

even for acute careeven for acute care• Quality-safetyQuality-safety

Summary: Driving Forces for Summary: Driving Forces for ReformReform

Demands for Reform in Nursing Demands for Reform in Nursing Education 1985-2005Education 1985-2005

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

shortageshortage

Summary: Driving Forces for Summary: Driving Forces for ReformReform

Demands for Reform in Nursing Demands for Reform in Nursing Education 1985-2005Education 1985-2005

Need for a “new” nurseNeed for a “new” nurse Other pressures:Other pressures:

Content explosionContent explosionAdvances in the science of learningAdvances in the science of learningOutdated model of Clinical educationOutdated model of Clinical education

Part II: The Oregon Consortium for Part II: The Oregon Consortium for Nursing EducationNursing Education

OCNEOCNE

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

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

• Increase the number of nurses prepared Increase the number of nurses prepared with baccalaureate degreewith baccalaureate degree

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

A very short history of OCNEA very short history of OCNE 2000: Study of nursing shortage in Oregon2000: Study of nursing shortage in Oregon 2001: Strategic plan developed by Oregon Nursing leaders2001: Strategic plan developed by Oregon Nursing leaders 2002: Education plan unveiled and political turmoil ensued2002: Education plan unveiled and political turmoil ensued 2003: Launched OCNE with Project Director2003: Launched OCNE with Project Director 2004: Began curriculum development & Phase I of Faculty 2004: Began curriculum development & Phase I of Faculty

DevelopmentDevelopment 2005: Curriculum change approved by OSBN, NLNAC & 2005: Curriculum change approved by OSBN, NLNAC &

CCNECCNE 2006: Phase I Clinical Education Project launched2006: Phase I Clinical Education Project launched 2006: First class of 255 students admitted on 6 campuses 2006: First class of 255 students admitted on 6 campuses

to nursing coursesto nursing courses 2007: Phase II Faculty Development2007: Phase II Faculty Development 2008: Preceptor Development2008: Preceptor Development 2009: First Baccalaureate class graduates2009: First Baccalaureate class graduates

OCNE as a response to these OCNE as a response to these challengeschallenges

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

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

Teaching approaches that rest on the Teaching approaches that rest on the science of learningscience of learning

Faculty development as an integral part of Faculty development as an integral part of curriculum developmentcurriculum development

Reform of clinical educationReform of clinical education

Guiding Principles in Curriculum Guiding Principles in Curriculum DesignDesign

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

gradsgrads• JCAHO (2002) – continental divide JCAHO (2002) – continental divide

between education and practicebetween education and practice• IOM reportsIOM reports

Guiding Principles in Curriculum Guiding Principles in Curriculum DesignDesign

Responsive to demands for reformResponsive to demands for reform Emerging health care needsEmerging health care needs

• Aging populationAging population• Increasing acuityIncreasing acuity• Increasing prevalence of chronic Increasing prevalence of chronic

illnessesillnesses• Demands placed on caregiving families Demands placed on caregiving families

with inadequate nursing care supportwith inadequate nursing care support

Guiding Principles in Curriculum Guiding Principles in Curriculum DesignDesign

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

environment of chronic, severe RN environment of chronic, severe RN shortagesshortages

More efficient & effective with dwindling More efficient & effective with dwindling supply of nursing facultysupply of nursing faculty

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

Overview of the CurriculumOverview of the Curriculum

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

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

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

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

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

Transformation of the Nursing Transformation of the Nursing Curriculum:Some FeaturesCurriculum:Some Features

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

Transformation of the Nursing Transformation of the Nursing Curriculum: Some FeaturesCurriculum: Some Features

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

carecare• Leadership and outcomes Leadership and outcomes

managementmanagement• Clinical immersion or integrative Clinical immersion or integrative

practicum for twenty weekspracticum for twenty weeks

Transformation of the Nursing Transformation of the Nursing Curriculum: Some FeaturesCurriculum: Some Features

Redefines nursing fundamentals to:Redefines nursing fundamentals to:• Clinical JudgmentClinical Judgment• Evidence-based PracticeEvidence-based Practice• Patient-centered carePatient-centered care• LeadershipLeadership

Transformation of the Nursing Transformation of the Nursing Curriculum: ApplyingThe New Curriculum: ApplyingThe New

PedagogyPedagogy Draws on tremendous advances in Draws on tremendous advances in

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

The New PedagogyThe New Pedagogy

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

Prevalence of conditionPrevalence of condition Useful to teach integration across Useful to teach integration across

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

evidence-based practice, health systems issues & evidence-based practice, health systems issues & leadership,leadership,

The New PedagogyThe New Pedagogy

Emphasizes deep understanding of Emphasizes deep understanding of the discipline’s most central the discipline’s most central conceptsconcepts

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

The New PedagogyThe New Pedagogy

Emphasizes deep understanding of Emphasizes deep understanding of the discipline’s most central the discipline’s most central conceptsconcepts

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

Authentic performance assessment & Authentic performance assessment & promotion of self-directed learningpromotion of self-directed learning

Process for Consensus Building Process for Consensus Building during Curriculum Developmentduring Curriculum Development

Institutional representativesInstitutional representatives Leadership modelLeadership model Faculty development combined with Faculty development combined with

curriculum development curriculum development Frequent Review & Counsel by Frequent Review & Counsel by

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

Challenges in Clinical Challenges in Clinical EducationEducation

Traditional clinical learning driven by placement Traditional clinical learning driven by placement opportunities and challengesopportunities and challenges

Insufficient number of “placements” using total Insufficient number of “placements” using total patient care modelpatient care model

High acuity, greater risk with neophyte studentsHigh acuity, greater risk with neophyte students Staff nurse burden for supervision of students in Staff nurse burden for supervision of students in

rapidly changing situationsrapidly changing situations Learning is dependent on…Learning is dependent on…

• Available patient populationAvailable patient population• Facility’s schedule availability Facility’s schedule availability • Availability of faculty with required expertiseAvailability of faculty with required expertise

Desired Features of New Desired Features of New Clinical Education ModelClinical Education Model

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

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

retain prep, coaching and debriefing and retain prep, coaching and debriefing and other best practices)other best practices)

Desired Features of New Desired Features of New Clinical Education ModelClinical Education Model

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

CompetenciesCompetencies• Include, but not dominated by “Total Patient Include, but not dominated by “Total Patient

Care”Care”• Developmentally appropriate for level of studentDevelopmentally appropriate for level of student• Vary faculty–student ratios & nursing staff roles Vary faculty–student ratios & nursing staff roles

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

• Culminate in one or more Immersion Culminate in one or more Immersion experiences.experiences.

Types of Clinical Learning Types of Clinical Learning ExperiencesExperiences

Focused direct care experiencesFocused direct care experiences• Patient-centered carePatient-centered care• Therapeutic relationshipTherapeutic relationship• Individualized careIndividualized care

Types of Clinical Learning Types of Clinical Learning ExperiencesExperiences

Focused direct care experiencesFocused direct care experiences Concept-based experiences: focus Concept-based experiences: focus

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

Types of Clinical Learning Types of Clinical Learning ExperiencesExperiences

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

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

Types of Clinical Learning Types of Clinical Learning ExperiencesExperiences

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

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

Types of Clinical Learning Types of Clinical Learning ExperiencesExperiences

Focused direct care experiencesFocused direct care experiences Concept-based experiencesConcept-based experiences Case-based experiencesCase-based experiences Skill-based experiencesSkill-based experiences Integrative experiences: opportunity Integrative experiences: opportunity

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

Types of Clinical Learning Types of Clinical Learning Experiences: Differentiated by:Experiences: Differentiated by:

Type of learning and appropriate Type of learning and appropriate pedagogypedagogy

Degree of accountability for patient Degree of accountability for patient carecare

Transformation of Clinical Transformation of Clinical EducationEducation

Phase I & II: consensus building on need Phase I & II: consensus building on need for changefor change

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

Phase IV: development of and consensus Phase IV: development of and consensus building on new modelbuilding on new model

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

6 Major Components of6 Major Components ofConsortium DevelopmentConsortium Development

Developmental Processes & Developmental Processes & InfrastructureInfrastructure

Faculty DevelopmentFaculty Development Simulation CapacitySimulation Capacity Curriculum DevelopmentCurriculum Development Clinical Education CapacityClinical Education Capacity Comprehensive evaluationComprehensive evaluation

A relationship-centered change A relationship-centered change process process

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

An African Proverb:An African Proverb:

To go quickly, go alone.To go quickly, go alone.

To go far, go together.To go far, go together.

For more informationFor more information

Visit us at www.ocne.orgVisit us at www.ocne.org