Dr. Notarianni is Associate Professor, Ms. Curry-Lourenco is Senior Lecturer, Ms. Barham is Senior Lecturer and Chief Academic Advisor, and Ms. Palmer is Associate Professor and Undergraduate Program Director, Old Dominion University School of Nursing, Norfolk, Virginia.
Address correspondence to Mary Ann Notarianni, DNSc, FNP, Old Dominion University, Health Sciences Building 2130, Norfolk, VA 23529.
Unprecedented generational diversity in the present day nursing work force (Sherman, 2006) has nurse educators in all settings charged with teaching a population whose learning styles and preferences often differ from their own. By understanding the differences between teacher and learner and adapting teaching strategies accordingly, the proverbial generation gap can be bridged, resulting in effective learning outcomes. Nurse educators facilitating the continued career competence of nurses in practice are faced with the greatest challenge: they must address learners with a variety of learning styles and learning needs. The increased demand to educate practicing nurses about current trends in important topics (i.e., patient safety, evidence-based practice, and rapidly changing technology) and orient new graduates (complicated by the need to place beginning nurses in specialty units), the increased acuity of acute care patients, the diversity of practice settings, and the shortage of nurses add to the complexity of meeting the demand for continuing nursing education. This overview of the Progressive Professional Development Model (PPDM) discusses a combination of strategies that can be applied in nursing continuing education settings to promote meaningful, effective, and efficient learning environments to meet the needs of current and future generations of nurses.
Progressive Professional Development Model
The PPDM is a framework to guide the design of instructional and evaluative experiences using virtual, simulated, and standardized patient learning environments in conjunction with clinical practice. The model addresses teaching and learning strategies in the cognitive, affective, and psychomotor domains. It is derived from the ideas presented in the Engagement Theory (Kearsley & Shneiderman, 1999), the Elaboration Theory of Instruction (Reigeluth & Stein, 1983), and Benner’s writings on the nature of nursing knowledge and how it is acquired (Benner, 2001).
The major premise of the Engagement Theory is “that students must be engaged in their course work in order for effective learning to occur” (Kearsley & Shneiderman, 1999). Engaged learning occurs when learners are actively involved in cognitively processing new information in an environment promoting interaction regarding a meaningful task. The use of technology can greatly facilitate engaged learning (Kearsley & Shneiderman).
A simple-to-complex sequencing in the Elaboration Theory of Instruction guides the combination of learning strategies to teach professional competencies. Concepts or skills are initially taught at a concrete application level prior to adding related content and complexity. Sequencing is “expected to result in easier and more enjoyable learning and better retention” (Reigeluth & Stein, 1983, p. 356).
Benner’s insights into professional skill acquisition also highlight the importance of experiential learning by an engaged learner. “Openness and responsiveness by the learner to improve practice over time” results in the ability “to recognize whole situations in terms of past concrete experiences” (Benner, 2004, p. 190). In addition, movement toward the highest levels of skilled performance necessitates experience with situations that require “context-dependent judgments and skill” (Benner, 2001, p. 21).
These theoretical concepts have led to the development of the PPDM. The model’s main assumption is that providing opportunities to encounter similar experiences with a variety of contextual differences facilitates a learner’s progress from beginner to professional-level practice. Building on this belief, the premise of PPDM is that use of virtual and simulated environments and standardized patients in conjunction with clinical experiences offers maximum control of the contextual differences in learning experiences. This control optimizes progressive learning experiences facilitating efficient student progress toward professional practice. Additional subpremises of the model guiding the design of instructional and evaluative strategies include the higher the level of reality of the experience, the better the learner is able to translate learning into practice; expertly guided learning experiences can enhance the movement of learners from simple to complex problem-solving approaches; and learners must be engaged for effective learning to occur.
Engaging a Multigenerational Nursing Work Force
Designing learning environments to engage learners with a variety of learning styles can present a challenge. Understanding the learning preferences of today’s generational cohorts allows educators to design engaging learning environments well suited to assist nurses in accomplishing career development goals (Johnson & Romanello, 2005; Sherman, 2006).
Today’s nursing work force contains members of three generational cohorts (Sherman, 2006). Many authors (Johnson & Romanello, 2005; Oblinger, 2003; Sherman; Skiba & Barton, 2006) suggest that each group has common characteristics shaping its learning styles and preferences. Although there is some variation in the names and birth years used to classify these groups, the categories used by Johnson and Romanello are typical. They refer to the Baby Boomers (born between 1943 and 1960), Generation Xers (born between 1961 and 1981), and the Millennial or Net generation (born between 1982 and 2002).
The Boomers, whose worldview was shaped by the Vietnam War, believe they can change the world. Their self-identity tends to be derived from their jobs; they are motivated by recognition and reward. As lifelong learning is valued for improving performance, Boomers are willing learners. Rather than self-directed experiences, they prefer structured environments and clear guidelines to be engaged in learning (Johnson & Romanello, 2005).
Generation Xers, as a group, prefer a learning environment where they are able to demonstrate their own expertise. They want to know the bottom line of what they need to know and view education as a necessary evil for goal attainment. Time is considered a precious commodity, thus engaging learning experiences need to be efficient and relevant (Sherman, 2006).
The Millennial generation, born immediately following the introduction of the personal computer, is a technologically savvy group. Their learning style differs the most from that of typical nurse educators. Personal feedback is important to them, but they also want structure, guidance, and extensive orientation. Millennials require immediate feedback and get frustrated if there is not a quick response. They tend to read less (Sherman, 2006), finding technology more appealing. Thus, integration of technology in instructional design must be considered by educators. Millennials gravitate toward group activities (Oblinger, 2003), such as creative activities, simulation with immediate feedback, and experiential learning (Johnson & Romanello, 2005; Oblinger). Another characteristic of Millennials is their difficulty honing skills of critical analysis due to the volume of information available to them (Johnson & Romanello). Additionally, they consider doing more important than knowing because the half-life of knowledge is so short. Millennials learn by trial and error and embrace multitasking as a way of life.
Designing Engaging Learning Environments
The short half-life of knowledge in health care disciplines has generated multiple strategies used in clinical practice settings to facilitate lifelong learning environments for nurses. The use of mentors for new graduates and newly hired nurses has been reported as a successful method of formalizing an educational process that occurs on nursing units in both acute care and community-based settings (Greene & Puetzer, 2002; Latham, Hogan, & Ringl, 2008). Clinical nurse specialists often mentor nurses who have less formal educational backgrounds and serve as a resource on nursing units (LaSala, Connors, Pedro, & Phipps, 2007). With the increasing availability of computer-based resources such as clinical decision support systems, personal digital assistants (PDAs) with clinical practice management tools, and high-speed Internet connections on nursing units, an engaging learning environment can be created at the point of nursing care. Application of the PPDM in creating lifelong learning cultures in nursing units can assist in promoting an efficient, effective learning environment.
The use of virtual patients in teaching skills to health care professionals (e.g., medical, dental, emergency medical response, physician assistants, and nursing) has been implemented, studied, and discussed for the past several years. Modalities for using virtual patients in health care education vary and range from text-based case scenarios placed on the web to immersive virtual patients in a three-dimensional avatar presentation (Lok et al., 2006; Stevens et al., 2006). Virtual patients have provided efficient and economical experiences equivalent to those experiences with live, standardized patients (Hubal, Kizakevich, Guinn, Merino, & West, n.d.; Triola et al., 2006) and can be used to engage learners, especially Millennials.
In 1999, Monarch General Hospital (MGH) was implemented as a full-service, acute care virtual facility at Old Dominion University with beginning nursing students. A computer-generated virtual learning platform, MGH is an example of a virtual practice environment that provides students with anytime or anyplace practice options via the web and allows for repetitive practice opportunities. A culturally diverse patient population provides access and exposure to a variety of patient situations likely to be encountered in practice, including patient scenarios that are increasingly difficult to find in clinical settings. For example, during a semester-long health assessment course, learners are able to collect health history data by interacting with a variety of virtual patients, who respond to typed queries with a video clip. This strategy requires learners to gather both auditory and body language cues and more accurately simulates actual nurse-patient interactions. Through MGH, learners can access information directly from the patient, the patient chart, the nursing shift report, and other staff to plan care for the assigned patient. Online discussion venues enable learners to share, compare, and prepare collegially planned interventions for use with an assigned high-performance human physiologic simulator scenario. A variety of web-based narrated graphic presentations, full-motion video presentations, electronic reserve articles, and web links are available to learners to simulate the availability of resources in a hospital environment. Faculty, other learners, third-party vendors, and others may provide these multimedia presentations. Electronic resources extend to library services available through the university library.
Using virtual patients allows faculty to assess thoroughness and accuracy of data collection, enhancing evaluation of experiences. Faculty feedback with virtual patient scenarios guides learners in honing skills in important aspects of care provision with real patients. Learners can work individually or in groups while developing comprehensive data collection and care planning competencies. Faculty can carefully construct patient scenarios beginning with simple nursing problems and adding complexity as student problem-solving abilities increase. The extent of opportunities for the use of virtual patients is limited only by the imagination of faculty developing “cases” for MGH.
Application of virtual learning practice is not limited to any particular setting. Teaching and learning metaphors such as MGH can easily be adapted to a specific health care system, reflecting the mission and goals of that system, used for staff orientation, and used to enhance the knowledge of staff members at multiple levels of service provision. Virtual patient cases can be used to update staff information, introduce new nursing care approaches, and provide hands-on safe learning experiences with new techniques or equipment. The interactive system can provide opportunities for staff to have anytime and anyplace self-paced learning and to demonstrate proficiency. The interactivity of this learning modality encourages independent learning and problem-solving skills essential in today’s health care environment.
Simulated practice is an additional strategy that can be used alone or combined with virtual practice to create efficient, effective learning environments. Simulation is an umbrella term used to describe a variety of technologies used across disciplines. It often defines a mechanism by which realistic life situations can be represented for purposes of instruction or evaluation of practical performance. Medley and Horne (2005) define simulation as the “reproduction of the essential aspects of a real life situation” (p. 31). Toward this goal, human physiologic simulators have been used in health care education since the early 1960s. The advent of Resusci-Annie for teaching and evaluation of proficiency in cardiopulmonary resuscitation established the early model for many high-fidelity simulators used today (Lake, 2005). Increasing numbers of educational institutions are integrating human physiologic simulators into curricula as a means of providing safe, consistent, controllable patient care experiences (Medley & Horne). Human physiologic simulators are highly technical manikins capable of responding physiologically to interventions performed or overlooked by care providers. Data can be electronically transmitted to monitoring devices at the bedside for real-time display of physiologic status. Vital signs and physiologic sounds may be auscultated (Seropian, Brown, Gavilanes, & Driggers, 2004). The simulator may be programmed to auto-run a scenario with predetermined trends and responses, or may be manually adapted by the learning facilitator as a patient care scenario unfolds. Additionally, learners have the opportunity to enhance psychomotor skill through insertion of catheters, nasogastric tubes, and intravenous catheters (Peteani, 2004). Complex wound assessment and dressing changes can be accomplished via reproductions of severe injuries.
At Old Dominion University, the use of human physiologic simulators is an integral component of the PPDM. Learners engage in guided instructional and evaluative patient care situations. Patients are initially introduced within the MGH virtual care environment. Human physiologic simulators provide the opportunity to operationalize concepts through concrete experiences acquired during the virtual patient care scenario. Patient care scenarios follow a storyline threaded across learning modalities, allowing students to develop a relationship with the character. Through this continuity of experiences and combination of learning environments, the human physiologic simulator becomes the patient and students often demonstrate compassionate and empathetic behaviors. This unique framework establishes the opportunity for evaluation of the affective domain. PPDM scenarios are designed to meet outcome objectives addressing cognitive, affective, and psychomotor domains.
Simulation offers promising potential for graduate nurse orientation and continuing education of experienced nurses and health care professionals. Holcomb et al. (2002) demonstrated the effectiveness of human physiologic simulators in evaluating response time and skill proficiency of a trauma response team. Teams consisting of military physicians, nurses, and medics were tested on arrival and before completion of a 28-day trauma resuscitation course. This comparative study measured performance of the military team against that of an expert trauma team used as the control group. Although the expert team’s performance remained superior to the military team’s performance, overall response time and skill proficiency of the military team improved significantly from initial to final testing, with the performance of the military team closely approaching that of the control group.
Health care institutions are pressured to verify competency of nurses entering the system, as well as continuing education and competence in response to changes in practice and technology (Winslow, Dunn, & Rowlands, 2005). The use of human physiologic simulators creates a “risk free and reproducible environment,” which may be instrumental in providing continuing education for health care professionals as well as members of a multidisciplinary team (Holcomb et al., 2002, p. 1085). Simulated situations can be created to meet individual learning needs without fear of harm to patients. Establishing a hospital-based simulation skills laboratory can be instrumental in orienting staff, providing continuing education, and measuring competency-based outcomes.
Rauen (2004) stated that health care professionals must acquire and maintain combined knowledge in physical and behavioral sciences. Live practice environments do not often provide consistent learning situations and carry the risk of potential harm to patients. Orientation and continuing education programs using simulated patient care scenarios offer non-threatening environments with the capability for reproducible learning situations.
Standardized Patient Practice
Standardized patients are actors or real patients who have been instructed to portray the critical elements of a scenario (Manning & Kripalani, 2007). Historically, the use of standardized patients in health care education occurred primarily in medical schools with student physicians for instructional purposes. However, expanding applications are becoming more common in evaluating ongoing competence. In one exploratory, comparative study, standardized patients were used to measure physicians’ quality of care. The population for this study was composed of internal medicine physicians, faculty, and first-, second-, and third-year residents. Standardized patients presented unannounced to outpatient clinics. Physicians’ process of care was compared using standardized patients, chart abstractions, and vignettes. Quality of care measures were highest for the standardized patients (76.2%). Case vignettes and chart abstraction measured quality of care at 71% and 65.6%, respectively (Peabody, Luck, Glassman, Dresselhaus, & Lee, 2000).
The use of standardized patients in nursing education is expanding. A study by Rentschler, Eaton, Cappiello, McNally, and McWilliam (2007) described the use of standardized patients in the evaluation of senior-level undergraduate nursing students. The Objective Structured Clinical Evaluation tool was used to measure synthesis and knowledge of clinical skills during student interactions with both simulated and standardized patients. A standardized evaluation tool, along with the controllable, reproducible environment offered by simulation and standardized patients, provided a means for decreasing student anxiety and standardizing measurement of learning outcomes.
At Old Dominion University, standardized patients are used in the undergraduate program as a graded, summative evaluation. The implementation of standardized patients allows learners to interact in a realistic manner with a “client.” Feedback is offered by the standardized patient to enhance learning and explain rationale for particular responses or behaviors. In other applications, the standardized patients are videotaped and become virtual patients for repetitive practice.
Standardized patients offer many benefits similar to those of simulation. Interactions and care provided to standardized patients occur within a controlled environment with no risks to actual patients. Orientation for new nurses as well as continuing education and competency verification may be accomplished by using standardized patients.
Making It All Work
A model’s value is measured by its potential for application. Successfully implementing the PPDM requires that several issues be considered. Necessary support resources include instructional technology, instructional design, and clinical laboratory personnel. Training time must be allotted for development and execution of learning scenarios. Equipment needs include purchase and maintenance of computer software and hardware, human physiologic simulators, and audiovisual equipment. Additionally, dedicated space for a realistic simulated practice environment, a classroom, a computer and DVD recording room, and an educator observation room are required. Efficient use of resources can be accomplished through collaboration with other institutions, creating a shared center for excellence.
With careful planning and guidance from models such as the PPDM, the combined use of teaching strategies such as standardized patients and virtual and simulated environments can assist nurse educators in creating lifelong learning cultures in nursing units. Time and effort taken to implement this approach will result in a greater ability to provide meaningful and efficient learning opportunities for nurses with a variety of learning styles. Moreover, organizations that facilitate the ability of nurses to maintain their professional competence in such a manner will find that it contributes greatly to their ability to provide safe, high-quality nursing care.
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